# Implementing screening, brief intervention and referral to treatment in a French cohort of people living with HIV: a pilot study

J-M Jacquet, H Donnadieu-Rigole, M Peries, A Makinson, N Nagot, H.

Peyriere, Jacques Reynes

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## ► To cite this version:

J-M Jacquet, H Donnadieu-Rigole, M Peries, A Makinson, N Nagot, et al.. Implementing screening, brief intervention and referral to treatment in a French cohort of people living with HIV: a pilot study. HIV Medicine, 2019, 20 (4), pp.286-290. 10.1111/hiv.12709. hal-02095225

HAL Id: hal-02095225

https://hal.umontpellier.fr/hal-02095225v1

Submitted on 21 Jan 2025

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# Implementing screening, brief intervention and referral to treatment in a French cohort of people living with HIV: a pilot study

J-M Jacquet,¹,² H Donnadieu-Rigole,³ M Peries,⁴ A Makinson,¹,⁵ N Nagot,⁴ J Reynes¹,⁵ and H Peyriere ID ⁴,⁵
for the MesConsos study group name†

¹Department of Infectious Diseases, Montpellier University Hospital, Montpellier, France, ²Department of Addictology, Nimes University Hospital, Nimes, France, ³Department of Addictology, Montpellier University Hospital, Montpellier, France, ⁴Pathogenesis and Control of Chronic Infections, Montpellier University, INSERM UMR1058, CHU Montpellier, Montpellier, France and ⁵INSERM U1175/IRD UMI 233, Montpellier University, Montpellier, France

## Objectives

Screening, brief intervention and referral to treatment (SBIRT) is an evidence-based practice used to identify, reduce and prevent problematic use and abuse of, and dependence on, tobacco, alcohol and psychoactive substances. To date, the pertinence of this practice among people living with HIV (PLHIV) is unknown. In this pilot study, we aimed to assess the acceptability of SBIRT in a cohort of HIV-infected out-patients who were asked about their consumption of alcohol, tobacco and psychoactive substances.

## Methods

A monocentric study was performed at the University Hospital of Montpellier. In a 6-month period, 20 trained physicians screened for the consumption of alcohol [using the Alcohol Use Disorders Identification Test (AUDIT)], tobacco (using the Short Fagerstrom Test) and psychoactive substances [using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) V3.0] via an auto-questionnaire and proposed a brief intervention to patients with misusage.

## Results

One thousand and eighteen PLHIV completed the questionnaire, and 861 [84.6%; 95% confidence interval (CI) 82.2–86.7%] PLHIV returned it to the physician. Among the latter, 650 patients wished to discuss the answers with their physician (75.5%; 95% CI 72.5–78.3%), and brief interventions were realized in 405 patients (62.3%).

## Conclusions

SBIRT is a simple screening and harm reduction tool that is well accepted by PLHIV in out-patient clinics. This method could be implemented in routine HIV care to screen and manage patients systematically for harmful substance use.

**Keywords:** early medical intervention, HIV, pilot study, substance abuse detection

Accepted 28 November 2018

## Introduction

The consumption of alcohol, tobacco and psychoactive substances seems to be higher in people living with HIV (PLHIV) than in the general population [1–3]. Psychoactive substance use (PSU) is increasingly prevalent in

PLHIV in Europe [4], especially among HIV-infected men who have sex with men (MSM) [4]. In this context, we recently assessed the frequency of PSU and alcohol and tobacco consumption among 1018 PLHIV followed in HIV medical consultations in a tertiary university hospital during a 6-month period [5]. In this predominantly (76.8%) male population, including 528 (51.8%) MSM, with a median age of 49 years [interquartile range (IQR) 42–46 years], we found excessive alcohol drinking in 22.0% [95% confidence interval (CI) 19.5–24.7%], high dependence on tobacco in 29.1% (95% CI 24.9–33.7%),

Correspondence: Dr Hélène Peyriere, Département de Pharmacologie Médicale et Toxicologie, Hôpital Lapeyronie, 191 avenue du Doyen Gas-ton Giraud, 34295 Montpellier Cedex 5, France. Tel: 33 4 67 33 67 53; fax: 33 4 67 33 67 51; e-mail: h-peyriere@chu-montpellier.fr

†Members of MesConsos study group are listed in the Appendix.
and a prevalence of PSU of 60.2% (95% CI 57.1–63.3%) in the patient's lifetime and 37.8% (95% CI 34.8–41.0%) in the past 3 months [5]. Given the harmful events induced by PSU and alcohol and tobacco consumption [4,6–9], we applied the concept of screening, brief intervention and referral to treatment (SBIRT) to this same cohort of PLHIV [5]. SBIRT is an evidence-based practice used to identify, reduce and prevent problematic use and abuse of, and dependence on, tobacco, alcohol and psychoactive substances. SBIRT is based on brief motivational intervention, with proven efficacy and cost-effectiveness for significant and sustained reductions in misuse of alcohol and other drugs [10–12]. First applied to alcohol use, SBIRT was subsequently extended to PSU. To date, studies evaluating SBIRT in PLHIV have been scarce, but the few studies performed showed a positive impact [13,14]. However, limitations of SBIRT implementation in PLHIV have been highlighted, including a lack of awareness of substance use problems, time limited for investigators, and lack of specialized services for patient referral [15]. We aimed to evaluate the acceptability of an SBIRT approach among PLHIV attending an HIV outpatient department for consultation.

