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Cathy Sun

I. del Canto, M. Halpern, S. Cunto-Amesty, L. Lerebours Nadal, M. Cruz and A. Bowman
Columbia University IFAP Global Health Program

Columbia University IFAP Global Health Program Columbia University College of Physicians and Surgeons.

New York, NY. USA.

The primary purpose of this cross-sectional investigation was to quantify illicit substance use among the HIV population at Clínica de Familia La Romana, Dominican Republic. The secondary goal was to identify whether there was a relationship between alcohol consumption and condom use. Of the 97 participants that were interviewed in the study, 49% self-reported alcohol or tobacco use in the last three months. Based on the calculated ASSIST risk score, 20% of participants were classified as ‘moderate’ or ‘high risk,’ requiring an intervention. Additionally, 51% of the sample reported having sexual intercourse in the last 30 days. Out of the 49 participants that were sexually active, 67% reported using a condom during their last sexual experience, 31% reported not using a condom, and the remaining 2% declined to respond. Contrary to prior research, no association was found between alcohol consumption and unprotected sex at Clínica de Familia La Romana, possibly due to the low percentage of patients that report consuming alcohol frequently.

Introduction

The Caribbean has the second highest prevalence of human immunodeficiency virus (HIV) globally, after sub-Saharan Africa, with an adult prevalence of 1%.1 Within the Caribbean, the Dominican Republic (DR) reports the second highest prevalence rate of HIV infection, after Haiti,2 with an estimated prevalence of 0.7% for those 15 to 49 years old.3 Still,the estimated number of new infections has decreased over the past years from 41,000 in 2003 to less than 1,000 in 2013.4 A major reason for this decline was the introduction of highly active antiretroviral treatment (HAART) in 2004.5

The primary mode of HIV transmission in the Dominican Republic is via heterosexual sexual intercourse.6 HIV transmission is most prevalent within certain regions of the DR, particularly those with high tourism, such as La Romana, Puerto Plata and Santo Domingo.7 A review of epidemiological studies suggests that HIV is prevalent in tourist areas due to the mixing of local population with outside carriers, commercial sex work, and heavy alcohol and illicit drug use.8

The primary narcotics used in the Caribbean are alcohol, marijuana and cocaine; the injection of drugs, such as heroin, remains rare.9 In contrast to the rest of the Caribbean, research has found drug abuse in the DR to be low, with the exception of alcohol.10 11 This finding is of particular importance in people living with HIV/AIDS (PLWHA) due to the impact of alcohol on HAART treatment and adherence. An overwhelming amount of research has found that alcohol consumption has deleterious effects on markers of immunological functioning and viral suppression.12 13 14 Other research has found a significant association between alcohol and drug use, and non-adherence to HAART therapy.15 16

In a study by Harris et al. (2011), researchers investigated barriers to medical adherence in 300 HIV-infected individuals in the Dominican Republic. Researchers found that alcohol users were 2.5 times more likely (95% CI: 1.4-4.5) to be non-adherent to medical treatment compared to non-users.17 The benefits of high adherence rates are consistent across cultural settings and include increased immunologic response, and lower rates of resistance, mortality and improved survival.18 Therefore, there are several significant health concerns associated with alcohol consumption and drug use among patients with HIV.

Another health concern associated with alcohol consumption is unprotected sex, particularly among PLWHA. Approximately 70% PLWHA remain sexually active after diagnosis19 and one-third of PLWHA engage in unprotected sex.20 Alcohol prevails as a frequently implicated risk factor for unprotected sex, and alcohol consumption tends to be more prevalent among PLWHA than the general population.21 22 Through meta-analysis, Baliunas et al. (2010) discovered that those who consumed alcohol prior to or during sexual relations were at an 87% higher risk of acquiring HIV.23 In a literature review of 27 relevant studies, Shuper et al. (2009) demonstrated through meta-analysis that alcohol consumption in sexual contexts was significantly associated with unprotected sex among PLWHA.24

Most of the research on alcohol consumption and risky sex in the DR has revolved around sex worker populations because sex work is legal and they makeup an especially vulnerable population. Research has found that drugs are used prior to sexual exploits in order to earn more money, even at the cost of having unprotected sex.25 Research on alcohol consumption and risky sex among PLWHA, who are not sex workers, in the DR remains rare.

Substance use has not yet been quantified among HIV patients at Clínica de Familia La Romana (CFLR). Additionally, the association between alcohol consumption and unprotected sex had not been investigated. This study assessed both factors through interviews in order to achieve an understanding of alcohol and substance use within our population, and to determine if certain subpopulations within the clinic are at higher risk for transmitting the virus.

