Self-reported alcohol abstinence associated with ART initiation among HIV-infected persons in rural Uganda

Medicinal plants used by traditional medicine practitioners in treatment of alcohol-related disorders in Bushenyi District, southwestern Uganda

Background

Alcohol-related disorders rank seventh among risk factors for morbidity and mortality globally, posing a significant public health burden. In Africa, including Uganda, there is limited availability and utilization of pharmacotherapies to treat alcohol-related disorders. This study documented medicinal plant species, plant parts used, and the methods of preparation and administration utilized by Traditional Medicine Practitioners (TMPs) in treating alcohol-related disorders in southwestern Uganda.

Methods

A descriptive cross-sectional ethnopharmacological survey was conducted among TMPs within Bushenyi District, southwestern Uganda. Data was collected with key informant interviews using semi-structured questionnaires. The TMPs identified medicinal plants by local names. Plant specimens were collected and deposited at the Department of Biology, Faculty of Science, Mbarara University for identification and voucher numbers allocated. The plant scientific names and species were identified based on the International Plant Names Index. Plant species, family, life form, number of mentions, method of collection, preparation and administration were analyzed using descriptive statistics in Microsoft Excel. The survey data were utilized to compute Frequency of Citation, Relative Frequency of Citation, and Informant Consensus Factor.

Results

We enrolled 50 traditional medicine practitioners aged between 34 and 98 years, with a mean age of 67. Approximately two-thirds were female (66%, 33/50), and mean experience in traditional healing was 31 years. The total number of plants identified were 25 belonging to 20 families. The most prevalent plant life form was herbs (36%) while grasses (4%), were the least. Leaves (48%) were the most utilized plant parts with the least utilized being the barks. The most prevalent method, adopted by approximately one-third of the TMPs, involved drying the plant material in the sun. The Informant Consensus Factor was 0.67.

Conclusion

The study shows that the traditional medicine practitioners in Bushenyi district use a wide diversity of plants species to treat alcohol related disorders. The relatively high Informant Consensus Factor suggests a significant level of agreement among TMPs regarding the use of the identified plants. We recommend further investigations into phytochemistry, safety, efficacy, and mechanisms of action of the identified plants.

Patient perceptions of facilitators and barriers to reducing hazardous alcohol use among people living with HIV in East Africa

BACKGROUND

Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use.

METHODS

We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 - 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time.

RESULTS

People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers' recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social environment, alcohol accessibility and alcohol dependency.

CONCLUSIONS

Interventions that capacity-build professional and lay health care workers with the skills and resources to decrease problematic alcohol use, along with alcohol cessation in peer support structures, should be explored.

Two or more significant life-events in 6-months are associated with lower rates of HIV treatment and virologic suppression among youth with HIV in Uganda and Kenya

Youth living with HIV in sub-Saharan Africa have poor HIV care outcomes. We determined the association of recent significant life-events with HIV antiretroviral treatment (ART) initiation and HIV viral suppression in youth aged 15-24 years living with HIV in rural Kenya and Uganda. This was a cross-sectional analysis of 995 youth enrolled in the SEARCH Youth study. At baseline, providers assessed recent (within 6 months) life-events, defined as changes in schooling/employment, residence, partnerships, sickness, incarceration status, family strife or death, and birth/pregnancy, self-reported alcohol use, being a parent, and HIV-status disclosure. We examined the frequencies of events and their association with ART status and HIV viral suppression (<400 copies/ul). Recent significant life-events were prevalent (57.7%). Having >2 significant life-events (aOR = 0.61, 95% CI:0.45-0.85) and consuming alcohol (aOR = 0.61, 95% CI:0.43-0.87) were associated with a lower odds of HIV viral suppression, while disclosure of HIV-status to partner (aOR = 2.39, 95% CI:1.6-3.5) or to family (aOR = 1.86, 95% CI:1.3-2.7), being a parent (aOR = 1.8, 95% CI:1.2-2.5), and being single (aOR = 1.6, 95% CI:1.3-2.1) had a higher odds. This suggest that two or more recent life-events and alcohol use are key barriers to ART initiation and achievement of viral suppression among youth living with HIV in rural East Africa.Trial registration: ClinicalTrials.gov identifier: NCT03848728..

