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Screening for alcohol use disorders in HIV patients using the modified Alcohol Use Disorders Identification Test Chris Ward and Sameena Ahmad Int J STD AIDS 2014 25: 538 DOI: 10.1177/0956462414521166 The online version of this article can be found at: http://std.sagepub.com/content/25/7/538
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Letter to the Editor International Journal of STD & AIDS 2014, Vol. 25(7) 538–539 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414521166 std.sagepub.com
Screening for alcohol use disorders in HIV patients using the modified Alcohol Use Disorders Identification Test
Sirs, I read with interest the article by Surah et al. about the use of Alcohol Use Disorders Identification Test (AUDIT) to determine the prevalence of alcohol misuse among HIV-infected individuals in Dublin. We have been using the modified AUDIT-C questionnaire over the last 18 months to assess alcohol misuse among our HIV cohort in South Manchester. The AUDIT-C questionnaire is a three-item alcohol screening tool that has been modified from the 10-question AUDIT instrument. The screening questions and scores can be seen in Table 1. For patients with a score >4, AUDIT-C has a sensitivity of 86% at identifying patients with heavy drinking and/or active alcohol abuse or dependency, with a specificity of 72%.1 We assessed our HIV cohort for alcohol use disorder using the AUDIT-C questionnaire and present a retrospective audit of our data from the first six months. The clinician reviewing the patient completed the questionnaire. Patients with a score >4 were identified as higher risk for alcohol use disorder, and provided with verbal advice about alcohol, delivered by a trained healthcare clinician. Patients perceived to be at higher risk by the clinicians, with AUDIT-C scores >6 were offered written information on risk reduction in the form of a drink smart guide (DSG). Demographic data were collected along with hepatitis B and C status, information on sexually transmitted infection (STI) testing and diagnosis. A total of 352 patients were seen in clinic over a sixmonth period with a mean age of 41; 297 (84.4%) patients were men, 235 (66.8%) were Caucasian and 251 (71.3%) were men who have sex with men. Two hundred seventy-seven (78.7%) patients were on antiretroviral therapy with 254 (91.7%) of these having an undetectable viral load. Alcohol use disorders were assessed using the AUDIT-C score in 332 (94.3%) patients. Twenty (5.7%) patients were not assessed
due to time restraints in clinic. One hundred sixty-six (50%) patients had an AUDIT-C score >4 signifying higher risk for alcohol use disorder, and alcohol advice was provided to 161 (97%) of these patients. A DSG offering advice on alcohol self-help was offered to 103 (64%) patients and accepted by 45 (43.7%). One hundred two (30.7%) patients had an AUDIT-C score >6. Of these, 100 (98%) patients were provided with alcohol advice, and 73 (71.5%) were given DSGs. Several patients with very high scores saw the health advisor for motivational interviewing, or self-referred to the Alcohol Community Team. An opportunistic STI screen was offered to 258 (73.3%) patients on that visit in line with best practice guidelines2 and was accepted by 83 (32.2%). Twenty-five infections were found in 20 patients, of which 13 (65%) had AUDITC scores >4, although the numbers are too small to show a link. Our results show that screening for alcohol use disorders using the AUDIT-C questionnaire has high acceptability among HIV patients. All patients who were offered the questionnaire agreed to complete it and in the 20 patients (5.7%) who were not assessed this was due to clinician factors. The use of the threequestion AUDIT-C tool was well received and took very little time to complete, contributing to the high uptake of the screening tool. What was striking was that half the study population were found to have AUDIT-C scores >4 indicating higher risk drinking and increased risk of alcohol use disorder. The British HIV Association (BHIVA) recommends that HIV patients are asked about alcohol due to its effect on adherence to antiretroviral therapy.3 Furthermore, the National Institute of Clinical Excellence recommends screening for alcohol use disorders in patients attending genitourinary medicine clinics.4 The 10-question AUDIT tool has good tolerability in HIV outpatient settings,5 and we have shown that the abbreviated AUDIT-C tool has good acceptability and uptake. This screening tool may be useful in time limited settings and can be used to identify patients at need of more detailed assessment for alcohol use disorders. With half our study population found to have higher risk drinking, it is of paramount
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Ward and Ahmad
539
Table 1. AUDIT-C questionnaire. Questions
0 point
1 points
2 points
3 points
4 points
How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 units if female, or 8 units if male, on a single occasion in the last year?
