Date of Award

January 2026

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jennifer E. Edelman

Abstract

Background: Unhealthy alcohol use (UAU), defined as alcohol consumption at a level that has caused or has the potential to cause adverse physical, psychological, or social consequences, and particularly heavy episodic drinking (HED), is a risk factor for HIV infection that is often overlooked in HIV prevention settings. UAU impacts HIV infection risk through sexual decision-making mechanisms including condom use and pre-exposure prophylaxis (PrEP) adherence. Community-based HIV service organizations (HSO) may provide an opportunity to reach individuals with overlapping HIV risk, UAU, and low access to traditional healthcare systems. The feasibility and utility of UAU screening and intervention in the community-based HIV prevention setting remains understudied. Research Aims: In partnership with A Place to Nourish your Health (APNH), a large New Haven-based HSO, we sought to: 1) develop protocols for integrating UAU screening into HIV testing; 2) characterize the prevalence and associated sociodemographic and clinical correlates of UAU among clients presenting for HIV testing at the HSO and 3) elicit client and staff perspectives on the appropriateness, feasibility, and utility of integrated alcohol screening and intervention at the point of HIV testing. Methods: Together with APNH, we first collaboratively developed protocols for integrating the USAUDIT-C into HIV testing processes. Then, using data collected by trained APNH staff during the HIV testing process, we determined the percentage with UAU defined by USAUDIT-C >5 and characteristics independently associated with UAU using multivariable logistic regression. Consistent with a parallel mixed methods approach and guided by the Health Equity Implementation Framework (HEIF), we conducted interviews with clients with documented UAU and a focus group with APNH staff to elicit perspectives on the appropriateness, feasibility, utility and ideal format of alcohol screening and intervention at the point of HIV testing. We analyzed data using thematic analysis and used NVivo to facilitate data organization and retrieval. Results: Based on discussions with HSO leadership and Prevention staff, we integrated the 3-question USAUDIT-C into the counselor-administered HIV testing intake risk assessment, and trained counselors in its administration. From August 23, 2023, to September 25, 2025, among 1198 HIV testing encounters, 94% (1122/1198) received USAUDIT-C screening, 27% (303/1122) of encounters screened positive for UAU, and 25% (282/1122) endorsed past-year HED. Younger age was significantly associated with increased odds of UAU. Identifying as female versus male, men who have sex with men (MSM) versus non-MSM, and Multiracial versus White had reduced odds of UAU. Based on interviews with 12 clients and a focus group with 9 HSO staff, we found that: 1) the HSO is well-positioned as a trusted alternative for individuals with medical establishment mistrust, 2) alcohol screening was well-received as useful, and the HSO was perceived as an appropriate setting capable of developing an effective alcohol intervention program, and 3) clients trusted HIV counselors to deliver an evidence-based alcohol intervention, and counselors identified existing skillsets as well as training needs. Scientific Impact: This work has identified a substantial burden of UAU among clients seeking HIV testing at a community HSO. Our findings highlight the potential for integrated alcohol screening and intervention in this setting, particularly among young adults, to simultaneously address under-detected UAU and optimize HIV prevention.

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