1. 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

2. 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.

3. 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

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

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

6. 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)

7. *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Shaffer et al., 2004; Wools et al., 2006, Diero et al., 2006; Justice et al., 2006; Sidle et al, unpublished manuscript

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

9. 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

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

11. 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

12. 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)

14. 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)

15. 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