E. Jennifer Edelman

Aims: Unhealthy alcohol use (UAU) and cigarette smoking drive morbidity and mortality among persons with HIV (PWH). Few studies have focused on UAU among PWH receiving tobacco treatment. Methods: Exploratory analysis of A SMART Approach to Treating Tobacco Use Disorder (SMARTTT) trial Stage 1 data, during which participants were randomized to clinical pharmacist-delivered nicotine replacement therapy (NRT) alone or NRT with contingency management (NRT+CM) in HIV clinics from 7/2020-3/2024. Analyses were restricted to participants with baseline AUDIT-C; UAU was defined by AUDIT-C (women=3+/men=4+). Outcomes included visit completion rates, adjusted differences in cigarettes per day (CPD) and abstinence at week 12. Results: Participants (n=314) smoked a mean of 13 CPD and 27% reported UAU at baseline. Participants with UAU were more likely to be younger, Black, healthier, report using cannabis and stimulants and greater reliance on the bus or walking for transportation. Participants with UAU generally had lower visit completion rates. Treatment differences in CPD between NRT+CM and NRT alone at week 12 did not vary by UAU (least squares means UAU: 6.0 vs. 6.7 and no UAU: 6.1 vs. 5.3, respectively; difference in adjusted treatment difference [95% CI]=1.6 [-2.1, 5.3]). Treatment differences in abstinence were also not moderated by UAU (UAU: 18.9% vs. 5.5% and no UAU: 21.7% vs. 10.0%; difference in adjusted difference [95% CI]=1.7% [-14.3%, 17.8%]). Conclusions: Among SMARTTT participants, UAU was common and associated with lower visit completion, without observed effects on smoking outcomes. Future studies should focus on targeting UAU and TUD together to optimize outcomes.

Using qualitative methods, we investigated barriers and facilitators to promoting physical activity in an HIV clinic in New Haven, CT. We conducted focus groups with HIV clinicians/staff ( n = 12) and interviews among people with HIV with unhealthy substance use ( n = 10). Data collection and deductive analysis were guided by the Health Equity Implementation Framework domains. Innovation barriers included lack of evidence-based interventions; facilitators included behavioral strategies and app-based programs. Clinical encounter barriers included lack of protocols and competing priorities; facilitators included discussing the benefits of physical activity. Recipient-level barriers included cost, physical capacity restrictions, and unhealthy substance use; facilitators included social support and tailoring interventions to individual interests/fitness levels. Contextual barriers included budget restrictions and lack of billing options; facilitators included having a physical activity specialist and infrastructure to link patients to physical activity services. Future research should investigate the feasibility of implementing a physical activity intervention into HIV clinical care.

Importance: There is a lack of robust strategies to reduce cigarette smoking among people with HIV. Objective: To identify optimal adaptive treatment strategies involving clinical pharmacist–delivered medications for tobacco use disorder and contingency management (CM) for smoking reduction among people with HIV. Design, Setting, and Participants: From July 27, 2020, through March 28, 2024, using a sequential multiple-assignment randomized clinical trial, people with HIV who smoked cigarettes were recruited and randomized 1:1 to nicotine replacement therapy (NRT) with or without CM (stage 1). After 12 weeks of treatment (stage 2), individuals with confirmed abstinence continued stage 1 treatment; individuals without confirmed abstinence were rerandomized to switch to oral medications for tobacco use disorder or to intensified CM. Interventions were delivered by clinical pharmacists in HIV clinics across 24 weeks. Interventions: Stage 1 included NRT with or without CM (rewards for confirmed abstinence). Stage 2 included either a switch to varenicline or bupropion or intensification to more rewards for abstinence. Each stage involved 5 clinical pharmacist visits. Main Outcomes and Measures: The primary outcome was cigarettes per day (CPD), and the secondary outcome was 7-day confirmed abstinence at 12 and 24 weeks with imputation. Analyses were conducted using intention-to-treat principles. Results: In total, 323 participants (181 [56.0%] male at birth; 317 [72.5%] Black or African American; mean [SD] age, 55.1 [10.7] years) smoked a mean (SD) of 12.8 (7.2) CPD at baseline. At 12 weeks, participants in the NRT plus CM (least-squares mean [LSM], 4.9 [97.5% CI, 3.5-6.2] CPD) and NRT (LSM, 5.2 [97.5% CI, 3.9-6.5] CPD) groups smoked similar numbers of CPD (adjusted LSM difference, −0.3 [97.5% CI, −1.9 to 1.3]; P = .66). Abstinence was greater at 12 weeks in the NRT plus CM group (36 of 160 [22.5%]) compared with the NRT group (16 of 163 [9.8%]) (adjusted odds ratio [AOR], 2.70 [99.0% CI, 1.19-6.14]; P = .002). Among participants without week 12 abstinence, the effect of intensifying vs switching on week 24 CPD varied by stage 1 treatment. Intensifying was better among individuals starting with NRT alone (adjusted LSM difference, −3.8 [97.5% CI, −6.0 to −1.5] CPD; P < .001) but not among individuals initially receiving NRT plus CM (adjusted LSM difference, 0.3 [97.5% CI, −2.1 to 2.6] CPD; P = .80). Abstinence at 24 weeks was similar among individuals in intensified vs switched groups regardless of stage 1 treatment (AOR, 1.5 [99% CI, 0.4-4.2]; P = .37; P = .85 for interaction). Overall, 24-week CPD was lowest with the adaptive treatment strategy involving NRT followed by NRT plus CM (eg, LSM, 2.6 [99% CI, 1.1-4.1] CPD vs 4.2 [99% CI, 2.6-5.9] CPD for NRT plus CM followed by NRT plus CM intensified), and abstinence was highest for the NRT plus CM followed by the intensified strategy (eg, LSM, 30.0% [99% CI, 16.2%-48.7%] vs 12.8% [99% CI, 5.2%-28.3%] for NRT followed by NRT plus CM intensified). Conclusions and Relevance: In this randomized clinical trial of people with HIV who smoked cigarettes, CM was an effective adjunct to clinical pharmacist–delivered NRT for improving tobacco-related outcomes. Optimal timing to add CM differed based on treatment goals. Trial Registration: ClinicalTrials.gov Identifier: NCT04490057

