Jinsi ya kuishi maisha marefu (Learning to live longer): A stage 1 behavioral trial to reduce alcohol use among HIV-infected Kenyans Rebecca Papas, PhD

Kenya-U.S. HIV & alcohol research and prevention partnership (K-HARPP) members Amy Justice, M.D., Ph.D. Rebecca Papas, Ph.D. David Ayuku, Ph.D. Joyce Ballidawa, M.S. Kathleen Carroll, Ph.D. Stephen Maisto, Ph.D. John Sidle, M.D. Claris Ojwang Otieno Omolo, M.D. Willis Owino-Ong’or, M.D.

Alcohol in Kenya Substance of abuse in sub-Saharan Africa Poverty Sociocultural life Hazardous drinking in Eldoret 68% general medicine patients 53% HIV patients Unprotected Sex 6% HIV prevalence in Kenya – women 8%, men 4% (2005) (~22% among some tribes) ~10% condom use among AMPATH patients Adverse outcomes for HIV infected Medical diseases and AIDS-defining illnesses ARV nonadherence Shaffer et al., 2004; UN AIDS, 2005; Justice et al., 2006

Men at the bar, Kenyan style (at the community brewery)

Serving sizes of changaa (spirits) or busaa (mash) are based on purchase price

AMPATH strengths and commonalities Patients in HIV care (n = 38,000), 50% on ARVs Full reference laboratory Electronic medical records Multipronged, multidisciplinary approach Nutritional program Microbusiness training (local crafts)

*Employed data from town clinic, when possible Shaffer et al., 2004; Wools et al., 2006, Diero et al., 2006; Justice et al., 2006; Sidle et al, unpublished manuscript

Expanded “laboratory” Different medical presentations HIVAN Influences on frailty Nutrition/wasting Brew contaminants Alcohol behavior mediators Stigma Social motivations for change

CBT: Stage 1 feasibility trial A U.S. standard of care for alcohol abuse Focused, skills-based approach Avoiding or Coping with cues/triggers Thoughts/feelings/behaviors leading to abuse directly targets alcohol use, not sexual risks Teaches skills, self-efficacy Local conceptual compatibility Peer-led group format Dearth of mental health providers

Usual care HIV support group Discuss stigma experiences Health/nutritional advice Learn self-acceptance

Two study phases Training phase Train Kenyan psychologists to inter-rater reliability to supervise intervention All supervisors train peer facilitators to criterion Training pilot groups (6 weeks) Using Yale Adherence and Competence Scale

Intervention phase 56 HIV-infected, ARV-eligible, hazardous or binge drinkers 6 weekly sessions In Kiswahili! 2 facilitators per group, videotaped closed group format (stigma) 8 same-sex groups of 7 (50% women, 50% CBT)

Outcomes Primary: TLFB at 30-days post-intervention Secondary: saliva tests for alcohol, HIV risk behaviors, depressive symptoms, CD4 counts, AST biomarkers, WHO AIDS staging, and weight Via patient interview (ACASI not feasible)

Evaluation criteria for Stage 2 trial Minimum of 80% of participant retention in CBT through 6 weeks Minimum effect size of 35% PDA for CBT relative to usual care at 30-days post-treatment