Alcohol Consumption Among HIV-Infected Women:
Impact on Time to Antiretroviral Therapy and Survival
Robyn C. Neblett, M.D., M.P.H.,1Heidi E. Hutton, Ph.D.,2Bryan Lau, Ph.D.,3
Mary E. McCaul, Ph.D.,2Richard D. Moore, M.D., M.H.S.,1and Geetanjali Chander, M.D., M.P.H.1
Objective: Alcohol use is prevalent among HIV-infected people and is associated with lower antiretroviral
adherence and high-risk sexual and injection behaviors. We sought to determine factors associated with alcohol
use among HIV-infected women engaged in clinical care and if baseline alcohol use was associated with time to
combination antiretroviral therapy (cART) and death in this population.
Methods: In an observational clinical cohort, alcohol consumption at the initial medical visit was examined and
categorized as heavy, occasional, past, or no use. We used multinomial logistic regression to test preselected
covariates and their association with baseline alcohol consumption. We then examined the association between
alcohol use and time to cART and time to death using Kaplan-Meier statistics and Cox proportional hazards
Results: Between 1997 and 2006, 1030 HIV-infected women enrolled in the cohort. Assessment of alcohol use
revealed occasional and hazardous consumption in 29% and 17% of the cohort, respectively; 13% were past
drinkers. In multivariate regression, heavy drinkers were more likely to be infected with hepatitis C than non-
drinkers (relative risk ratios [RRR] 2.06, 95% confidence interval [CI] 1.29-3.44) and endorse current drug
(RRR 3.51, 95% CI 2.09-5.91) and tobacco use ( RRR 3.85 95% CI 1.81-8.19). Multivariable Cox regression adjusting
for all clinical covariates demonstrated an increased mortality risk (hazard ratio [HR] 1.40, 95% CI 1.00-1.97,
p<0.05) among heavy drinkers compared to nondrinkers but no delays in cART initiation (1.04 95% CI 0.81-1.34)
Conclusions: Among this cohort of HIV-infected women, heavy alcohol consumption was independently as-
sociated with earlier death. Baseline factors associated with heavy alcohol use included tobacco use, hepatitis C,
and illicit drug use. Alcohol is a modifiable risk factor for adverse HIV-related outcomes. Providers should
consistently screen for alcohol consumption and refer HIV-infected women with heavy alcohol use for treatment.
HIV=AIDS diagnoses.1High-risk heterosexual contact is the
source of 80% of newly diagnosed HIV=AIDS infections
HIV epidemic. Although African American women comprise
only 12% of the female population in the United States, they
account for 66% of new HIV infections.3
In the United States, approximately 50% of adults are cur-
rent, regular drinkers.4Men are more likely than women to be
current drinkers. Among women, white women are more
likely to be current drinkers compared to African American
women (48% of non-Hispanic white women vs. 27% of non-
n the United States, women are at risk for HIV infection
and account for more than one quarter of all new
Hispanic black women).4Alcohol use is also prevalent
acquisition and transmission through high-risk sexual and
injection-related behaviors. Hutton et al.7found that women
binge drinkers engaged in anal sex at three times the rate of
women who abstained from alcohol and were more than
twice as likely to have multiple sexual partners. Among HIV-
infected women in particular, alcohol consumption has also
been found to be strongly associated with unsafe sexual
practices, including inconsistent condom use and multiple
male sexual partners.8Furthermore, alcohol consumption
may cause more rapid disease progression and HIV-related
complications.9–12Studies have demonstrated that HIV-
infected individuals with heavy alcohol use are less likely to
adhere to combination antiretroviral therapy (cART) and
1Department of Medicine and2Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, and
3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
JOURNAL OF WOMEN’S HEALTH
Volume 20, Number 2, 2011
ª Mary Ann Liebert, Inc.
achieve viral suppression.9,13–16In addition, one study found
that heavy alcohol consumption had a negative impact on the
CD4cell count of HIV-infected people not on combined an-
At present, little is known about factors associated with
varying levels of alcohol consumption among HIV-infected
women. Identifying andtreating alcoholuse disorders among
HIV-infected women may improve their treatment outcomes.
Thus, we sought to determine demographic and clinical fac-
tors associated with different levels of alcohol use in a sample
of HIV-infected women entering clinical care and to evaluate
the association between baseline alcohol consumption and
time to cART and death among HIV-infected women.
