Welcome to the Project ReACH website on alcohol and health for men living with HIV

Over the past 10 years, we have come to realize the potential negative effects that drinking alcohol can have on HIV infection. This website is intended to provide you with summaries of some relevant information in an effort to help you make informed decisions about your drinking. There are links to web resources that teach you about ways to reduce your alcohol consumption, if that is something you decide to do.

Further, we have prepared brief written summaries and short video clips, written by experts, which provide answers to questions that many men living with HIV might have.

This webpage is designed for informational purposes only. What you decide to do and how you do it are entirely up to you!

A “drink” is a defined as a 12 ounce can of beer, a 5 ounce glass of wine, or a 1.5 ounce shot of 80-proof hard alcohol, like vodka or rum. Providers recommend that men drink no more than 14 drinks in a week, and never drink more than 4 drinks in the course of one day. For men without other medical or mental health problems, drinking less than this amount is not likely to bring about medical, emotional, or social problems. However, for men living with HIV, alcohol may have more negative effects on health than it does for other men. Currently, there are no established ‘safe’ levels of alcohol use for men living with HIV. Therefore, men with HIV should be careful to limit alcohol consumption as much as possible. Especially if you have chronic hepatitis B or C, or a recent hepatitis A infection, avoiding drinking completely is the best way to protect your liver and your health.

Alcohol can have negative effects on people living with HIV, both on their bodies and in terms of how they behave. On the body, alcohol can weaken the immune system and lower CD4 counts. The effects of alcohol on HIV infection depend on how much a person drinks. A number of studies have found that heavy drinkers, and those with alcohol problems, have lower CD4 counts than moderate drinkers—and are likely to have more copies of the HIV in their body (that is, a higher viral load). Regardless of how much you drink, it is still very important to take HIV medications to help control the effects of the virus on the body.

In terms of behavior, alcohol use can increase the chances that people living with HIV skip or miss doses of their HIV medications. People taking medications to fight HIV need to take their pills at least 95% of the time to get the best possible effect. If people don’t take their medications as prescribed, over time the virus will become resistant to the medications, which could have a serious impact on long-term health. People who miss doses regularly have to be prescribed new regimens and are more likely to have opportunistic infections and inpatient hospital stays. Those who drink heavily or have alcohol problems are especially likely to miss their medication doses. However, even moderate amounts of alcohol have been shown to increase the chances that people take their medications less than they’re prescribed.

The bottom line is that alcohol, especially heavy drinking, can negatively impact the progression of HIV in your body, both by directly affecting your body and through changing your behavior. If you’re going to drink alcohol, limit yourself to no more than 1 or 2 drinks a day, and make sure to take your HIV medications even when you are drinking. Some people have heard that it’s not safe to take their medications when alcohol is in their system but, for most people, that’s not true. It’s always better to take your medications than to skip taking them.

The liver is a vital organ that plays a major role in metabolism, digestion, controlling infections, and getting rid of toxins and bacteria from the blood. For people living with HIV, this organ is related to overall health and chances of survival.

Many HIV-infected people have liver disease, which is one of the leading causes of death in this population. Liver disease can occur because of alcohol abuse, being on HIV medications for a long period of time, and also having Hepatitis C—which is a chronic viral disease that harms the liver.

People living with HIV who drink alcohol have an increased chance of developing liver-related problems. People who drink heavily—which is defined as drinking more than 14 drinks a week, or who binge drink (which is drinking 5 or more drinks in a 2-hour period)—have an increased risk for liver damage, and are more likely to have advanced liver disease.

Certain classes of HIV medications, including nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs), have been associated with liver damage in HIV-infected people. If you are unsure of the type of medication you are on, ask your provider—because you may need to monitor your liver function more closely, and be especially careful about how much alcohol you drink. It’s also important to be honest with your provider about how much alcohol you’re drinking, to make sure that they’re aware of the need to monitor your liver functioning as part of your medical care.

While alcohol use and the use of anti-HIV medications can lead to liver problems on their own, alcohol use can also impact how well the HIV medications actually work. Among HIV-infected people who abuse alcohol and who also have liver function problems, the HIV medications may become less effective because the liver processes some of these medications; that is, you need your liver to help make best use of the medications. If the dose of medication is not properly adjusted, liver problems could lead to a harmful build-up of the medications in the system—thus making you sicker.

Other health problems also impact HIV medications and alcohol use. About 25% of HIV-infected people are also infected with Hepatitis C. People living with HIV who also have Hepatitis C need to be especially cautious about potential negative effects of alcohol on the liver. For example, a recent study found that 75% of HIV-infected people who died from end-stage liver disease also had Hepatitis C, and almost half of those who died were heavy drinkers. Therefore, people living with both HIV and Hepatitis C must be very careful when drinking—and the only safe drinking goal is to avoid alcohol altogether.

Liver function tests and assessing your drinking patterns can be important step in figuring out what your risk for liver damage. For many people, reducing drinking is an effective way to improve liver function.