## Methods

In this cross-sectional study, all consecutive adult PLHIV attending the Infectious Diseases Department of Montpellier University Hospital for consultation between 1 October 2013 and 31 March 2014 were invited to participate [5]. On arrival, a member of staff systematically informed consultants about the study, and after informed consent had been obtained, an SBIRT approach was initiated [16].

Referent doctors received brief training by addiction specialists (HR and JMJ) to screen for substance misuse and to perform brief interventions. The first step of the SBIRT approach consisted of screening for alcohol consumption [via the Alcohol Use Disorders Identification Test (AUDIT)], tobacco consumption (via the Short Fagerstrom Test) and PSU [via the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) v3.0], using an anonymous, self-administered questionnaire which all out-patients were asked to complete while awaiting their usual visit, as previously described [5].

Patients were invited to discuss screening results. Brief interventions were carried out by the patients' HIV specialist doctor, and consisted of (1) counselling, such as recalling the World Health Organization (WHO) thresholds for alcohol consumption misuse and offering help to quit smoking, (2) an interview in which motivation to quit and the level of concern about substance use

were discussed, and (3) a proposal to refer a patient with misuse to an addiction specialist. Risk consumptions were defined as an alcohol AUDIT test score ≥ 6 in women and ≥ 7 in men, a Fagerstrom Test score > 2 and psychoactive substance consumption in the past 3 months.

## Results and Discussion

During the study period, 1018 PLHIV completed the questionnaire: of these, 861 [84.6%; 95% confidence interval (CI) 82.2–86.7%] PLHIV returned the questionnaire to their physician (Fig. 1). Of the latter, 650 patients wished to discuss the results with their doctor (75.5%; 95% CI 72.5–78.3%), and brief interventions were performed in 405 patients (62.3%). Thus, 211 patients did not wish to discuss their results with the physician (24.5%). The sociodemographic characteristics of these patients did not differ from those of patients willing to discuss the results, except that alcohol dependence was less common in the former (AUDIT test score ≥ 13: 4.3% versus 9.3% in those unwilling and willing to discuss results, respectively; $P = 0.026$).

For alcohol consumption, a brief intervention was performed for 224 patients, including counseling for 211 patients, a motivational interview for 44 patients (19.6%) and referral to an addiction specialist for 18 patients (8.0%). The level of intervention was proportional to the severity of alcohol consumption: counseling was given to 98 (99%) patients with low-risk consumption, 68 (96%) patients with excessive consumption, and 45 patients (83%) with suspicion of alcohol dependence ($P < 0.001$). A motivational interview was performed for two (2%) patients with low-risk consumption, 15 (21%) patients with excessive consumption, and 27 patients (50%) with suspicion of alcohol dependence ($P < 0.001$). Referral to an addiction specialist was performed for three (4.2%) patients with excessive consumption and 15 (28%) patients with suspicion of alcohol dependence ($P < 0.001$).

For tobacco consumption, the results of the test were discussed with the physician in 243 patients; 86 (35.4%) of them accepted a smoking cessation aid, and 103 (42.4%) benefited from a motivational interview (Table 1). Among the 86 patients who accepted a smoking cessation aid, 35 (40.7%) were referred to an addiction specialist.

Concerning PSU, 309 patients who had consumed drugs in the last 3 months returned the questionnaire, 240 agreed to discuss the answers and 137 patients had at least one intervention: 136 (99%) received counseling, 20 (15%) had a motivational interview and nine (6.6%)
<figure><img src="image_3.png" /><figcaption>Fig. 1 Flow chart for the study patients [1]. PLHIV, people living with HIV.</figcaption></figure>

were referred to an addiction specialist: of these, 55% consumed synthetic cathinones every week or every day.

