Substance Use Disorders in HIV People of Cameroon

1. Introduction 1.1. Background In low and middle income countries, 28.6 million people were eligible for antiretroviral therapy (ART) based on 2013 guidelines and only around 10 million were currently on ART. Cameroon is a lower-middle-income country with a prevalence of human immunodeficiency virus (HIV) infection in adults of 4.3% in 2011. In the same year, coverage for antiretroviral therapy in adults and children was 49.6%, demonstrating the immensity of the work to be done to achieve the goals of good ART coverage. The considerable expansion of access to HIV treatment in the world has changed the epidemic of HIV infection. The importance of ART is well established. Life expectancy of adults receiving ART is approximately 80% of the normal life expectancy. The preventive effect of ART is increasingly evident, even in cases where the HIV epidemic is concentrated. There exists the link between alcohol consumption and infectious diseases, with the deleterious effect of alcohol on disease progression. In Cameroon, in general population, adult (15+ years) per capita alcohol consumption was 13.74 litters of pure alcohol. Heavy episodic drinking is 8.4% and 2.1% respectively among males and females in Cameroon in general population. Alcohol binge drinking was found in 11.6% of people living with HIV on ART and in 20.6% of those who were interrupted their treatment. Binge drinking was defined for male as consumption of 5 or more drinks, for female as consumption of 4 or more drinks, in about 2 hours. Alcohol use disorders screened with cutting down, annoyance by criticism, guilty feelings, eye-openers (cage) questionnaire are present among 17% of adults HIV-infected in Cameroon. In Cameroon, the prevalence of non-adherence to ART was 22.5% based on the Community Programs for Clinical Research on AIDS index and 34.9% based on the Centre for Adherence Support Evaluation index. Alcohol is one of the main factors of ART interruption and ART non-adherence. The consumption of alcohol being on ART decrease response to highly active ART, and decrease health related quality of life. In general, health data, including HIV prevalence data, are less robust for key populations than for general populations due to complexities in sampling (and lack of size estimation data), legal concerns and issues of stigma and discrimination. To date, studies on injecting drug user in Cameroon, and even in sub-Sahara Africa are scarce among HIV-infected people. The estimation showed that in 2012 worldwide about 12.7 million people had recently injected drugs and that, of these, 13.1% was living with HIV. 1.2. Study rationale With this demonstrated burden so harmful of alcohol consumption and injecting drug use (IDU) among people living with HIV, it is necessary to measure the weight of alcohol consumption and IDU among HIV-infected adult on HAART; to understand why HIV-infected people consume alcohol and use injecting drug being on HAART in Cameroon, sub-Saharan Africa country; and to assess the impact of alcohol consumption and IDU on adherence to ART.
2. Study objectives The aim of this study is (1) to determine and describe the prevalence of alcohol consumption and IDU among HIV-infected people on HAART; (2) to determine sociodemographic factors associated with alcohol consumption and IDU among people on HAART; (3) and to determine impact of alcohol consumption and IDU on adherence to HAART.
3. Methods 3.1. Design The investigators will use cross-sectional design. The recruitment of participants will be conducted from January to June 2015. Socio-demographic data, adherence to ART, alcohol consumption will be self-reported by the patients with a questionnaire, but patient will can ask more clarifications if he/she not understood a question. The investigators will follow STROBE guidelines for the report this study. 3.2. Setting Cameroon is a sub-Saharan central Africa country, divided in ten region and with a population of 19,406,100 inhabitants in 2011. The adult prevalence rate of HIV in the country is 4.3%. In Yaoundé, capital of Cameroon, site of recruitment, the adult prevalence rate of HIV infection is 6.4% (3.6% for men and 8.9% for women). Subjects were recruited at Day Hospital in Yaoundé Central Hospital. It is the largest HIV clinic in the country. This is an urban center in the heart of Yaoundé city. 3.3. Participants The investigators will include in this study subjects who are aged 18 years or above and who were on HAART for at least one month. The investigators will exclude pregnant women. Informed consent will be a prerequisite for participating in the study, and will be provided verbally. 3.4. Data collection 3.4.1. Sociodemographic profile The investigators will collect age, gender, sexual orientation, last level of education, monthly household income, area of habitation, number or person in household, mode of healthcare payment, marital status, employment status, probable route of HIV infection and when, and disclosure of HIV status. 3.4.2. Alcohol consumption The investigators will use the Alcohol Use Disorders Identification Test (AUDIT) to identify subjects with at-risk, hazardous, or harmful drinking. AUDIT has a possible range from 0 to 40. A score ≤ 7 is classified as no current problem (low risk drinking), a score range between 8 - 15 is classified as probable current problem drinking (risky or hazardous drinking), a score range between 16 - 19 is classified as high risk or harmful drinking, and a score ≥ 20 as define harm and likely to be alcohol dependent. The investigators prefer to use self-reported questionnaire vs. interview questionnaire because it may produce more accurate answers, but patients who will not well understand a question, could ask more clarifications. The investigators will therefore use AUDIT screening instrument test to classify current drinkers as problem or non-problem drinkers at cut-off ≥ 8. Sensitivity and specificity of AUDIT is respectively 51%-97% and 78%-96%. The investigators will define as current drinkers, all patients who had consumed alcohol in the last 12 months. 3.4.3. Adherence to antiretroviral therapy The investigators will use several methods to measure adherence to ART: a linear visual analogue scale (VAS) on the past month and self-rate of adherence to ART in the last month using scale from '1 - very good' to '5 - very bad'. 3.4.4. Injecting drug use Patients will report if Yes or No, they have already used an injectable drug. If yes, they will give frequency and last time of use. 3.5. Statistical analysis 3.5.1. Sample size The sample calculation was based on alcohol consumption, because there is no data for IDU in Cameroon among HIV-infected people. The investigators assume that alcohol abuse among adults HIV-infected is 17%. With a 95% confidence interval (95%CI), acceptable difference of 5%; the minimal required sample size was 217 adult HIV-infected on ART. The investigators have used Windows Program for Epidemiologist (WinPepi, version 11.43) to estimate required sample size. Because the investigators will use self-reported questionnaire, the investigators suppose 20% for missing data. Therefore, the minimal required sample size will 272 for male and 272 for female because alcohol consumption was different between both sex (14). The investigators hope to have a sample of about 1,000 patients to have a high powered study. 3.5.2. Statistical method Data will be coded, entered, and analyzed using the Statistical Package for Social Science version 20.0 for Windows (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, New York: IBM Corp.). The investigators will describe continuous variables using means with standard deviations or using median with interquartile range, and categorical variables using their frequencies and percentages. For all tests, we will use 2-sided p-values with alpha < 0.05 level of significance. The investigators used χ² test or equivalents for categorical variables, Student T test for means, and Mann-Whitney U test for medians. Null hypothesis of no difference was rejected if the 95% CI of odds ratio (OR) estimates excluded 1. All regression analyses will be conducted with stepwise forward method with entry in model if p value ≤ 0.2. Multiple imputation will be used to handle missing data, creating a new data set which was the average of five data sets of imputed values. The investigators will only impute socio-demographic data for regression analysis.
4. Ethical considerations The study will be conducted in accordance with Helsinki Declaration. Prior to enrolment, all eligible participants will provide verbal consent. Patients with alcohol consumption, injecting drug use and/or non-adherence to ART will receive a counseling to address this problem according WHO recommendations.
5. Discussion

