Unhealthy Alcohol Use in People Living with HIV: A Narrative Review

This narrative Review provides a synthesis of the current evidence on the epidemiology, mechanisms, and interventions for unhealthy alcohol use (UAU) in people living with HIV (PLWH). UAU and HIV form a syndemic relationship that negatively impacts HIV treatment outcomes, including reduced antiretroviral therapy (ART) adherence and viral suppression, and increased mortality. Despite the high prevalence rates of UAU among PLWH, screening and treatment gaps persist in this population. Behavioral factors-such as intentional ART skipping and condomless sex-and structural barriers, including poverty and alcohol-related stigma, further worsen HIV outcomes. Moreover, underutilized screening tools and provider hesitancy continue to hinder alcohol treatment for PLWH. Consequently, UAU remains underdiagnosed in PLWH, while those diagnosed are less likely to receive treatment. Promising interventions such as pharmacotherapy (e.g., naltrexone), cognitive behavioral interventions (e.g., motivational interviewing and contingency management), and combination economic empowerment programs (e.g. conditional and non-conditional cash transfers) are currently inconsistently implemented. Action is urgently needed to implement and standardize UAU screening and management in PLWH. Addressing this syndemic phenomenon demands a holistic approach combining medical/clinical, behavioral, and structural solutions to improve survival and quality of life for PLWH.