Materials and Methods
Study design and population
We performed a retrospective cohort study of HIV-infected
women enrolled in the Johns Hopkins HIV Clinical Cohort
(JHHCC), a clinic-based observational longitudinal cohort of
patients who receive primary HIV care in the Johns Hopkins
HIV Clinic. Details of the cohort design have been described
previously.17Data collection is comprehensive and includes
extensive demographic, socioeconomic, laboratory, thera-
peutic, and diagnostic information that is collected longitu-
dinally starting with the first visit to the Johns Hopkins HIV
Clinic. Maintenance of the database and use of its contents for
analysis ofpatient outcomes are approved bythe Institutional
Review Board of the Johns Hopkins University School of
Medicine, and participants provided written informed con-
sent. Women were included in this study if they enrolled in
the clinic between January 1997 and December 2006 and they
were not currently on ART at the time of enrollment.
Alcohol, illicit drug, and cigarette use.
first clinic visit, the medical provider completed a standard
history and physical form. Trained coders then abstracted
baseline alcohol andillicit drug(heroin=cocaine) use, defining
current use as any use within the 6 months before enrollment
and past use as use >6 months before enrollment but none in
the past 6 months. Current alcohol use was categorized as
occasional or heavy. Occasional drinking included occasional
or light use; heavy drinking included binge drinking or daily
use. Because abstraction relied on provider documentation,
strict quantity=frequency definitions were not used for the
drinking categories. If the provider documented social use,
occasional or light use, this would fall into the occasional
category, as would lower quantities of alcohol use, such as
one or fewer drinks per day. Heavy drinking included binge
drinking, heavy alcohol use as well as quantities of ?4 drinks
per occasion, or daily drinking of >1 drink per day (National
drug use included use of heroin or cocaine within 6 months of
enrollment in the cohort. Participants who did not use alcohol
or drugs were defined as none. Cigarette use was abstracted
from the baseline visit and coded as either smoking or non-
At a participant’s
Combination antiretroviral therapy.
the use of an antiretroviral regimen containing a protease
cART was defined as
inhibitor, a nonnucleoside reverse transcriptase inhibitor,
three nucleoside reverse transcriptase inhibitors, or a fusion
inhibitor. We defined baseline cART as documented cART
within the first 90 days of clinic enrollment. Any ART before
enrollment in the clinic was ascertained from the baseline
history and physical form and clinical records, where this
information is recorded.
registry maintained by the clinic that receives reports from
families, funeral homes, other medical institutions, and local
coroners. In addition, death records of the Maryland Bureau
of Vital Records and the Social Security Death Index were
Information on death was obtained from a death
HIV risk factor.
factors included injection drug use (IDU) and heterosexual
transmission (defined as either heterosexual activity with a
partner at high risk for HIV or sex with an HIV-infected in-
dividual). Risk factor information was provided by patient
self-report and documented by the clinician. Risk factor as-
signment was not mutually exclusive.
For our analyses, HIV transmission risk
Hepatitis C status.
presence of antibodyto thehepatitis Cvirus. This information
was electronically captured through laboratory data, and in-
dividuals were categorized as hepatitis C antibody positive,
negative, or unknown.
Hepatitis C status was defined as the
Ifa diagnosisofdepression wasrecordedin theclinical record
within 6 months of clinic enrollment, the participant was
designated as having depression.
Depression was determined by manual ab-
All statistical analysis was performed using Stata version
9.1 for windows (StataCorp, College Station, TX). We com-
pared participant characteristics by drinking categories us-
ing Kruskal Wallace test for continuous variables and
Pearson’s chi-square test for categorical variables. We used
multinomial logistic regression to examine bivariate and
multivariable associations between preselected covariates
(age, race, cART, illicit drug use, enrollment HIV RNA, CD4
lymphocyte count, and HIV transmission risk) and drinking
category. We report relative risk ratios (RRR) for increased
alcohol use with 95% confidence intervals (CI). We then ex-
amined the association between alcohol use and time to
cART and time to death using Kaplan-Meier statistics and
Cox proportional hazards regression. Our time origin for
analyses examining time to cART was the date of clinic en-
rollment and for time to death was 90 days after date of
enrollment to account for the 90-day window for which we
defined baseline cART. We used the log rank test to compare
survival curves. In multivariable analysis, we adjusted for
baseline characteristics, including age, race, HIV risk factor,
CD4cell count, active drug use, and hepatitis C status. We
tested the interactive effect of drug and alcohol use on our
outcomes of interest and the interaction between alcohol use
and hepatitis C status on our outcomes.
280NEBLETT ET AL.
A subsample (n¼114) of individuals within our cohort
participated in an audio computer-assisted self-interview
(ACASI) within 6 months of their enrollment into the cohort.