Before there were effective treatments for HIV, it was very common for people with AIDS to show severe changes in their mental functioning. The good news is that effective HIV treatment has made such severe mental problems rare. However, even when treatment is so effective that HIV cannot be detected in the blood, people living with HIV do tend to show faster changes in their mental abilities as they get older compared to people without HIV.  In particular, people living with HIV are more likely to report memory problems, slowness in their thinking, difficulties in concentration and planning, and find it more difficult to do multiple tasks at the same time.

The most important thing you can do to maintain your mental abilities as you age is to follow the directions of your treatment provider, and treat HIV as effectively as possible. For most people, this means taking antiretroviral therapy as prescribed by your provider, at least 95% of the time. However, it is also is up to you to make sure you are taking care of your health in a way that helps your brain stay strong. This also includes watching how much you drink.

Our brains are very vulnerable to alcohol and, over a long period of time, a great deal of damage can be caused by heavy drinking. The areas that are most affected are those responsible for short-term memory, fast mental processes and movements, memory for words, attention, and decision making. Unfortunately, these are many of the same areas that are typically affected by HIV. In fact, in people living with HIV, heavy drinking appears to be especially harmful to the brain.

On average, people living with HIV report feeling “drunk” with less alcohol than those who do not have HIV, and they are more likely to forget to take their medications when drinking alcohol compared to people without HIV. This suggests that HIV infection makes the brain particularly vulnerable to alcohol’s effects.

Limiting drinking as much as you can, and avoiding heavy drinking in a given day, are two things you can do to help keep your brain healthy in the long-term.

If you have noticed worsening of your mental abilities over the past few years, there are many reasons that could occur—including the normal process of aging. However, many changes that are caused by heavy drinking may improve if you were to reduce or stop your drinking.

If your mental abilities have been not affected by age, HIV, or alcohol, limiting your drinking and getting the best possible treatment for your HIV should help maintain your mental abilities to be as strong as possible while you age.

The research evidence tells us a few important things about how alcohol plays a role in people’s ability to take their HIV medications regularly.

Does alcohol affect people’s ability to take their medications?
Yes. First, we know that many people who are living with HIV report drinking alcohol. Also, we know that some people living with HIV have reported “alcohol use” as a significant reason for their missing doses. A variety of research studies have born this out, and it’s definitely something that our patients report to us as well. Research also shows us that people living with HIV who drink alcohol tend to have a higher viral load and lower CD4 count—and we think these differences are mostly due to medication non-adherence, although it’s also possible that having alcohol in one’s body has a direct affect on the immune system as well.

So, why is it important to take your medicines?
Just a little reminder: it’s essential to take every dose of your HIV medications, everyday, as prescribed by your doctor. Taking nearly all of the doses prescribed to you is essential for maintaining your health. Taking doses “95% of the time” is a common figure that providers encourage patients to try to meet. The combination of multiple medicines is needed to fight the virus in different ways, so it’s important to always take all of the pills in a given dose. Also, for the medications to work best, they need to consistently be fighting the virus—so there always needs to be ‘enough’ medicine in your body at a given time to keep the virus under control.

How much drinking appears to affect medication adherence?
Overall, the more a person drinks, the poorer we find their ability to take their medications consistently. This appears to be true for people who drink frequently, as well as for people who don’t drink as often but who ‘binge’ when they do. Some studies have shown simply that the more drinks a person reports having in a given week, the more doses of medication that they missed. In other studies, people who drink a couple drinks a week didn’t appear to have problems with adherence but, after a certain threshold, adherence dropped off quickly. People who have problems in their lives from drinking—like having arguments with friends of family about how much they drink, or getting into trouble at work or school because of falling behind or not showing up—appear most consistently to have problems with adherence. In one study of alcohol use and HIV medication adherence, the researchers found that, on days in which participants drank, they were nine times more likely to miss a dose, and that each drink they had increased the odds of their missing a dose by 20%.

People living with HIV who drink more than 14 drinks a week, or who drink more than 4 drinks in a day, are most likely to be non-adherent and in need of some support. Also, medication regimens that are more complicated (that is, those with more doses or with special instructions) appear to be especially difficult to stick to on drinking days.

If you ever think your alcohol use is getting in the way of taking your medications, you should be sure to bring it up at your next appointment with your counselor or your medical provider.

It would be impossible to be living in modern society and not to be exposed to images and ideas indicating that alcohol and sex go together. This has been a topic under intense study for decades, and there is a big body of research literature out there. Here are a few highlights:

Do alcohol and sex go together?
You know, for a lot of people, they do. On average, people are more likely to have sex on days when they drink alcohol compared to days when they do not. Men who have sex with men are more likely to drink alcohol than other men, and studies show that many men engage in ‘binge drinking’ two or three times a month. There are lots of reasons why men drink; some of them are to relax or escape from life more generally, and some of them have to do with sex specifically.