Never
Less than monthly 3–4
2–4 times per month 5–6
2–3 times per week 7–9
4þ times per week 10þ
Less than monthly
Monthly
Weekly
Daily or almost daily
1–2 Never
A total >4 indicates increased or higher risk drinking.
importance to assess alcohol screening and the need for intervention in routine HIV care. Conflict of interest The authors declare no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Treatment/2012/hiv1029_2.pdf (2012, accessed 1 October 2013). 4. National Institute for Health and Clinical Excellence. Alcohol use disorders – preventing harmful drinking, http://publications.nice.org.uk/alcohol-use-disorderspreventing-harmful-drinking-ph24 (2010, accessed 1 October 2013). 5. Surah S, Kieran J, O’Dea S, et al. Use of the alcohol use disorders identification test (AUDIT) to determine the prevalence of alcohol misuse among HIV infected individuals. Int J STD AIDS 2013; 24: 517–521.
References 1. Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998; 158: 1789–1795. 2. Fakoya A, Lamba H, Mackie N, et al. British HIV Association, BASHH and FSRH guidelines for the management of the sexual and reproductive health of people living with HIV infection 2008, http://www.bhiva.org/ documents/Guidelines/Sexual%20health/Sexual-reproductive-health.pdf (2008, accessed 27 November 2013). 3. BHIVA writing group. BHIVA guidelines for the treatment of HIV-1 positive adults with antiretroviral therapy 2012, http://www.bhiva.org/documents/Guidelines/
Chris Ward Manchester Centre for Sexual Health, Central Manchester Foundation Trust, Manchester, UK Sameena Ahmad Department of Genito-Urinary Medicine, Withington Hospital, University Hospital of South Manchester, Manchester, UK Corresponding author: Chris Ward, Manchester Centre for Sexual Health, Central Manchester Foundation Trust, Manchester, M13 9WL, UK. Email: [email protected]
Downloaded from std.sagepub.com at OREGON STATE UNIV LIBRARY on May 25, 2014
Screening for alcohol use disorders in HIV patients using the modified Alcohol Use Disorders Identification Test Chris Ward and Sameena Ahmad Int J STD AIDS 2014 25: 538 DOI: 10.1177/0956462414521166 The online version of this article can be found at: http://std.sagepub.com/content/25/7/538
Published by: http://www.sagepublications.com
Additional services and information for International Journal of STD & AIDS can be found at: Email Alerts: http://std.sagepub.com/cgi/alerts Subscriptions: http://std.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - May 14, 2014 What is This?
Downloaded from std.sagepub.com at OREGON STATE UNIV LIBRARY on May 25, 2014
Letter to the Editor International Journal of STD & AIDS 2014, Vol. 25(7) 538–539 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414521166 std.sagepub.com
Screening for alcohol use disorders in HIV patients using the modified Alcohol Use Disorders Identification Test
Sirs, I read with interest the article by Surah et al. about the use of Alcohol Use Disorders Identification Test (AUDIT) to determine the prevalence of alcohol misuse among HIV-infected individuals in Dublin. We have been using the modified AUDIT-C questionnaire over the last 18 months to assess alcohol misuse among our HIV cohort in South Manchester. The AUDIT-C questionnaire is a three-item alcohol screening tool that has been modified from the 10-question AUDIT instrument. The screening questions and scores can be seen in Table 1. For patients with a score >4, AUDIT-C has a sensitivity of 86% at identifying patients with heavy drinking and/or active alcohol abuse or dependency, with a specificity of 72%.1 We assessed our HIV cohort for alcohol use disorder using the AUDIT-C questionnaire and present a retrospective audit of our data from the first six months. The clinician reviewing the patient completed the questionnaire. Patients with a score >4 were identified as higher risk for alcohol use disorder, and provided with verbal advice about alcohol, delivered by a trained healthcare clinician. Patients perceived to be at higher risk by the clinicians, with AUDIT-C scores >6 were offered written information on risk reduction in the form of a drink smart guide (DSG). Demographic data were collected along with hepatitis B and C status, information on sexually transmitted infection (STI) testing and diagnosis. A total of 352 patients were seen in clinic over a sixmonth period with a mean age of 41; 297 (84.4%) patients were men, 235 (66.8%) were Caucasian and 251 (71.3%) were men who have sex with men. Two hundred seventy-seven (78.7%) patients were on antiretroviral therapy with 254 (91.7%) of these having an undetectable viral load. Alcohol use disorders were assessed using the AUDIT-C score in 332 (94.3%) patients. Twenty (5.7%) patients were not assessed