For this ACASI, individuals provide information on the
number of drinks per week they consumed within the past 6
months. With this information, we used a multiple imputa-
tion for measurement-error correction to provide a sensitivity
analysis for the association between alcohol use and our
outcomes of time to cART and time to death.19
A total of 1030 HIV-infected women who enrolled in care
between January 1997 and December 2006 were assessed. The
median follow-up time was 1571 days (interquartile ratio
[IQR] 821–2466), and 3% of women per year were lost to fol-
low-up. Baseline characteristics for the cohort, stratified by
level of alcohol consumption, are listed in Table 1. The cohort
was predominantly African American (83.5%) and had het-
erosexual contact as the principal mode of HIV transmission
(76%) and a mean age of 38.4 years. Assessment of alcohol use
revealed heavy consumption in 17% and occasional con-
sumption in 29%; 13% were past drinkers. Active illicit drug
use (heroin or cocaine) was present in 42.3% of the cohort
(70% of heavy drinkers). Approximately 45% of the cohort
was hepatitis C antibody positive.
Factors associated with level of alcohol consumption
The results of bivariate and multivariable analyses are
presented in Table 2. In multivariable regression, heavy
drinkers were 3 times more likely to report active illicit drug
use (RRR 3.51, p<0.001) and twice as likely to endorse past
heroin or cocaine use (RRR 2.71, p<0. 01) as nondrinkers.
Heavy drinkers were more likely to have hepatitis C. Women
with past alcohol consumption were older and significantly
more likely to be diagnosed with depression and report illicit
drug use compared to nondrinkers. Occasional and heavy
alcohol consumption were both associated with cigarette
Factors associated with time
to cART and time to death
In our cohort, there were 630 women (61%) initiated on
cART during the time of observation. Cox proportional haz-
ards model for factors associated with time to cART and
survival are presented in Table 3. Current illicit drug use was
associated with delayed cART initiation (hazard ratio [HR]
hepatitis C status. In bivariate analysis, heavy alcohol use was
associated with delayed cART; however, this association did
not persist after multivariable analysis.
Table 1. Baseline Demographic and Clinical Characteristics Among HIV-Infected Women,
Stratified by Levels of Alcohol Consumption
40.3 (8.7) Mean age (SD)
HIV risk factor
Heroin or cocaine use***
Hepatitis C status***
Prior h/o cART
*p<0.05; **p<0.01; ***p<0.001.
cART, combination antiretroviral therapy; Prior h/o cART, prior history of cART prior to enrollment in clinic, HET, heterosexual; IVDU,
intravenous drug use; SD, standard deviation.
HIV, WOMEN, AND ALCOHOL281
Overall, there were 254 deaths in our sample. The median
time to death was 1065 days (IQR 482–1849 days). Factors
associated with more rapid time to death in bivariate analysis
use, heavy or past alcohol use, and being hepatitis C positive.
Multivariable Coxregression adjusting forall othercovariates
demonstrated an increased mortality risk (HR 1.40, 95% CI
1.00-1.97 p<0.05) among heavy drinkers compared to non-
drinkers. Kaplan-Meier statistics assessing time to death by
curves demonstrate improved survival among social drinkers
and nondrinkers compared to HIV-infected women who are
past or heavy drinkers. There was no interactive effect be-
tween alcohol and drug use or alcohol use and hepatitis
When our sample was limited to the 114 women who com-
pleted an ACASI within 6 months of clinic enrollment, point
estimates oftheassociation between occasional alcohol use and
death (adjusted hazard ratio [AHR] 95% CI 0.63, 0.09-4.18) and
heavy alcohol use and death (AHR 1.70, 95% CI 0.25-11.47)
were similar in magnitude and direction to the overall cohort.
Because the validation sample was small, the standard errors
greatly inflated, resulting in wide confidence intervals.
Among this cohort of HIV-infected women, heavy alcohol
consumption was independently associated with earlier
death. Active illicit drug use was also associated with in-
creased risk of mortality. In contrast to active drug use,
delayed time to cART initiation. Baseline factors associated
with heavy alcohol use included tobacco use, hepatitis C, and
illicit drug use. These findings underscore the importance of
identifying alcohol use among HIV-infected women entering
care and counseling on the hazards associated with alcohol
consumption ingeneralandwhencoinfected withhepatitisC.