Sometimes men drink alcohol so that they can feel less shy or anxious, and then it feels easier to pursue other men for dating or sex. Some men find that alcohol makes them feel sexy, or more sexual (like, they feel more ‘in the mood’ to have sex). And some report that drinking increases their enjoyment of sexual activities. Also, historically, we’ve seen a lot of men meeting each other, and looking for dates or sex, in places where drinking is occurring—like in bars and clubs. That is somewhat different today, given the use of the internet to meet partners, but still drinking alcohol appears to go hand-in-hand with sex for many men.

What are the downsides of combining alcohol and sex?
So it seems that drinking makes some men more interested in sex, and some men use alcohol to help them to be more direct at expressing their interest in sex with potential partners. However, we know that there are definitely some downsides to the alcohol-sex combination as well.

First, some men find it difficult to maintain an erection when they’ve been drinking, especially when they’ve had a lot to drink on a given day. Not being able to ‘perform’ as well as they’d like can be embarrassing. Also, research shows that, when people are drinking, they are more likely to report having sex with someone they wouldn’t have had sex with otherwise. This can lead to sexual encounters that they regret later.

Research shows that, even though drinking may help get people together for sex, it actually gets in the way of them negotiating what happens next. Communication about sexual interests and preferences—like ‘how far’ they want the interaction to go, and whether or not they want to use a condom—can get muddled when alcohol is involved. Thus, alcohol use can lead to situations in which people have sex (or even engage in a particular sex act) that they weren’t sure they wanted, which can be upsetting or even traumatic. What seems more common is that, even if men are comfortable with the sex that happens, they may end up having unprotected sex when they hadn’t intended to. For men living with HIV, there exists the possibility of transmitting HIV to an uninfected partner, which continues to spread the virus within the community. Also, having unprotected sex can lead to men contracting other sexually transmitted infections (STIs), which can divert the immune system’s resources away from fighting HIV—and increase the chances of getting sick or needing a hospital stay. Also, some STIs, like herpes, tend to be more severe in people with HIV.

Limiting drinking can help keep you in control of your body and your choices. Limiting drinking can allow you to make decisions for yourself about what sexual experiences you have and who you have them with.

If you have decided that it is important to change your drinking, the first step in making that change is setting a goal. The safest goal for your health is to choose not to drink at all. This goal is most appropriate if you have chronic hepatitis, or any other medical or mental health condition worsened by drinking—or if you have tried to limit your drinking in the past and not been able to do so.

If you decide you want to keep drinking but cut down on your alcohol use, there are a few limits to keep in mind. First, in general, men are advised not to drink more than 14 drinks per week (that’s an average of 2 drinks/day) AND never to drink more than 4 drinks on any one day. However, these limits have not been established to be safe for men living with HIV.  We would expect the recommendations to be lower for people living with any chronic illness, including HIV. Thus, we recommend that you set your limits to no more than 2 drinks on any day.

Set specific goals for how often you will drink alcohol, and how much you will drink. Then, keep track of what you are drinking. Write down what you drink each day on a 3 X 5 card or a calendar, or keep track on your smart phone or PDA. If you write down each drink before you start drinking it, that will slow you down, and help you think through whether you want to drink another drink beforeyou have it. It will also help you keep more accurate records!

Remember, one drink is equal to a 12 ounce can or bottle of beer, 5 ounces of wine, or one shot of hard alcohol, like vodka or whiskey.

To slow yourself down when drinking, plan to drink no more than 1 drink each hour. Sip the drink rather than gulp it. If you finish the drink in less than an hour, get a non-alcoholic drink. That will give you something to sip on until it’s time for your next scheduled alcoholic drink. Drinking alcohol with food also can slow down how fast the alcohol is absorbed, keeping the alcohol levels in your blood lower, and helping you stay in control.

It is also important to become aware of the people and places that you tend to be around when you drink heavily. Plan alternative activities or spend time with friends who do not drink or who drink moderately.

If you get a craving to drink more quickly and get drunk, remind yourself of why you have made the decision to limit your drinking. Think about the reasons for why you want to work to reduce your drinking, and how you’ll benefit. Notice the urges you have to drink (or binge drink), accept that you’re having them, and let them run their course—without acting on them. Urges will definitely pass if you ride them out.

Finally, there may be times where you have decided it is better not to drink. In those situations, be ready to say “no.” Sometimes the hardest part of maintaining your commitment not to drink is not giving in when other people pressure you to drink with them. Practice what you’ll say, and say it quickly. The more clearly you indicate that you intend not to drink, the less likely people will be to continue to offer you drinks in the future.

These are some simple tips for cutting down on drinking. Many people are successful in reducing their drinking and improving their health by following these strategies. If these don’t work for you, quitting drinking altogether may be a better option. Seek support for quitting from friends, family, and medical or mental health professionals. Attending a mutual support group like Alcoholics Anonymous can also be very helpful, as can some of the other resources listed on this webpage. Good luck and good health.

Project ReACH

Ansin Building

1340 Boylston Street
Boston, MA 02215




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