Methods

PubMed and Google Scholar databases were queried for articles that had standardized questionnaires on substance use that were also culturally relevant to the clinic’s population. After extensive research, a substance abuse program protocol was obtained from the World Health Organization website. The manual explains how to implement the Alcohol, Smoking and Substance Involvement Screening Test (“ASSIST”), an eight-item questionnaire developed by an international group of addiction researchers and clinicians.26 The ASSIST questionnaire determines a risk score for each substance by assigning greater involvement, i.e. drinking daily versus monthly, with a higher risk score (see supplemental information for ASSIST questionnaire and scoring). Based on the risk score for each substance, participants are placed in either ‘low,’ ‘moderate’ or ‘high risk’ categories and assigned the appropriate intervention for that level of use (i.e., ‘no treatment,’ ‘brief intervention’ or ‘referral to a specialist,’ respectively).

The ASSIST questionnaire is paired to a “Brief Intervention” (also from WHO), which contains detailed instructions on how health care workers can conduct an intervention for patients at‘moderate’ to ‘high risk’ for substance use. 27 The brief intervention consists of: a feedback report card that lists health risks associated with chronic use for each substance; a self-help handout that provides participants with strategies to reduce use; and a motivational interviewing dialogue that enables patient and health care worker to discuss triggers and build a support system for the patient. The World Health Organization translated the ASSIST manual and brief intervention to Spanish and have implemented both in cultural settings similar to those in the DR. The manual and intervention have proven to be efficacious in randomized controlled trials to significantly reduce ASSIST scores in patients receiving the intervention compared to control patients who did not. Moreover, 80% of participants reported a desire to cut down on their substance use after receiving the brief intervention.28

The eight-item questionnaire was combined with a standard demographic information questionnaire and a sexual history questionnaire adapted from another study at the clinic. This three-part questionnaire was performed on a convenience sample of 100 patients in the HIV program at CFLR. The HIV program includes all patients with HIV, except for sex workers who are part of the Women’s program at the clinic. Only adults (18+) who could communicate in Spanish were entered into the study. Adult patients who were waiting for their doctors’appointments at CFLR were randomly sampled by asking every third participant whether they would like to participate in a brief questionnaire.

Patients who accepted were taken into a private consultation office where they were told that the study consisted of questions on: their demographic information; consumption of alcohol, tobacco, illicit drugs, and prescription medications that may have been taken more frequently or in higher doses than prescribed; and their sexual history in terms of condom use. Participants were told that their responses would remain strictly confidential and would not affect their treatment at the clinic. Additionally, they were informed that they could refuse to respond to any question and/or terminate their participation in the study at any point. Finally, participants were asked to give verbal consent if they agreed to enter the study.

A health care worker completed all questionnaires through a guided interview in Spanish to ensure that participants clearly understood the questions and could respond to the best of their ability. From the ASSIST questionnaire, the health care worker calculated the participant’s risk score for each substance and offered a brief intervention for patients at ‘moderate’ to ‘high risk’ for substance use. If the participant accepted, s/he was given the feedback report card with her/his risk score and a list of health concerns associated with chronic use for each substance. For example, some of the health risks related to chronic alcohol consumption are memory loss, liver and pancreatic disease, and compromised immune response. The risk score was used to start a discussion with participant about her/his drug use.

The motivational interviewing phase of the intervention began by asking participants if s/he had experienced any of the health concerns listed in the feedback report card. The participant was then asked to reflect on the positive and negative effects of her/his substance use, if the negative effects outweighed the positive, and if that was enough to motivate them to quit. Then, the participant and health care worker constructed a support network that included family, friends and the clinic’s psychologist. Those who wanted to reduce and eliminate their substance use were referred to the clinic’s psychologist for continued motivational therapy. Participants who were hesitant to quit were reminded of the health risks associated and informed that the psychologist will always be a resource for when they change their mind. For participants at high risk, the health care worker concluded the motivational interviewing phase by introducing participants to the clinic’s psychologist to encourage follow-up treatment.

Results

Of the 100 patients interviewed, 97 completed the full questionnaire. Table 1 displays the results of the demographic information collected. In general, the study consisted of an approximately equal ratio of men to women (48% to 52%, respectively), and a mean age of 43 years. The sample consisted primarily of Dominican patients (85%) with 15% identifying as Haitian. Participants reported completion of either primary (39%) or secondary (39%) schooling, and a substantial number were unemployed (48%). They identified predominantly as heterosexual (88%) and single (41%), but did not reside alone (80%). The majority of patients (81%) identified as religious, with 79% reporting Christianity as their religion.

The second part of the questionnaire quantified the amount of substance use in the sample. 99% of the study participants had used alcohol or tobacco at least once in the last 12 months. Figure 1 displays the amount of substance use for each drug used in the past 12 months. Predominately, patients had used alcohol (98%). The second most common drug used was tobacco (52%). The other substances were used at lower rates, and only in conjunction with alcohol or tobacco.

