AIDS and Behavior

, Volume 21, Issue 7, pp 1825–1835 | Cite as

Direct and Indirect Effects of Heavy Alcohol Use on Clinical Outcomes in a Longitudinal Study of HIV Patients on ART

  • Christopher W. KahlerEmail author
  • Tao Liu
  • Patricia A. Cioe
  • Vaughn Bryant
  • Megan M. Pinkston
  • Erna M. Kojic
  • Nur Onen
  • Jason V. Baker
  • John Hammer
  • John T. Brooks
  • Pragna Patel
Original Paper


In a cohort of patients receiving care for HIV, we examined longitudinally the impact of past 30-day frequency of heavy drinking (consuming 5+ drinks on one occasion) on HIV-related (detectable viral load and CD4+ T cell count) and non-HIV-related (hemoglobin and biomarkers of kidney function and liver fibrosis) clinical outcomes and the extent to which these effects were due to reduced antiretroviral therapy (ART) adherence. Data came from the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy. Between March 2004 and June 2006, 533 individuals receiving ART were recruited and followed every 6 months for six years. Using longitudinal mediation analysis, we estimated natural direct effects (NDE) of heavy drinking frequency (never, 1–3 times, or 4+ times in the past 30 days) on clinical outcomes and natural indirect effects (NIE) mediated via ART adherence. A one-level increase in heavy drinking frequency had a significant negative NDE on CD4+ T-cell counts (-10.61 cells/mm3; 95 % CI [-17.10, -4.12]) and a significant NIE through reduced ART adherence of -0.72 cells/mm3 (95 % CI [-1.28, -0.15]), as well as a significant NIE on risk of detectable viral load (risk ratio = 1.03; 95 % CI [1.00, 1.05]). Heavy drinking had a significant detrimental NIE on a combined index of 5-year mortality risk and detrimental NDE and total effect on a biomarker of liver fibrosis. Heavy drinking has deleterious effects on multiple clinical outcomes in people living with HIV, some of which are mediated through reduced ART adherence.


Alcohol HIV Adherence Viral load Liver function VACS Index 



This work was supported by the Centers for Disease Control and Prevention contract numbers 200-2002-00,610, 200-2002-00611, 200-2002-00612, 200-2002-00613, 200-2007-23633, 200-2007-23634, 200-2007-23635, and 200-2007-23636. Additional support was provided by grant number P01 AA019072 from the National Institute on Alcohol Abuse and Alcoholism, grant number T32 DA016184 from the National Institute on Drug Abuse, and the Lifespan/Tufts/Brown Center for AIDS Research (CFAR) grant number P30 AI042853.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.


The findings and conclusions from this review are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Christopher W. Kahler
    • 1
    Email author
  • Tao Liu
    • 2
  • Patricia A. Cioe
    • 1
  • Vaughn Bryant
    • 3
  • Megan M. Pinkston
    • 4
  • Erna M. Kojic
    • 5
  • Nur Onen
    • 6
  • Jason V. Baker
    • 7
  • John Hammer
    • 8
  • John T. Brooks
    • 9
  • Pragna Patel
    • 10
  1. 1.Center for Alcohol and Addiction StudiesBrown University School of Public HealthProvidenceUSA
  2. 2.Center for Statistical SciencesBrown University School of Public HealthProvidenceUSA
  3. 3.Department of Clinical and Health PsychologyUniversity of FloridaGainesvilleUSA
  4. 4.Department of Psychiatry and Human BehaviorAlpert Medical School of Brown UniversityProvidenceUSA
  5. 5.Department of Infectious DiseaseBrown UniversityProvidenceUSA
  6. 6.Washington University School of MedicineSt. LouisUSA
  7. 7.Division of Infectious Diseases, Hennepin County Medical CenterUniversity of MinnesotaMinneapolisUSA
  8. 8.Denver Infectious Disease ConsultantsDenverUSA
  9. 9.Division of HIV/AIDS PreventionCenters for Disease Control and PreventionAtlantaUSA
  10. 10.Division of Global Health ProtectionCenters for Disease Control and PreventionAtlantaUSA

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