Our finding of earlier death among heavy drinking HIV-
infected women is consistent with the literature about women
without HIV. Several large prospective cohort studies have
evaluated the association between alcohol use and mortal-
ity among women. One study, examining data from the
Nurses’ Health Study, found a U-shaped relationship; light-
to-moderate alcohol consumption (1.5–29.9g of alcohol per
day) was associated with decreased mortality, whereas heavy
drinking (?30g of alcohol per day) was associated with in-
creased mortality.20An earlier study found that among heavy
drinkers, women were at much greater relative risk than men
for noncardiovascular death.21Braithwaite et al.22estimated
the impact of alcohol use on survival among a cohort of HIV-
infected individuals, the majority of whom were male. They
examined 2702 HIV-positive people and found that hazardous
alcohol consumption decreased overall survival by >3 years if
frequency of alcohol use was once per week or greater and by
6.4 years with daily alcohol use. Decreased survival was also
found among nonhazardous drinkers. Our finding that heavy
alcohol consumption was associated with decreased survival
among HIV-infected women, independent of such clinical
factors as hepatitis C, cART, orCD4 countat baseline, suggests
that the association between alcohol and mortality may be
Table 2. Multinomial Regression of Factors Associated with Occasional and Heavy
and Past Alcohol Consumption Compared to None Among HIV-Infected Women
Occasional consumption Heavy consumptionPast consumption
Variable BivariateMultivariateBivariate Multivariate BivariateMultivariate
Heroin or cocaine
1.00 (0.97-1.02) 1.02 (1.00-1.05)
1.20 (0.69-2.09) 0.68 (0.41-1.13)
7.31 (4.70-11.38) 3.51*** (2.09-5.91) 3.93 (2.44-6.33)
4.83 (2.53-9.21) 2.71** (1.34-5.46) 9.07 (5.05-16.27) 7.14*** (3.71-13.77)
10.83 (5.56-21.10) 3.85*** (1.81-8.19) 4.21 (2.47-7.18)
1.81 (1.25-2.62) 1.22 (0.81-1.82) 2.15 (1.44-3.21)
0.85 (0.57-1.27) 1.35 (0.86-2.12) 0.61 (0.40-0.94)
0.50 (0.29-0.87)0.60 (0.33-1.08) 0.87 (0.51-1.47)
1.0 (Ref) 1.0 (Ref)1.0 (Ref)
1.04 (0.67-1.60) 0.99 (0.67-1.48)
1.0 (Ref)1.0 (Ref)
1.29 (0.78-2.11) 1.14 (0.69-1.88)
0.72 (0.42-1.23) 0.90 (0.56-1.46)
1.0 (Ref) 1.0 (Ref)
1.65* (1.03-2.65) 2.41 (1.58-3.66)
1.59 (0.75-3.40) 1.37 (0.69-2.74)
1.0 (Ref)1.0 (Ref)
Alcohol: never is the base outcome.
aRelative risk ratio (RRR) and 95% confidence interval (95% CI).
*p<0.05; **p<0.01; ***p<0.001.
282 NEBLETT ET AL.
for potential confounders, occasional alcohol use was associ-
ated with delayed death. Although this would be consistent
with data from the Nurses’ Health Study, this is an area that
requires further investigation.
We found no differences in time to cART by level of alcohol
consumption, which lends support to recent findings in the
Swiss HIV Cohort Study, which examined treatment-naı ¨ve
individuals with CD4 count <200cells=mL across alcohol
consumption levels and found no association between de-
layed cART initiation and alcohol consumption.23However,
our finding that active drug use was associated with delayed
cART initiation in our cohort supports well-established evi-
dence that physicians may be highly reluctant to prescribe
cART to HIV-infected IDUs.24
Although we found no delay in cART initiation among
heavy drinkers, alcohol use was associated with earlier death.
One possible explanation is that although women with heavy
alcohol consumption are receiving cART, their increased
mortality may be secondary to lower adherence and, conse-
quently, poorer response to cART. Hazardous alcohol con-
nonadherence.25–29Given that our study population was ex-
clusively HIV-infected women, it is important to note that
gender-specific differences in alcohol use and antiretroviral
adherence may exist. Evaluation of two longitudinal pro-
spective cohort studies found a dose-response relationship
between alcohol use and decreasing adherence among
women only.30Even small reductions in antiretroviral
adherence may compromise its effectiveness and have
important survival implications.31It is also possible that
increased mortality among women with heavy alcohol use
risk factorfor cART
Table 3. Multivariate Cox Proportional Hazard Analyses for Predictors
of Time to Initiation of cART and Mortality
Time to cART Time to Death
Variable BivariateMultivariateBivariate Multivariate
Heroin or cocaine use
1.02 (0.73-1.43)2.22 (1.84-2.68) 2.04*** (1.69-2.48)
All variables included in the final model except baseline cART in Time to cART analysis.
aRelative hazard (95% CI).
