Enhancing HIV prevention and reducing alcohol use among people receiving STI care in Malawi: An HIV status neutral approach

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PROJECT SUMMARY HIV continues to be a significant public health problem throughout sub-Saharan Africa, including in Malawi. Sexually transmitted infection (STI) care settings are underutilized venues to simultaneously reach virally unsuppressed people with HIV (PWH) and those at high risk of HIV and have the potential to optimize HIV prevention and treatment outcomes. Hazardous alcohol use is widespread in Malawi and among people receiving STI care and is a critical barrier to the success of HIV prevention efforts. TrEAT is a brief, highly effective, culturally appropriate, scalable, evidence-based intervention (EBI) for alcohol reduction. While culturally appropriate for diverse settings, TrEAT has not been adapted for the shifting HIV care environment that includes both PWH and people at high risk for HIV. Through preliminary work, our team has demonstrated that: 1) Hazardous alcohol use is highly prevalent among people receiving STI care in SSA, including Malawi; 2) TrEAT is culturally appropriate, feasibile, acceptable, and effective at reducing alcohol use and improving viral suppression among PWH across global settings, including in SSA; and 3) Successfully led alcohol reduction and HIV prevention and treatment effectiveness and implementation studies. The overall goal for this R34 application is to produce a culturally adapted, scalable HIV ‘status-neutral’ EBI for alcohol reduction and HIV prevention and treatment optimization to test in an R01 hybrid effectiveness-implementation trial. We will conduct a 2-arm pilot randomized controlled trial (RCT) comparing TrEAT4All to usual care to assess the preliminary efficacy and implementation of HIV prevention and treatment within one STI care setting which serves as an early Pre-exposure Prophylaxis (PrEP) implementation site in Lilongwe, Malawi. Drawing from our previous manualized interventions, we will develop a 3-session intervention, TrEAT4All, that integrates HIV prevention and treatment counseling into TrEAT to improve HIV prevention outcomes—PrEP use for those who are at risk for HIV and viral suppression for PWH. Our specific aims are to 1) Adapt TrEAT, an EBI for alcohol reduction, to integrate HIV status-neutral counseling (TrEAT4All) for PWH and those at high risk of HIV who report heavy drinking and are receiving STI care in Malawi; 2) Evaluate short-term efficacy and implementation of TrEAT4All for optimizing HIV prevention and treatment outcomes (viral suppression among PWH; PrEP use among those at high risk of HIV) and proportion of heavy drinking days in past 30 days; and 3) Explore pathways of TrEAT4All responsiveness among intervention participants. Results will have relevance for integrating alcohol reduction EBIs into real-world STI care settings to optimize HIV prevention and treatment programs throughout sub-Saharan Africa and other regions where alcohol plays a role in HIV spread.