Contingency management (CM), an evidence-based behavioral strategy that rewards positive behavior change including tobacco cessation, is rarely offered to support people with HIV (PWH) who smoke. In this study, we explored perspectives among patients and research staff engaged in a multi-site randomized clinical trial involving clinical pharmacist-delivered CM within HIV clinics. Between February and September 2023, we conducted 1:1 interviews with 12 PWH randomized to receive CM and one focus group with 8 staff (i.e., clinical pharmacists and research coordinators). Qualitative data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework to understand barriers and facilitators related to evidence (perspectives on CM for smoking cessation), context (HIV clinics), and facilitation (promoting effectiveness and sustainability). Regarding evidence, PWH and staff had limited prior experience with CM and supported the use of exhaled carbon monoxide to promote accountability. PWH and staff thought CM was useful in bolstering internal motivation, but differed on ideal target behaviors (i.e., cessation vs. reduction). Regarding context, clinical pharmacist-delivered tobacco treatment within HIV clinics was viewed favorably, with mixed perspectives regarding optimal visit schedules and utility of remote CM. Regarding facilitation, PWH and research staff discussed strategies to increase participant engagement and retention such as incorporating behavioral counseling services. PWH endorsed application of CM beyond smoking cessation and for people without HIV. Future efforts should consider expanding the use of CM to target smoking cessation and related health behaviors and tailoring the intervention to individual needs and goals.

Background: We examined the impact of integrated stepped alcohol treatment with contingency management (ISAT + CM) on alcohol abstinence among people with HIV (PWH) and unhealthy alcohol use. Methods: In this multisite 24-week trial, we randomized PWH reporting untreated unhealthy alcohol use and with phosphatidylethanol (PEth) >20 ng/mL to receive ISAT+CM or treatment as usual (TAU). Intervention: Step 1: Social worker-delivered CM; Step 2: Addiction physician management plus motivational enhancement therapy. Participants were advanced to step 2 at week 12 if they lacked evidence of abstinence over the prior 21 days. TAU: Health handout, and for those who met criteria for alcohol use disorder, a referral to substance use treatment. Primary outcome: self-reported abstinence for the past 21 days at week 24. Results: We enrolled 120 PWH between January 5, 2018, and March 1, 2022. Mean age was 59 years, 96% were men, and 83% were Black. Eight percent were lost to follow-up. In the ISAT+CM group, 87% were advanced to Step 2. The posterior mean proportion of participants with self-reported abstinence at 24 weeks was higher among those randomized to ISAT+CM [posterior mean proportion 9% (95% credible interval [CrI]: 0%–33%)] compared with TAU [posterior mean proportion 0.3% (95% CrI: 0%–4%)] [posterior mean treatment effect 9%, (95% CrI: 0%–32%)], the posterior probability of TAU being superior to ISAT + CM was <0.0001. Discussion: ISAT + CM delivered in HIV clinics modestly increased self-reported 3-week abstinence among PWH. Our findings indicate a need for more effective treatments to promote abstinence and a potential role for ISAT + CM for reductions in alcohol use. Trial registration: Clinicaltrials.gov (NCT03089320).