Abstract Alcohol consumption is a critical predictor of poor HIV outcomes such as reduced antiretroviral adherence and lack of viral suppression. Reducing unhealthy alcohol use among those with HIV may improve HIV outcomes and thus is a high priority. HIV prevalence and unhealthy drinking rates are high in sub-Saharan Africa (SSA). Multi-session approaches to screening and brief counseling have good evidence for reducing alcohol use in resource rich settings and in persons with HIV. However, multiple in-person sessions are costly and unlikely to be scalable in SSA. Thus, there is a need to develop and test low-cost alternatives. A successful multi-contact alcohol intervention studied in the US uses phone-based booster sessions with a live counselor (“live boosters”) to reinforce the content of two brief in-person sessions. Because cell phone coverage is widespread in SSA, an intervention that uses live boosters may be feasible, particularly if the in-person sessions coincide with regular clinic visits. However, live booster calls can be labor intensive and dependent on a good phone network. Alternatively, automated booster sessions can be conducted via cell phone using short message service (SMS, i.e. text) or interactive voice response (IVR) systems, to provide brief 2-way interactive sessions (“tech boosters”). These systems are likely to be at low cost and burden to providers and patients. The SMS/IVR systems allow for tailoring the 2-way booster sessions on variables such as gender and drinking goals. The primary aims of this developmental study are (1) To adapt a successful alcohol intervention for unhealthy drinkers with HIV in Uganda to include in-person sessions that coincide with two routine quarterly clinic visits, with live booster calls delivered between in-person sessions, and to develop tech boosters as a scalable alternative to live calls. We will collect qualitative data via focus group discussions and individual in- depth interviews to elicit community and patient input into the content and delivery of the interventions. (2) To conduct a pilot randomized controlled trial (RCT) to test these methods for unhealthy drinkers in HIV care in rural Uganda (n=270). The study arms will be: (a) in-person counseling during 2 quarterly clinic visits plus live booster calls every 3 weeks in the interim, (b) in-person counseling during 2 quarterly clinic visits plus twice weekly tech (choice of SMS or IVR) boosters in the interim, and (c) standard of care control (brief unstructured advice, with a wait-listed intervention). We will obtain preliminary estimates of uptake, acceptability, cost, and efficacy in reducing alcohol use and decreasing viral failure for each study arm at six months. We will utilize an alcohol biomarker, phosphatidylethanol, in addition to self-reported alcohol use, and measure viral suppression via dried blood spots. This study will be conducted in a large rural Ugandan HIV clinic where we have 10 years of collaborating on alcohol/HIV research. The study will adapt a successful intervention and develop low-cost delivery methods, and the pilot RCT results will inform the design of a larger trial of a low-cost intervention to reduce alcohol use and increase viral suppression among those with HIV in SSA.

Project Narrative This project aims to conduct formative work to adapt an existing brief alcohol intervention and to develop 2-way tailored mobile phone based messages as booster sessions, with the goal of reducing unhealthy drinking and increasing viral suppression in persons with HIV in Uganda. After formative work to adapt the existing intervention and develop the tech component, we will conduct a pilot randomized controlled trial to compare the uptake, acceptability, and effectiveness in reducing unhealthy alcohol use and increasing viral suppression. The study arms are (a) in-person counseling timed with routine clinic visits plus live counselor-delivered phone- based booster calls every 3 weeks between clinic visits, (b) in-person counseling timed with routine clinic visits plus twice weekly 2-way tailored mobile phone based booster sessions between clinic visits, and (c) the standard of care (brief unstructured advice).