Scaling up the brief alcohol intervention to prevent HIV infection in Vietnam: a cluster randomized, implementation trial

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PROJECT SUMMARY More than 25% of people with HIV (PWH) globally report unhealthy alcohol use, defined as a spectrum of use from risky/hazardous (drinking more than the recommended daily, weekly or per-occasion amounts resulting in increased risk for health consequences) to alcohol use disorder. PWH with unhealthy alcohol use may not adhere to their antiretroviral therapy (ART), leading to unsuppressed virus and increasing the potential for HIV transmission to sexual and injection partners. Interventions that address alcohol use among PWH are needed to prevent HIV transmission. We previously showed that the brief alcohol intervention (BAI) is effective at reducing alcohol use and increasing viral suppression in Vietnam. The BAI is ready for scale-up but one barrier to scale-up is attitudes towards alcohol interventions among clinical staff, especially in regions with normative unhealthy alcohol use. Addressing clinical staff attitudes may be essential for scale-up. We propose a hybrid type 3, cluster randomized implementation trial to examine effective strategies to scale up the BAI in ART clinics in Vietnam. One arm will receive only facilitation for BAI implementation. Facilitation is a flexible strategy that helps clinics to address common barriers, such as counselor skills, competing priorities, and resource deficits. In the other arm, in addition to facilitation, clinic staff, irrespective of their own alcohol use, will be offered the BAI themselves as experiential learning to address their own alcohol-related attitudes and behaviors. We hypothesize that EBAI, added to facilitation, will increase BAI fidelity, acceptability, and penetration at the clinic level, and improve viral suppression among PWH with unhealthy alcohol use. Our specific aims are to: 1) Compare BAI implementation using facilitation (FAC) only to experiential BAI plus facilitation (EBAI+FAC) in ART clinics in Vietnam; 2) Explore the mechanisms of successful BAI scale up in both the FAC and EBAI+FAC arms; and 3) Measure the impact of EBAI on clinic staff. ART clinics (n=30) across Vietnam will be randomized to receive FAC or EBAI+FAC. PWH in the clinics will be screened for unhealthy alcohol use with the AUDIT-C; if positive, they will be offered the BAI. The primary implementation outcomes are clinic-level BAI fidelity (primary), with secondary outcomes of acceptability, penetration, and cost. The effectiveness outcomes are viral suppression (primary) and alcohol use (secondary), measured among a cohort of PWH recruited in each clinic. Outcomes will be measured at 3 months (implementation outcomes only) and 12 months (all outcomes). In parallel with the trial, we will use mixed methods to examine the organizational and clinic staff characteristics that underly successful BAI scale-up. Given the importance of the clinic staff in the BAI implementation, we will also explore the impact of the BAI on their own alcohol-related attitudes and use and considering whether they received the BAI themselves or not. This trial will present critical information for worldwide HIV treatment as prevention efforts, providing strategies for effective scale-up of the BAI among PWH with unhealthy alcohol use.