Inclusion Criteria:
* Veteran.
* WHO risk drinking level of Very High or High in the 30 days prior to screening.
* Current diagnosis of moderate or severe AUD (i.e., meeting at least 4 of 11 DSM-5 AUD criteria) based on semi-structured diagnostic exam.
* Able and willing to provide informed consent.
Exclusion Criteria:
Medical and Psychiatric:
* Type 1 diabetes.
* Current serious psychiatric illness (i.e., schizophrenia, bipolar disorder, severe or psychotic major depression, borderline or antisocial personality disorder, eating disorder).
* Current DSM-5 diagnosis of a SUD (other than moderate-to-severe alcohol, any nicotine, or mild cannabis use disorders).
* At the time of randomization, moderate-to-severe alcohol withdrawal (Clinical Institute Withdrawal Assessment for Alcohol (CIWA-AR) \>8).
* BMI \<21 kg/m2.
* Unstable body weight defined as \>5% change in body weight (documented or self-report; intentional or not) in the 90 days prior to randomization.
* History of acute or chronic pancreatitis.
* History of diabetic ketoacidosis.
* History of proliferative diabetic retinopathy.
* History of ascites, advanced liver fibrosis, compensated cirrhosis with portal hypertension, decompensated cirrhosis, variceal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, or hepatocellular carcinoma (HCC).
* History of stage 3 fibrosis or stage 4 cirrhosis from a liver biopsy.
* Presence of gastroparesis.
* History of acute gallbladder disease in the prior 6 months.
* History of advanced fibrosis or cirrhosis, including (but not limited to) transient elastography (liver stiffness) of \>12 kPa, FIB-4 2.67, ELF 9.8, MRE 3.63 kPa.
* History of esophageal varices on endoscopy or imaging.
* History of nodular liver, cirrhosis, splenomegaly, varices or splenic venous shunting or collaterals on prior imaging.
* History or acute alcohol hepatitis (by liver biopsy or elevated bilirubin \> 1.5 times the upper limit of normal).
* History of primary biliary cholangitis.
* History of primary sclerosing cholangitis.
* History of autoimmune liver disease.
* History of hemochromatosis.
* History of Wilson's disease.
* History of alpha-10 antitrypsin-related liver disease.
* History of drug-induced liver disease.
* Personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2).
* Acute high risk of suicide requiring hospitalization at the time of screening or randomization.
* Medical, psychiatric, behavioral, or logistical conditions which, in the judgment of the Local Site Investigator (LSI) or Sub-Investigator (Sub-I), make it unlikely the participant can participate in or complete the 28-week active phase of the study.
* Recent major cardiovascular event in the 90 days prior to randomization (myocardial infarction, stroke, New York Heart Association class IV heart failure, transient ischemic attack (TIA), or unstable angina.
Laboratory
* Hemoglobin A1c (HbA1c)\>10.
* Estimated glomerular filtration rate (eGFR) \<30 mL/min.
* Albumin \< 3.5 g/dl.
* Aspartate aminotransferase (AST) \>3 the Upper Limit of Normal (ULN).
* Alanine aminotransferase (ALT) \>3 the ULN.
* Lipase \> 2 times the upper limit of normal.
* Alkaline phosphatase \> 1.5 times the ULN.
* Total bilirubin \> 1.5 times the ULN except with documented Gilbert's syndrome.
* International Normalized Ratio (INR) \> 1.3 unless due to anticoagulation therapy.
* Platelet count \<150,000/µL unless consistent with baseline and reflects the participant's habitual thrombocyte level, and there was no presence of portal hypertension.
* Hepatitis B surface antigen positive.
* Hepatitis C virus RNA positive - participants treated and cured of hepatitis C must have at least 2 years of negative testing.
* Anti-HIV antibody positive test with uncontrolled or unstable treatment.
* Positive urine drug screen for substances other than cannabis and prescribed medications.
* Positive urine pregnancy test at screening in those considered of childbearing potential.
Concurrent Treatments:
* Current (within the past 30 days) use of pharmacotherapy for AUD (including oral or intramuscular naltrexone, acamprosate, disulfiram, topiramate).
* Known history of prior hypersensitivity reaction to semaglutide, any of the product components, or any other GLP-1 analogue.
* Current (within the past 30 days) use of the following medications with glucose-lowering properties: GLP-1 analogues; sulfonylurea; insulin and insulin products; dipeptidyl peptidase-4 (DPP-4) inhibitors; sodium-glucose cotransporter-2 (SGLT-2) inhibitors or other medications that may interact with semaglutide.
* Recent changes in dose (within 2 months of randomization) of psychiatric medications (i.e., antidepressants, antianxiety, mood stabilizing).
Other
* Pregnant, actively breastfeeding, or female of childbearing potential who is unwilling to use a highly effective method of contraception as defined by the NIH \[67\].
* Currently enrolled in another therapeutic or investigational clinical trial.
* Participant is incarcerated.
