Title: HIV and Alcohol: Ending the Epidemic (EHE)

Contact: Kendall Bryant Ph.D.

Background

The U.S. Department of Health and Human Services (HHS) launched the Ending the HIV Epidemic in the U.S. (EHE) initiative in 2019. The initiative aims to reduce new HIV infections in the U.S. by 90% by 2030 by scaling up key HIV prevention and treatment strategies. This ambitious goal to end the HIV epidemic in the United States by 2030 is through the application of nearly four decades of investments in scientific research that have yielded prevention and treatment breakthroughs that now make it possible to control HIV infection.  However, the role of alcohol use, and alcohol-related mental health and other substance use problems as well as environmental consequences of alcohol exposure (e.g., homelessness) exist at an individual, group, and societal level. These complex alcohol-related interconnected problems in living continue to impede this ambitious goal to End the Epidemic. Improved alcohol-focused assessment, a further understanding of impaired decision making, distribution of alcohol-related services and the implementation of effective HIV and alcohol-focused interventions at multiple levels can facilitate the achievement of EHE goals to substantially reduce new HIV infections.

The EHE initiative is also working to address racial, ethnic, and geographic disparities that have contributed to HIV prevention gaps. Many HIV and alcohol-related health disparities are part of the U.S. population and may impair the HIV Ending The Epidemic. Reducing alcohol use disorders and/or patterns of heavy drinking (AUD) is one of the most important of these interventions, influencing HIV transmission, HIV progression, HIV medication adherence, and non-HIV mortality. Conditions that often co-occur with AUD in particular, tobacco use, unhealthy substance use, and psychiatric disorders are alcohol-related HIV risk factors which form intra- and inter- personal clusters of risk. These clusters are increasingly understood to be mutually reinforcing and mutually interactive attributes of dysregulations in brain’s emotional circuitry that are exacerbated by social stressors, working in concert with environmental factors to increase HIV risk and difficulty of the application of simple interventions.

At the same time as commonalities in psychosocial-behavioral pathways are being appreciated, information on relevant social and contextual factors for these pathways is increasingly collected by health systems and through other data streams. The new widespread availability of this information may offer an opportunity to identify and address entrenched HIV-related disparities from a new vantage point that call for more comprehensive analytic approaches. In particular, individuals with a multitude of social stressors, common in disparity-impacted groups, are likely to have AUD and other alcohol-related manifestations. Anticipated coordinated efforts across government agencies promises to provide additional expertise, technology, and resources where they are needed most to integrate a comprehensive approach to HIV health.

In general, this initiative calls for the implementation of HIV and Alcohol -related intervention strategies to:

Provide an early diagnosis for all individuals with HIV and an identification of an amelioration of alcohol misuse and associated mental health and substance use disorders that impacts the prevention of HIV transmission in vulnerable populations.

Treat HIV infection rapidly and effectively to achieve sustained viral suppression in the context of alcohol’s impact on adherence to life-long medication regimens and reduce pathophysiological impact of continuing alcohol misuse.

Protect at-risk individuals who drink and are in “wet” environments (high density of alcohol outlets  that reinforce social norms that sustain unhealthy drinking) from acquiring HIV infection using proven HIV and Alcohol interventions, including pre-exposure prophylaxis (PrEP).

Rapidly detect and act on emerging HIV and alcohol clusters and prevent new infections within social networks of alcohol and alcohol-related disorders including depression, anxiety, pain, trauma, other substance use and medications that place individuals at greater risk for adverse outcomes.

Research objectives are focused in several primary areas of interest in which to address EHE goals including but not limited to:

Alcohol-Related Behavioral Research (ARBR) and its Integration into Primary and Secondary HIV Prevention Interventions

This  research initiative is designed to be responsive to the NIH FY2021-2025 Strategic Plan for HIV/AIDS. Research in the high priority areas of Reducing the Incidence and Cross-Cutting Research, that relates alcohol misuse, and patterns of  alcohol consumption to ending the HIV epidemic in the US and beyond. This cross-cutting initiative, focusing on dynamic behavioral research, was generated in response to the importance of ARBR whose ultimate goal is to facilitate HIV prevention efforts and therefore to increase awareness of its current scope and implications for HIV prevention and treatment. These targeted areas include:

• Increased understanding of community settings where HIV prevention and treatment occurs, sheds light on behavioral and cultural practices within key populations and networks that influence HIV transmission and prevention and facilitates awareness of how behaviors are shaped by environmental, social, and structural factors.
• Increased widespread adoption of new technologies such as smartphones, mobile apps, social media, and text messaging as components of Elemental BSSR offering new opportunities for monitoring HIV-related behaviors and for delivering tailored in-the-moment interventions.
• Expanded multidimensional HIV and Alcohol risk assessment and messaging interventions for rapid implementation by incorporation of comprehensive alcohol assessment and behavioral/polypharmacy risk messages into a series of  behavioral interventions for PLWH.
• Increased patient and practitioner readiness to report willingness to change unhealthy alcohol and polypharmacy use after receiving personalized risk messages that incorporate their direct alcohol measurement (Phosphatidyl ethanol or PEth) value, other alcohol monitoring technology, and genetic/familial liability.
• Assessment of additional environmental factors that increase risk for adverse outcomes and contribute to risk through social/behavioral and/or epigenetic phenomena (Envirome) to rapidly identify priority populations and geospatial locations where HIV is spreading and provide data-driven evidence-based guidance for public health decision-making to support the goals of the Ending the HIV Epidemic:

Targeted Resources

The initiative will target resources to the 48 highest burden counties, Washington D.C., San Juan, PR, and 7 states with substantial rural HIV burden.
Source: https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview

EHE’s comprehensive approach focuses resources where they are needed most and strives to meet people where they are with the services they need. The initiative provides a targeted infusion of new resources and support to 50 local areas that account for more than half of new HIV diagnoses (48 counties; San Juan, Puerto Rico; and Washington, D.C.), and seven states with a substantial rural burden. Through increased investments and local innovation, EHE aims to make history — and end the domestic HIV epidemic once and for all.

Applications that propose the following will be considered non-responsive and will not be reviewed:

• Research that does not focus on one of the geographically defined priority areas
• Projects that develop de novohealth interventions with a primary aim of testing efficacy
• Research that does not involve one or more collaborations with local implementing partners
• Animal studies, drug discovery or device safety trials with registrational requirements
• Studies that do not include a multidisciplinary team approach