• New York State Department of Health. Clinical management of alcohol use and abuse in HIV-infected patients. New York (NY): New York State Department of Health; 2008 Apr. 15 p. [41 references]

This is the current release of the guideline.

• Human immunodeficiency virus (HIV) infection
• Alcohol misuse
• Alcohol withdrawal symptoms

Counseling
Diagnosis
Evaluation
Management
Screening
Treatment

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine

Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Substance Use Disorders Treatment Providers

To focus on the identification and outpatient management of alcohol use and abuse among human immunodeficiency virus (HIV)-infected patients who are engaged in HIV care

Human immunodeficiency virus (HIV)-infected outpatients who abuse alcohol

Diagnosis/Evaluation/Screening

1. Screening human immunodeficiency virus (HIV)-infected patients for alcohol misuse to assess quantity and frequency of alcohol use
2. Assessing for physical signs and laboratory markers indicative of possible alcohol abuse (e.g., hypertension, resting tachycardia, puffy faces, hepatomegaly, elevated mean cell volume, etc.)
3. Routinely asking about alcohol consumption when assessing adherence to highly active antiretroviral therapy (HAART)

Counseling/Management/Treatment

1. Discussing behavioral risk-reduction measures (e.g., use of barrier protection)
2. Educating patients co-infected with HIV and hepatitis C virus (HCV) regarding the effects of alcohol on the course of HCV infection, advising to abstain from alcohol during HCV antiviral therapy, cautioning patients regarding toxicities from the overlapping effects of alcohol use, HAART and HIV infection
3. Conducting brief interventions including the following topics: risks commonly associated with alcohol use, benefits of abstaining from or reducing alcohol use, referrals to other services
4. Treatment of alcohol withdrawal symptoms using nonpharmacologic therapy or benzodiazepines
5. Referring patients to treatment programs, inpatient treatment or addiction specialists if indicated
6. Adjunctive pharmacological treatment with naltrexone, disulfiram, or acamprosate
7. Follow-up to monitor alcohol use, review goals and progress, and manage relapses

• Risks of alcohol intake
• Effectiveness of treatment in reducing alcohol use

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with human immunodeficiency virus (HIV) infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

*Current committees include:

• Medical Care Criteria Committee
• Committee for the Care of Children and Adolescents with HIV Infection
• Dental Standards of Care Committee
• Mental Health Committee
• Women's Health Committee
• Substance Use Committee
• Physician's Prevention Advisory Committee
• Pharmacy Committee

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

Identifying Alcohol Use and Abuse in Human Immunodeficiency Virus (HIV)-Infected Patients

Screening for Alcohol Use

Clinicians should screen all HIV-infected patients for alcohol use at baseline and at least annually. Screening methods should assess quantity and frequency of alcohol use as well as per-occasion amounts to identify binge drinking. If the results are positive, a more detailed screening tool such as the full AUDIT or CAGE should be administered (see Appendix II in the original guideline document).

For at-risk or hazardous drinkers, clinicians should evaluate alcohol use more frequently in order to identify the escalation of present drinking levels or the occurrence of harmful consequences from drinking.

Screening tests should not be performed when patients are under the influence of alcohol.

Clinicians should stress the confidential nature of discussions regarding alcohol use to encourage patients to be open and honest.

Refer to Table 1 in the original guideline document for definitions of terms "at-risk drinking", "hazardous drinking", "alcohol abuse", "alcohol dependence", and "binge drinking" used to describe alcohol misuse.

Clinical Indicators of Alcohol Use

Clinicians should consider alcohol misuse in the differential diagnosis of certain medical disorders that may be alcohol-induced, such as elevated liver enzymes, hypertension, seizures, gastrointestinal bleeding, cognitive impairment, and depression. The presence of clinical indicators should prompt a screen for alcohol use.

Effects of Alcohol Use in HIV-Infected Patients

Alcohol and Adherence

Clinicians should routinely ask about alcohol consumption when assessing adherence to highly active antiretroviral therapy (HAART).

Alcohol and Safer Sex Practices

Clinicians should discuss behavioral risk-reduction measures on a routine and ongoing basis with patients who consume alcohol. These discussions should include use of barrier protection, how to speak with partners about safer sex, and the circumstances under which high-risk sexual behavior might occur.

Alcohol and Hepatitis C Virus (HCV)

Clinicians should educate HIV/HCV co-infected patients regarding the effects of alcohol on the course of HCV infection. Patients who have other underlying liver disease should be advised to abstain from alcohol.

Clinicians should advise patients to abstain from alcohol during HCV antiviral therapy. Patients with alcohol abuse or dependence should be encouraged to enroll in a rehabilitation program and establish abstinence prior to HCV antiviral treatment.

Provider Assistance, Counseling, and Brief Interventions

Clinicians should:

• Conduct brief interventions with patients who are at-risk drinkers
• Use brief interventions to help motivate patients who meet diagnostic criteria for an alcohol use disorder (abuse and/or dependence) but decline referral for care
• Use nonjudgmental language when counseling patients who use alcohol

When brief interventions are not successful in motivating change, the clinician should refer the patient for further assessment and treatment from an addiction specialist.

