Alcohol interventions for persons with HIV: Meta-analysis of randomized controlled trials using phosphatidylethanol and self-report

Background: Interventions are needed to reduce alcohol use for people living with HIV (PWH), but prior randomized controlled trials (RCT) evaluated efficacy by self-reported alcohol use, potentially hampering validity. We aimed to determine alcohol intervention efficacy using the alcohol biomarker, phosphatidylethanol (PEth), combined with self-report, and compare results to each analysed alone. Methods: We conducted a systematic review of alcohol intervention RCTs to April 2023, followed by an individual participant data meta-analysis (IPD-MA) using two-step random effects modeling. Our primary outcome was unhealthy alcohol use defined as PEth/self-report (binary), i.e., PEth≥ 50 ng/mL or Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) ≥ 3 (women) and ≥ 4 (men). We also evaluated PEth and self-report alone. Results: We screened 280 studies, found 20 eligible, and obtained IPD for 16 (N = 3559, median age=41, 72.8 % male). Participants receiving an alcohol intervention had significantly lower odds of follow-up unhealthy alcohol use by PEth/self-report (OR=0.69, 95 % CI: 0.55–0.86; Cohen's d=0.21; I²=29.4 %, 95 % CI: 0.0 %-62.8 %). Risk-of-bias assessment indicated low or moderate risk. The certainty of evidence was moderate. Findings for PEth alone (OR=0.81, 95 % CI: 0.69–0.97; Cohen's d=0.12; I²=5.7 %, 95 % CI: 0.0 %-49.5 %) and self-report alone (OR=0.67, 95 % CI: 0.50–0.89; Cohen's d=0.22; I²=68.7 %, 95 % CI: 6.6 %-84.5 %) outcomes were similar, but heterogeneity was greater for self-report alone. Findings were robust to higher PEth/self-report cutoffs and continuous measures. Conclusions: Results confirm prior findings of significant efficacy of alcohol interventions for PWH. Effect sizes were small across measurements, while heterogeneity was high when using self-report alone. Combined PEth/self-report is a useful primary outcome for alcohol intervention studies.