When asked about substance use in the last three months, 48 (49%) of the study participants reported using substances from once or twice to daily. Figure 2 displays the amount of substance use in the last three months. Again, alcohol was the most commonly used drug: 42 participants (43%) reported consuming alcohol in the last three months, while only 19 (20%) reported using tobacco; 4 participants (4%) reported using the remaining substances and consumed them rarely.

Figure 3 further examines the two most used substances, depicting the frequency of use in the last three months. Tobacco was used more frequently, with 12 out of 19 participants (63%) reporting use on a daily basis, while alcohol was used less frequently, with 30 out of 42 participants (71%) reporting use once or twice to monthly.

Of the 97 participants that completed the questionnaires, 19 (20%) qualified for an intervention. All but one patient agreed to the intervention. Still, of the 19 that required an intervention, 12 (63%) required it for one substance, 5 (26%) required it for two substances, and 2 (11%) required it for three substances. Despite having a greater number of alcohol users, only 6 out of the 42 participants (14%) that reported consuming alcohol in the last 3 months required an intervention for alcohol, whereas 18 out of 19 participants (95%) that reported tobacco use required an intervention for tobacco. Almost all of the participants, 5 out of 6 (83%), that required an intervention for alcohol were also smokers. All participants that required an intervention for a drug other than alcohol or tobacco also required an intervention for alcohol and/or tobacco.

The third part of the questionnaire asked about sexual behavior and condom use. Of the 97 participants, 49 (51%) reported being sexually active (as defined by having sex in the last 30 days). Of those 49 participants, 33 (67%) reported using a condom during their last sexual experience, whereas 15 (31%) reported not using a condom. The remaining participant (the last 2%) refused to respond.

Alcohol use prior to or during sexual experience was quantified. For the 49 participants that were currently sexually active, 12 participants (24%) reported not consuming alcohol prior to or during their last sexual encounter, while the other 12 (24%) reported that they had; the remaining 25 participants (51%) had not consumed alcohol in the last 3 months. Of the 12 patients that had consumed alcohol in conjunction with sexual intercourse, 7 (58%) reported using a condom, whereas 4 (33%) had not used a condom; the final participant refused to respond. As shown in Figure 4, the relative risk29 of unprotected sex was 1.45 times greater (95% CI 0.41, 5.05) for those who consumed alcohol compared to those who did not.

Discussion

The present cross-sectional investigation consisted of a three-part questionnaire that was implemented as an interview to effectively quantify alcohol and illicit substance use among patients in the HIV program at Clínica de Familia La Romana (CFLR). Results can be used to estimate the number of patients at CFLR who consume drugs and the frequency of their use. Findings suggest that alcohol and other substances are consumed at lower rates at CFLR compared to PLWHA populations in the Caribbean, 30 the United States,31 and other regions of the DR.32 33

There are several limitations in the design of the study that should be addressed. First is a reporting bias that is associated with questionnaire-type settings. Patients at the clinic are explained the ways in which alcohol and other substances interact with their immune system and treatment, and are aware that they should not consume drugs while on anti-retroviral therapy. Therefore, when a health care worker asks about substance use, participants are likely to underreport use. This gives rise to a lower amount of reported substance use than what is true in the population. Another potential outcome of a more knowledgeable population is a “healthier” population, in which patients consume less drugs because they know that it negatively impacts their health. This might explain why there was a lower amount of reported alcohol and substance use at CFLR.

A second variable that may have influenced the amount of drug use is demographic factors. There was no association found at the 5% level of significance between substance use and several demographic factors, namely, age, sex, education and religion. However, during the questionnaire, several participants attributed their low substance use to their religious beliefs. About half (49%) of the participants reported having reduced their drug use after HIV diagnosis. Although not experimentally collected, the predominant explanation for this reduction was that patients joined a Christian church after diagnosis. 79% of participants identified with Christianity. Given that participants explained that their religious beliefs led them to lower or eliminate their use of alcohol and other substances, religion could provide a protective factor for patients at the clinic. This observation requires further and repeated investigation still it provides an understanding of what other factors may contribute to medical treatment adherence.

Results from the second part of the study found that half (51%) of the population remained sexually active after diagnosis; a decreased rate compared to previous literature reviews, such as Crepaz and Marks (2002), who found that 70% remain sexually active. Despite a lower rate of sexual activity, a third of the sample (31%) was engaging in unprotected sex, which is consistent with other research findings.34 Again, these results could have been due to a reporting bias, which would result in under-reporting sexual activity and over-reporting condom use.

