Syndemic Classes of Unhealthy Alcohol Use Reveal Inequities in Alcohol-Related Consequences and HIV Care Outcomes

Unhealthy alcohol use among people with HIV (PWH) often co-occurs with medical and mental health conditions and may negatively impact patient care. We examined syndemic classes of unhealthy alcohol use, substance use and comorbidities and their links to sociodemographic factors, alcohol treatment access, and HIV care outcomes.

Participants were 4574 adult PWH in Kaiser Permanente Northern California who reported alcohol use on routine primary care screening between 2013 and 2020 (index date). Latent class analysis identified subgroups based on alcohol use level and co-occurring conditions in the prior year, including smoking, alcohol and other substance use disorders, mental health diagnoses, chronic medical conditions, obesity, insufficient physical activity, and sexually transmitted infections. Age, race/ethnicity, sex, and HIV risk status were examined as predictors of class membership using latent class analysis (LCA) with covariates. HIV outcomes (viral suppression < 200 copies/mL, retention in care) and alcohol treatment in the year post-index (psychotherapy, medication) were compared across classes using Bolck, Croon, and Hagenaars (BCH) three-step procedure.

Four classes were identified: Heavy Use/Complex Behavioral Multimorbidity, Moderate Use/High Cardiometabolic Burden, Low Use/High Medical Morbidity, and Moderate Use/Low Morbidity. Black and women PWH were more likely to belong to the Moderate Use/High Cardiometabolic Burden class, while men who have sex with men were less likely to belong to the Heavy Use/Complex Behavioral Multimorbidity class. Classes differed in care outcomes: the Low Use/High Medical Morbidity class had the highest HIV care retention and viral suppression; the Heavy Use/Complex Behavioral Multimorbidity class had the highest alcohol treatment receipt; and the Moderate Use/High Cardiometabolic Burden class had the lowest psychotherapy rates.

Syndemic patterns of alcohol use and multimorbidity among PWH were associated with disparities in HIV outcomes and alcohol treatment. Findings highlight missed opportunities for integrated alcohol and cardiometabolic care and support targeted interventions to improve engagement.