Referral for Treatment

Clinicians should refer patients:

• With active alcohol use/abuse problems to treatment programs
• With alcohol abuse or dependence who are not willing to cut down on their alcohol consumption for further assessment and treatment by professional alcohol treatment services
• Who require more intensive management for alcohol withdrawal to inpatient treatment or to addiction specialists

Table 3 in the original guideline document shows the various alcohol treatment referral options that are available for patients who abuse or are dependent on alcohol.

Treatment for Alcohol Withdrawal

Clinicians should use nonpharmacologic therapy or benzodiazepines to manage patients with mild or moderate alcohol withdrawal symptoms.

Clinicians should hospitalize patients with a history of severe alcohol withdrawal symptoms for medical management.

Pharmacologic Management of Alcohol Abuse

Clinicians should determine the benefit of pharmacotherapy with naltrexone, disulfiram, or acamprosate for the treatment of alcohol use disorders on a case-by-case basis. Pharmacotherapy should be used as an adjunct to behavioral therapy.

Clinicians should avoid naltrexone in patients with acute hepatitis or liver failure.

Refer to Table 4 in the original guideline document for information on adjunctive pharmacological agents such as disulfiram, naltrexone, and acamprosate for the treatment of alcohol misuse.

Follow-Up

At-Risk or Hazardous Drinkers

Clinicians should:

• Review goals, progress, and laboratory results (when applicable) with the patient during each follow-up appointment
• Assess the patient's motivation for change
• Reinforce safe drinking levels
• Actively support patient efforts to reduce alcohol use

Patients Receiving Treatment for Alcohol Use

Clinicians should:

• Arrange follow-up appointments to monitor the patient's alcohol consumption and progress
• Provide supportive feedback to patients who are engaged in a recovery program
• Ask patients about the date of last use of alcohol at every monitoring visit to identify relapses
• Inform patients that relapse is common and part of the therapeutic process
• Assess the patient's continued motivation for further change, when applicable

Relapse of Alcohol Use

Clinicians should:

• Anticipate relapses
• Adopt a nonjudgmental attitude toward the patient's resumption of alcohol use when/if it occurs
• Encourage participation in treatment

None provided

The type of evidence supporting the recommendations is not specifically stated.

Appropriate identification and management of alcohol use and abuse in human immunodeficiency virus (HIV)-infected patients

Adverse effects of naltrexone include nausea, headache, arthralgias, anxiety, and sedation

• Contraindications to disulfiram include concomitant use of alcohol or alcohol-containing preparations.
• Naltrexone is contraindicated in patients currently using opioids or in acute opioid withdrawal (patients who use opioids should be opioid-free for 3 to 4 days before initiating naltrexone) and patients with acute hepatitis or liver failure.
• Acamprosate is contraindicated in severe renal impairment (creatinine clearance [CrCl] <30mL/min).

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with human immunodeficiency virus (HIV) infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Educational Training Centers (AETC) and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the New York State Department of Health (NYSDOH) Distribution Center for providers who lack internet access.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AETC. The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• New York State Department of Health. Clinical management of alcohol use and abuse in HIV-infected patients. New York (NY): New York State Department of Health; 2008 Apr. 15 p. [41 references]

Not applicable: The guideline was not adapted from another source.

2008 Apr

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Substance Abuse Committee

Chair: Marc N Gourevitch, MD, MPH, New York, University School of Medicine, New York, New York

Committee Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Julia H Arnsten, MD, MPH, Montefiore Medical Center, Bronx, New York; Lawrence S Brown, Jr, MD, MPH, FASAM, Addiction Research and Treatment Corporation, Brooklyn, New York; Brenda Chabon, PhD, Montefiore Medical Center, Bronx, New York; Barbara H Chaffee, MD, MPH, Binghamton Family Care Center, Binghamton, New York; Michael L Christie, MD, AIDS Community Health Center, Rochester, New York; Chinazo O Cunningham, MD, Montefiore Medical Center, Bronx, New York; Nereida L Ferran-Hansard, MD, Jacobi Medical Center, Bronx, New York; Steven S Kipnis, MD, FACP, FASAM, New York State Office of Alcoholism and Substance Abuse Services, Orangeburg, New York; Joseph P Merlino, MD, MPA, Mount Sinai School of Medicine, New York, New York; Nancy Murphy, NP, St. Luke's Roosevelt Hospital Center, New York, New York; Edward Nunes, MD, New York State Psychiatric Institute, New York, New York; David C Perlman, MD, Beth Israel Medical Center, New York, New York; Sharon L Stancliff, MD, Harm Reduction Coalition, New York, New York; Robert Whitney, MD, Erie County Medical Center, Buffalo, New York

Liaisons: Daliah I Heller, MPH, Liaison to the New York City Department of Health and Mental Hygiene, New York, New York

AIDS Institute Staff Liaisons: Diane M Rudnick, MEd, Liaison to the New York State Department of Health AIDS Institute, New York, New York

AIDS Institute Staff Physician: Eunmee H Chun, MD, New York State Department of Health AIDS Institute, New York, New York

Principal Contributor: Joseph Conigliaro, MD, MPH, VA Pittsburgh Healthcare System, and the University of Pittsburgh School of Medicine, Pittsburgh

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on July 3, 2008.