Screening by AUDIT, Fagerstrom or ASSIST questionnaires is used to determine whether the patient is eligible for a brief intervention: advice, motivational discussion or referral to a specialist physician. This method has been used among PLHIV for alcohol use [17]. Few data are available on the application of SBIRT in PLHIV for PSU [13,14]. The study by Graham *et al.* [14], performed between 2008 and 2013, showed positive screening (whatever the substance) in 58% of patients with

increased SBIRT penetration (Total number of SBIRT screens / total number of visits): 36% in 2008 and 69% in 2013, emphasizing the acceptability of the method. In our study, 84.6% of PLHIV gave the medical sheet to the physician and 62.3% received a brief intervention, highlighting the very good acceptability of the method and perhaps the willingness of the patients to initiate a dialogue with the doctor. Similarly, in another study in PLHIV, 85% of participants completed the clinician-based SBIRT intervention versus 40.6% who completed the web-based SBIRT intervention [13], showing that the
<table><caption>Table 1 Adaptation of interventions according to the Short Fagerstrom score for tobacco use in 243 patients with at least one intervention</caption><thead><tr><th>Variable</th><th>No or low dependence<br>(n = 63)</th><th>Moderate dependence<br>(n = 105)</th><th>High dependence<br>(n = 75)</th><th>P</th></tr></thead><tbody><tr><td>Counseling</td><td>59 (93.7)</td><td>98 (93.3)</td><td>68 (90.7)</td><td>0.74</td></tr><tr><td>Smoking cessation aid</td><td>14 (22.2)</td><td>42 (40.0)</td><td>30 (40.0)</td><td>0.04</td></tr><tr><td>Motivational interview</td><td>16 (25.4)</td><td>50 (47.6)</td><td>37 (49.3)</td><td>&lt; 0.001</td></tr><tr><td>Referral to addictologist</td><td>5 (7.9)</td><td>30 (28.6)</td><td>21 (28.0)</td><td>&lt; 0.001</td></tr></tbody></table>

Values given are n (%).

referent physician is probably a key factor in this approach. Indeed, the rates of exchange with the HIV referent physician seem to increase from nondrinkers, to nonproblematic drinkers, to problematic drinkers [17]. Similarly, in our study, we observed that the level of interventions significantly increased with the AUDIT and Fagerstrom scores. For PSU, the risk was not scored. This finding may indicate that participants with higher scores were more interested or motivated to seek information or help for their tobacco or alcohol use. This approach allowed referral to an addiction specialist for 18 and 56 patients with excessive alcohol and tobacco consumption, respectively. For PSU, only nine patients were referred to an addiction specialist, which is a small number compared with the proportion of patients consuming harmful psychoactive substances. Unfortunately, in our study, we did not evaluate the impact of the intervention on patient consumption and their management in the long term, although published data underscore the efficacy of SBIRT for alcohol consumption reduction in PLHIV [17].

Patients with negative screening (AUDIT score < 6 in women and < 7 in men) for alcohol may also benefit from clinician feedback, through simple recall of the thresholds for alcohol units contained in a glass, as reported in a previous study [18].

Barriers to the implementation of SBIRT in different health systems have been described in previous studies: physicians' lack of time, conflicts with other priorities, and lack of consistent communication were noted as potential barriers to SBIRT implementation in the general population [19], as well as lack of awareness of substance use problems, limited space and time of investigators, and lack of specialized services to which to refer patients [15]. The barriers to implementation of SBIRT in our health system are the same as those reported in these studies: a lack of time to implement this approach systematically during out-patient visits and the need for training.

In our study, we noted good acceptability of SBIRT among patients; unfortunately we did not assess the acceptability among doctors. PSU by PLHIV is a sensitive topic: in our study, most patients and doctors agreed to

discuss this issue, which allowed screening for significant and often underestimated consumption of substances, primarily alcohol, but also other psychoactive substances. This study allowed for close cooperation between HIV doctors and addictologists of the University Hospital of Montpellier for the optimal management of these PLHIV with PSU.

This pilot study has some limitations. First, we have no information regarding the reasons why 157 patients did not return the questionnaire. Secondly, a follow-up evaluation of the intervention's impact on consumption was not performed.

Substance abuse is a serious public health concern impacting morbidity and mortality, especially in PLHIV. SBIRT is a simple and evidence-based tool for risk screening and reduction that should be made available in HIV out-patient centres and should be easy for physicians to use. This approach could be systematically proposed as part of routine care, at least once a year, to all PLVIH in care settings.

## Acknowledgements

We thank the patients of the department who agreed to participate in this study.

*Financial disclosure:* No funding was received.

## Appendix : Members of the MesConsos study group

Nadine Atoui, René Baglioni, Vincent Baillat, Anke Bourgeois, Marie-Laure Casanova, Eric Delaporte, Vincent Faucherre, Carine Favier, Vincent Lemoing, Rachid Mansouri, Corinne Merle, Ana Montoya, Christina Psomas, Cyril Rousseau, Bénédicte Satgé, Vincent Tribout, Edouard Tuillon and Antoine Villadoro.

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