DISCUSSION
PWH, viral suppression, Viral suppression
HIV VIRAEMIA
In this RCT, a brief culturally adapted alcohol counselling intervention over 12 weeks did not increase the likelihood of viral suppression at 24 weeks among adult PWH with unhealthy alcohol use and a high risk of HIV viraemia. Viral suppression at 24 weeks increased from 60% to over 80% in both intervention and control participants. Unhealthy alcohol use declined in both study arms with a significant 14% relative reduction in the intervention arm compared to the control arm.There are several potential explanations for our main findings. First, a 14% reduction in unhealthy alcohol use may have been insufficient to drive differences in viral suppression among intervention participants. Alcohol use has been linked to decreased viral suppression among PWH [Second, the lack of effect on viral suppression may be because modern ART regimens containing integrase strand transfer inhibitors (INSTIs) are robust and may yield viral suppression even with suboptimal adherence [Third, factors outside of the alcohol counselling intervention may have driven the high viral suppression in both arms. Our study procedures, which identified unhealthy alcohol use through screening, provided brief alcohol counselling in the control, gave viral load feedback and gave transportation reimbursements, coupled with universal ART eligibility may have been sufficient to increase engagement in care and adherence, yielding the increase in viral suppression from 60% to >82% in both arms. Additionally, adaptations to HIV care provision due to COVID‐19 pandemic restrictions and increased provision of differentiated care models [Our trial resulted in a significant reduction in unhealthy alcohol use among intervention participants compared to control. This is one of the first alcohol intervention trials, to our knowledge, to incorporate PEth into the alcohol outcome measure. The composite measure of unhealthy alcohol, comprised of self‐report and an alcohol biomarker (i.e. AUDIT‐C ≥3 for women, ≥4 for men or PEth ≥50 ng/ml), helps to overcome limitations in the sensitivity of either measure alone and to reduce bias introduced by potential discrepancies in self‐report and PEth that have been demonstrated in PWH in observational studies in Uganda [Our trial has several limitations. In this individual RCT, there was potential for contamination between trial arms if participants discussed or shared counselling resources [