*p<0.05; **p<0.01; ***p<0.001.
ETOH, ethyl alcohol.
sumption using the Kaplan-Meier method (p<0.001 by log-
Survival analysis stratified by level of alcohol con-
HIV, WOMEN, AND ALCOHOL 283
the literature from the Nurses’ Health Study and the study
by Klatsky et al.21which have described a general associa-
tion between heavy alcohol use and mortality. In addition,
among HIV-infected individuals, alcohol abuse is one of the
most important risk factors for bacterial community-ac-
quired pneumonia.32One study conducted among veterans
with HIV infection found a strong linear association between
bacterial pneumonia prevalence and level of alcohol use.33
The association between alcohol use and death among HIV-
infected women is likely multifactorial.
We did not find a baseline diagnosis of depression to be
associated with delayed CART or earlier death. This is in
contrast to other cohorts of HIV-infected women, where de-
pression and depressive symptoms havebeenassociated with
decreased medication adherence,34cART discontinuation,35
virological failure,36and death.37,38In our cohort, if depres-
sion was recorded in the clinical record within 6 months of
clinic enrollment, the participant was designated as having
depression. This may have missed women who had undiag-
nosed or undocumented depression, which may explain why
our findings differ from those of other cohort studies con-
ducted among HIV-infected women that demonstrated that
depression was associated with death.39In addition, there is
literature about HIV-infected individuals suggesting that
those with mental health disorders engaged in mental
healthcare have similar or even better outcomes than those
without mental health disorders.40
In this study, factors associated with heavy alcohol con-
sumption included hepatitis C and illicit drug use. Alcohol
constitute the majority of new hepatitis C infections.42Excess
alcohol consumption is known to hasten the progression of
liver disease related to hepatitis C and can reduce the effec-
tiveness of treatment for hepatitis C infection.42,43Women
with alcohol use and progression of hepatitis C disease.
There are several limitations to our study. First, this is an
observational cohort study; thus, there may have been resid-
ual confounding. In addition, our alcohol variable categori-
zation was based on provider interview, resulting in a crude
categorization of alcohol use. Although trained abstractors
retrieved the data, provider documentation may have been
variable, patients may have underreported alcohol use, and
providers may not have adequately assessed alcohol use, re-
sulting in some misclassification of alcohol use. Should the
level of alcohol use have been underreported, however, it is
likely that our estimates are conservative and actual associa-
tions are stronger. Notably, our sensitivity analysis revealed
associations that were similar in direction and of slightly
greater magnitude, although the confidence intervals were
wide because of the small validation sample. Although the
sensitivity analysis using ACASI data is reassuring, it is not in
itself a gold standard. Thus, additional studies using vali-
dated alcohol assessments, such as the Alcohol Use Disorders
Identification Test or the Time Line Follow Back, are needed
to confirm our findings.44–47In addition, both illicit drug use
and depression were obtained from provider documentation,
and, thus, it is possible that these variables may not have been
adequately assessed or documented. Further, variables, in-
cluding housing stability and baseline medication adherence,
were not collected in our cohort and were unable to be as-
sessed. Finally, our cohort was urban and predominantly
African American, which may limit generalizability.
Despite these limitations, this study evaluating the associ-
ation between baseline alcohol consumption and time to
cART and death among HIV-infected women has important
strengths. Ourstudy isone offewtodirectlyassess theimpact
of alcohol consumption on mortality among HIV-infected
women. In addition our cohort consists of a large sample of
women engaged in care, the majority of whom are urban
African American women acquiring HIV via heterosexual
contact, thus largely mirroring the epidemic of HIV among
women in the United States.
In summary, alcohol use is common among HIV-infected
women, and our results suggest that heavy alcohol con-
sumption is associated with decreased survival. Future lon-
gitudinal studies should continue to examine alcohol use and
HIV survival, as well as specific causes of death. In addition,
given that alcohol is a modifiable risk factor for adverse HIV-
related outcomes, providers should consistently screen for
alcohol consumption and refer HIV-infected women with
heavy alcohol use for treatment.
This work was supported by National Institute on Alco-
holism and Alcohol Abuse (NIAAA) R01 AA016893-02 and
NIAAA RO1-AA014500. R.D.M. was supported by the Na-
tional Institute on Drug Abuse K24DA000432-10. B.L. was
supported by K01-AI071754, and G.C. was supported by
NIAAA K23 AA015313.
No competing financial interests exist.
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