due to time restraints in clinic. One hundred sixty-six (50%) patients had an AUDIT-C score >4 signifying higher risk for alcohol use disorder, and alcohol advice was provided to 161 (97%) of these patients. A DSG offering advice on alcohol self-help was offered to 103 (64%) patients and accepted by 45 (43.7%). One hundred two (30.7%) patients had an AUDIT-C score >6. Of these, 100 (98%) patients were provided with alcohol advice, and 73 (71.5%) were given DSGs. Several patients with very high scores saw the health advisor for motivational interviewing, or self-referred to the Alcohol Community Team. An opportunistic STI screen was offered to 258 (73.3%) patients on that visit in line with best practice guidelines2 and was accepted by 83 (32.2%). Twenty-five infections were found in 20 patients, of which 13 (65%) had AUDITC scores >4, although the numbers are too small to show a link. Our results show that screening for alcohol use disorders using the AUDIT-C questionnaire has high acceptability among HIV patients. All patients who were offered the questionnaire agreed to complete it and in the 20 patients (5.7%) who were not assessed this was due to clinician factors. The use of the threequestion AUDIT-C tool was well received and took very little time to complete, contributing to the high uptake of the screening tool. What was striking was that half the study population were found to have AUDIT-C scores >4 indicating higher risk drinking and increased risk of alcohol use disorder. The British HIV Association (BHIVA) recommends that HIV patients are asked about alcohol due to its effect on adherence to antiretroviral therapy.3 Furthermore, the National Institute of Clinical Excellence recommends screening for alcohol use disorders in patients attending genitourinary medicine clinics.4 The 10-question AUDIT tool has good tolerability in HIV outpatient settings,5 and we have shown that the abbreviated AUDIT-C tool has good acceptability and uptake. This screening tool may be useful in time limited settings and can be used to identify patients at need of more detailed assessment for alcohol use disorders. With half our study population found to have higher risk drinking, it is of paramount
Downloaded from std.sagepub.com at OREGON STATE UNIV LIBRARY on May 25, 2014
Ward and Ahmad
539
Table 1. AUDIT-C questionnaire. Questions
0 point
1 points
2 points
3 points
4 points
How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 units if female, or 8 units if male, on a single occasion in the last year?
Never
Less than monthly 3–4
2–4 times per month 5–6
2–3 times per week 7–9
4þ times per week 10þ
Less than monthly
Monthly
Weekly
Daily or almost daily
1–2 Never
A total >4 indicates increased or higher risk drinking.
importance to assess alcohol screening and the need for intervention in routine HIV care. Conflict of interest The authors declare no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Treatment/2012/hiv1029_2.pdf (2012, accessed 1 October 2013). 4. National Institute for Health and Clinical Excellence. Alcohol use disorders – preventing harmful drinking, http://publications.nice.org.uk/alcohol-use-disorderspreventing-harmful-drinking-ph24 (2010, accessed 1 October 2013). 5. Surah S, Kieran J, O’Dea S, et al. Use of the alcohol use disorders identification test (AUDIT) to determine the prevalence of alcohol misuse among HIV infected individuals. Int J STD AIDS 2013; 24: 517–521.
References 1. Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998; 158: 1789–1795. 2. Fakoya A, Lamba H, Mackie N, et al. British HIV Association, BASHH and FSRH guidelines for the management of the sexual and reproductive health of people living with HIV infection 2008, http://www.bhiva.org/ documents/Guidelines/Sexual%20health/Sexual-reproductive-health.pdf (2008, accessed 27 November 2013). 3. BHIVA writing group. BHIVA guidelines for the treatment of HIV-1 positive adults with antiretroviral therapy 2012, http://www.bhiva.org/documents/Guidelines/
Chris Ward Manchester Centre for Sexual Health, Central Manchester Foundation Trust, Manchester, UK Sameena Ahmad Department of Genito-Urinary Medicine, Withington Hospital, University Hospital of South Manchester, Manchester, UK Corresponding author: Chris Ward, Manchester Centre for Sexual Health, Central Manchester Foundation Trust, Manchester, M13 9WL, UK. Email: [email protected]
Downloaded from std.sagepub.com at OREGON STATE UNIV LIBRARY on May 25, 2014