The expansion of the use of ART helped make HIV infection as a chronic disease. One of the major challenges to overcome is the effective use of ARVs to improve the outcome of people living with HIV. Consumption of alcohol and injecting drug by patients on HAART may be obstacles. The scientific evidence is already done for the first for its negative effect on antiretroviral therapy in others people than Africa but very few studies on the IDU are done, particularly in Africa. Even if there are data on alcohol consumption being on antiretroviral therapy exist in Africa, very few studies have a large sample size. More and to the best of our best knowledge, there are almost no studies on the prevalence of injecting drug use among HIV infected people in Africa, particularly in Cameroon.

With this study, the gap in knowledge about injecting drugs and alcohol and their effects on adherence to antiretroviral therapy may be addressed. This will guide future research. This knowledge can also provide to clinicians and policy makers of health, a light on the implementation of guidelines to improve the outcomes of people living with HIV in our context.

One of the limitations that might emerge during the implementation of this study is the presence of missing data, particularly related to data collection of the study by patients themselves. It is nonetheless necessary to use this form of data collection, since we will collect data on adherence to ARV treatment, on alcohol consumption, and on injecting drug use. In general, people tend to underestimate their alcohol consumption and overestimate adherence to treatment when a third party ask them a question about. In addition, the use of drugs is prohibited by law. Some patients may therefore deny its consumption. This is why no name or contact will be asked, no signature or written consent for participation in the study will be required for this study. We will thus use verbal consent.

The final report of this study in the form of scientific paper will be published in peer-reviewed journals. Findings will further be presented at conferences and submitted to relevant health authorities.