Alcohol Use

Recommend screening for all persons with HIV at least once a year (in view of the high prevalence of problematic alcohol use)

Populations at particularly high risk

• Positive family and personal history of substance use
• Persons with mental health problems, particularly depression
• Adolescents
• Use of neurotropic and recreational drugs
• When assessing readiness to start and maintain ART
• As part of investigation of cognitive impairment, see Algorithm for Diagnosis and Management of Cognitive and Central Nervous System Neurological Symptoms

Ask: Do you ever consume alcoholic drinks?

If yes: explore with the Alcohol Use Disorders Identification Test-Concise (AUDIT-C), which is a brief alcohol screening instrument that identifies persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence):

1. Within the past year, how often did you have a drink of alcohol? (Score)
   Never (0)
   Monthly (e.g., on special or rare occasions) (1)
   2-4 times a month (2)
   2-3 times a week (3)
   4 or more times a week (4)
2. Within the past year, how many standard drinks containing alcohol did you have on a typical day? (Score)
   1 or 2 (0)
   3 or 4 (1)
   5 or 6 (2)
   7 to 9 (3)
   10 or more (4)
3. Within the past year, how often did you have six or more drinks on one occasion? (Score)
   Never (0)
   Less than monthly (1)
   Monthly (2)
   Weekly (3)
   Daily or almost daily (4)

> Alcohol use at risk if score is ≥ 5 (men) or ≥ 4 (women)

Explore whether three or more of the following characteristics appear simultaneously, or have been present in the last 12 months (ICD-10 criteria)

1. Intense desire or compulsion to consume
2. Decreased ability to control:
   • difficulties in controlling the onset of consumption
   • difficulties in ending intake and controlling the amount
3. Withdrawal symptomatology
4. Tolerance or neuroadaptation
5. Progressive abandonment of activities
6. Persistence in consumption despite the harmful consequences

Does the person meet ICD-10 criteria?
• NO: risky / harmful consumption
• YES: alcohol dependence - refer the patient to the addiction unit

For risky consumption or where alcohol services are not available, initiate brief intervention (Chander et al, 2015) or motivational interviewing (Hasin et al, 2013). See "Brief intervention and referral protocol of the College of Family Physicians of Canada and the Canadian Centre on Substance Abuse"