Department of Psychiatry, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
Syst Rev. 2019 Oct 28;8(1):244. doi: 10.1186/s13643-019-1176-4.
Alcohol use disorders (AUDs) in people living with HIV/AIDS (PLWH) are a significant impediment to achieving virological control. HIV non-suppression in PLWH with AUDs is mainly attributable to sub-optimal antiretroviral therapy adherence. Sub-optimal adherence makes control of the epidemic elusive, considering that effective antiretroviral treatment and viral suppression are the two key pillars in reducing new infections. Psychological interventions have been proposed as effective treatments for the management of AUDs in PLWH. Evidence for their effectiveness has been inconsistent, with two reviews (2010 and 2013) concluding a lack of effectiveness. However, a 2017 review that examined multiple HIV prevention and treatment outcomes suggested that behavioural interventions were effective in reducing alcohol use. Since then, several studies have been published necessitating a re-examination of this evidence. This review provides an updated synthesis of the effectiveness of psychological interventions for AUDs in PLWH.
A search was conducted in the following databases: PubMed, Cochrane Central Register of Trials (CENTRAL), MEDLINE (Ovid), EMBASE, PsychInfo (Ovid) and Clinical trials.gov (clinicaltrials.gov) for eligible studies until August 2018 for psychotherapy and psychosocial interventions for PLWH with AUDs. Two reviewers independently screened titles, abstracts and full texts to select studies that met the inclusion criteria. Two reviewers independently performed data extraction with any differences resolved through discussion. Risk of bias was assessed by two independent reviewers using the Cochrane risk of bias tool, and the concordance between the first and second reviewers was 0.63 and between the first and third reviewers 0.71. Inclusion criteria were randomised controlled trials using psychological interventions in people aged 16 and above, with comparisons being usual care, enhanced usual care, other active treatments or waitlist controls.
A total of 21 studies (6954 participants) were included in this review. Studies had diverse populations including men alone, men and women and men who had sex with men (MSM). Use of motivational interviewing alone or blended with cognitive behavioural therapy (CBT) and technology/computer-assisted platforms were common as individual-level interventions, while a few studies investigated group motivational interviewing or CBT. Alcohol use outcomes were all self-report and included assessment of the quantity and the frequency of alcohol use. Measured secondary outcomes included viral load, CD4 count or other self-reported outcomes. There was a lack of evidence for significant intervention effects in the included studies. Isolated effects of motivational interviewing, cognitive behavioural therapy and group therapy were noted. However for some of the studies that found significant effects, the effect sizes were small and not sustained over time. Owing to the variation in outcome measures employed across studies, no meta-analysis could be carried out.
This systematic review did not reveal large or sustained intervention effects of psychological interventions for either primary alcohol use or secondary HIV-related outcomes. Due to the methodological heterogeneity, we were unable to undertake a meta-analysis. Effectiveness trials of psychological interventions for AUDs in PLWH that include disaggregation of data by level of alcohol consumption, gender and age are needed. There is a need to standardise alcohol use outcome measures across studies and include objective biomarkers that provide a more accurate measure of alcohol consumption and are relatively free from social desirability bias.
PROSPERO CRD 42017063856 .
在感染人类免疫缺陷病毒/艾滋病（PLWH）的人群中，酒精使用障碍（AUD）是实现病毒学控制的重大障碍。AUD 患者的 HIV 未能得到抑制，主要是由于抗逆转录病毒治疗的依从性不理想。不理想的依从性使得控制疫情变得困难，因为有效的抗逆转录病毒治疗和病毒抑制是减少新感染的两个关键支柱。心理干预已被提议作为管理 PLWH AUD 的有效治疗方法。然而，两项（2010 年和 2013 年）审查得出的结论是缺乏有效性，其有效性的证据不一致。但是，2017 年的一项审查研究了多种 HIV 预防和治疗结果，表明行为干预可有效减少饮酒。此后，发表了多项研究，需要重新审查这一证据。本综述提供了关于心理干预治疗 PLWH AUD 的有效性的最新综合信息。
在以下数据库中进行了搜索：PubMed、Cochrane 对照试验注册中心（CENTRAL）、MEDLINE（Ovid）、EMBASE、PsychInfo（Ovid）和临床试验.gov（clinicaltrials.gov），以查找符合条件的研究，直到 2018 年 8 月，研究对象为患有 AUD 的 PLWH 的心理治疗和心理社会干预。两名审查员独立筛选标题、摘要和全文，以选择符合纳入标准的研究。两名审查员独立进行数据提取，如果存在分歧，则通过讨论解决。两名独立的审查员使用 Cochrane 偏倚风险工具评估偏倚风险，第一和第二名审查员之间的一致性为 0.63，第一和第三名审查员之间的一致性为 0.71。纳入标准是使用心理干预的随机对照试验，纳入年龄在 16 岁及以上的人群，比较对象为常规护理、增强常规护理、其他积极治疗或候补对照。
本综述共纳入 21 项研究（6954 名参与者）。研究人群多样化，包括仅男性、男性和女性以及男男性接触者（MSM）。单独使用动机访谈或与认知行为疗法（CBT）和技术/计算机辅助平台混合使用是常见的个体干预措施，而少数研究则调查了小组动机访谈或 CBT。酒精使用结果均为自我报告，包括评估酒精使用的数量和频率。衡量次要结果包括病毒载量、CD4 计数或其他自我报告的结果。纳入的研究中没有证据表明干预有显著效果。注意到动机访谈、认知行为疗法和小组治疗的单独效果。但是，对于一些发现显著效果的研究，其效果大小较小，且无法持续。由于研究采用的结果测量方法存在差异，因此无法进行荟萃分析。
本系统评价未显示出心理干预对酒精使用或 HIV 相关次要结果的大或持续的干预效果。由于方法学的异质性，我们无法进行荟萃分析。需要进行包括按酒精摄入量、性别和年龄细分数据的 PLWH AUD 心理干预有效性试验。需要在研究中标准化酒精使用结果测量，并包括提供更准确的酒精摄入量测量且相对不受社会期望偏差影响的客观生物标志物。
PROSPERO CRD42017063856。
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