The selection of the sample is another limiting factor that could have contributed to the study’s results. Participants were selected on a convenience basis: patients who were waiting for their doctor’s appointment were asked if they would like to participate in the study. Only those that agreed to be interviewed entered into the study, giving rise to a self-selection bias; where patients who were more open to talk about their substance use and sexual history, enrolled in the study, while those who were not, were excluded from the sample. In general, the form of enrollment resulted in a relatively small sample size of 97 participants. A small sample size can give rise to doubt that the sample is reflective of the entire population. Therefore, the small sample is a significant weakness in the study that limits the strength of the data collected.

Contrary to prior research, there was no association between alcohol consumption and unprotected sex. The relative risk ratio found that unprotected sex was 1.45 times more likely when having consumed alcohol prior to or during sex, however, the confidence interval was broad (0.41 to 5.05), indicating that the finding was not significant, possibly due to the small sample size. Still, even with a larger sample unprotected sex and alcohol consumption may not be related in our population due to the small amount of patients who report drinking alcohol on a frequent basis.

Despite these limitations, the purpose of the study was a primary investigation into the substance use at CFLR, and therefore, the findings are important to gain a general idea of substance use among patients. Additionally, the findings can used to direct further investigations that might provide more concrete findings on substance use in CFLR.

Conclusion

The results from the study found that two major concerns persist within the targeted population: alcohol and other substance use, and low condom use. Despite the relatively low frequency of alcohol and other substance use at CFLR, about half of the surveyed sample reported to consuming alcohol in the last 3 months, which can further compromise their immune system and potentially contribute to non-adherence. The importance of treatment adherence is clear in medical literature, yet it remains unknown whether alcohol and drugs directly impact patient adherence at CFLR. A follow-up study could investigate whether patients who received the intervention obtain a lower risk score on the ASSIST questionnaire compared to before the intervention, and cross-analyze that data with biomarkers for adherence, such as, viral load.

As stated earlier, the small sample size limits the strength of the data collected and whether it reflects the HIV population at CFLR on the whole. Despite this drawback there were interesting findings that deserve further investigation, namely, the low frequency of alcohol consumption and lack of association between alcohol consumption and unprotected sex. Therefore, a repeated investigation that recruits a larger sample might lend more support to this finding and provide a concrete conclusion about whether alcohol consumption presupposes unprotected sex for the HIV population at CFLR.

Finally, it is concerning that a third of the population is engaging in unprotected sex despite their knowledge of HIV transmission. This study did not set out to investigate the several factors that contribute to low condom use, so it would be of use to survey the population at CFLR and find out the reasons for which patients are not using condoms.

In conclusion, the present investigation provided a preliminary investigation into substance use at Clínica de Famlia La Romana. A substance abuse program was designed to ensure that doctors are aware of substance use among their patients, which will enable doctors and patients to better understand another aspect that contributes to their health; and the brief intervention was incorporated into the clinic’s setting so as to provide at-risk patients with the necessary resources to reduce and eliminate their substance use.

Supplemental Information

ASSIST questionnaire from the World Health Organization that quantifies substance use and categorizes patients as ‘low,’ ‘moderate’ or ‘high risk’ depending on the patient’s score as evaluated below.

References

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  25. Guillamo-Ramos, V., et al. (2015). Illicit drug use and HIV risk in the Dominican Republic: Tourism areas create drug use opportunities. Global Public Health: An International Journal for Research, Policy and Practice, 10(3), 318-330. doi:10.1080/17441692.2014.966250.
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  29. The relative risk ratio can be used to assess the likelihood that an association represents a casual relationship. Bonita, R., Beaglehole, R., and Kjellström, T. (2006). Basic Epidemiology. Geneva. World Health Organization.
  30. Angulo-Arreola A., Bastos F.I., Strathdee S.A. (2011) Substance Abuse and HIV/AIDS in the Caribbean: Current Challenges and the Ongoing Response. Journal of the International Association of Physicians in AIDS Care (JIAPAC), 00(0), 1-19. doi:10.1177/1545109711417408.
  31. Galvan, F.H., et al. (2002). The Prevalence of Alcohol Consumption and Heavy-Drinking among People with HIV in the United States: Results from the HIV Cost and Services Utilization Study. Journal of Studies On Alcohol and Drugs, 63(2), 182-184. doi: 10.15288/jsa.2002.63.179.
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  33. Guilamo-Ramos, V., et al. (2015). Illicit drug use and HIV risk in the Dominican Republic: Tourism areas create drug use opportunities. Global Public Health: An International Journal for Research, Policy and Practice, 10(3), 318-330. doi:10.1080/17441692.2014.966250.
  34. Kalichman S.C. (2000) HIV transmission risk behaviors of men and women living with HIV-AIDS: prevalence, predictors, and emerging clinical interventions. Clinical Psychology Science and Practice, 7, 32–47.

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ASSIST

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