Alcohol-Antiretroviral Therapy Interactive Toxicity Beliefs and Intentional Medication Nonadherence: Review of Research with Implications for Interventions

The successful treatment of HIV infection relies on adherence to antiretroviral therapy (ART). Alcohol use remains a threat to ART adherence, including the beliefs held by people who drink alcohol that it is harmful to take ART when consuming alcohol (i.e., alcohol-ART interactive toxicity beliefs, AA-ITB). We reviewed the current research that has investigated AA-ITB and their relationship to intentional ART nonadherence. The review of 17 published studies found that AA-ITB are prevalent among people receiving ART and that AA-ITB are directly associated with ART nonadherence and incomplete HIV suppression. Family, friends and healthcare providers are common sources and reinforcers of AA-ITB. Studies suggest that AA-ITB may best be explained by the Medication Necessity and Concerns Beliefs Model, treating AA-ITB as a specific circumstance of medication concerns. Interventions are needed to communicate the realities of potential medication interactions and dispel myths that it is harmful to mix alcohol with ART, while not inadvertently suggesting that it is safe to drink with all medications, which could undermine adherence to ART by increasing alcohol use.

Pancreatogenic Diabetes: Triggering Effects of Alcohol and HIV

Multiorgan failure may not be completely resolved among people living with HIV despite HAART use. Although the chances of organ dysfunction may be relatively low, alcohol may potentiate HIV-induced toxic effects in the organs of alcohol-abusing, HIV-infected individuals. The pancreas is one of the most implicated organs, which is manifested as diabetes mellitus or pancreatic cancer. Both alcohol and HIV may trigger pancreatitis, but the combined effects have not been explored. The aim of this review is to explore the literature for understanding the mechanisms of HIV and alcohol-induced pancreatotoxicity. We found that while premature alcohol-inducing zymogen activation is a known trigger of alcoholic pancreatitis, HIV entry through C-C chemokine receptor type 5(CCR5)into pancreatic acinar cells may also contribute to pancreatitis in people living with HIV (PLWH). HIV proteins induce oxidative and ER stresses, causing necrosis. Furthermore, infiltrative immune cells induce necrosis on HIV-containing acinar cells. When necrotic products interact with pancreatic stellate cells, they become activated, leading to the release of both inflammatory and profibrotic cytokines and resulting in pancreatitis. Effective therapeutic strategies should block CCR5 and ameliorate alcohol's effects on acinar cells.

Alcohol Availability, Cost, Age of First Drink, and Its Association with At-Risk Alcohol Use in Moshi, Tanzania

BACKGROUND

The Kilimanjaro region has one of the highest levels of reported alcohol intake per capita in Tanzania. Age at first drink has been found to be associated with alcohol problems in adulthood, but there is less information on the age of first drink in the Kilimanjaro region and its associations with alcohol-related consequences later in life. Furthermore, local alcohol cost and availability may influence the prevalence of alcohol use and alcohol use disorders.

METHODS

Data on the age of first drink, alcohol use disorder identification tool (AUDIT), number and type of alcohol consequences (DrInC), and perceived alcohol at low cost and high availability for children and adolescents were collected from an alcohol and health behavior survey of injury patients (N = 242) in Moshi, Tanzania. Generalized linear models were used to test age at first drink, perceived alcohol cost and availability, and their association with the AUDIT and DrInC scores, and current alcohol use, respectively.

RESULTS

Consuming alcohol before age 18 was significantly associated with higher AUDIT and DrInC scores, with odds ratios of 1.22 (CI: 1.004, 1.47) and 1.72 (CI: 1.11, 2.63), respectively. Female gender is strongly associated with less alcohol use and alcohol consequences, represented by an odds ratio of 3.70 (CI: 1.72, 8.33) for an AUDIT score above 8 and an odds ratio of 3.84 (CI: 2.13, 6.67) with the DrInC score. Perceived high availability of alcohol for children is significantly related to higher alcohol use quantity, with the odds ratio of 1.6 (CI: 1.17, 2.20).

CONCLUSIONS

The first use of alcohol before the age of 18 is associated with higher alcohol use and alcohol-related adverse consequences. In Tanzania, age at first drink is an important target for interventions aiming to prevent negative alcohol-related consequences later in life.

Lower rates of ART initiation and decreased retention among ART-naïve patients who consume alcohol enrolling in HIV care and treatment programs in Kenya and Uganda

Objectives

Almost 13 million people are estimated to be on antiretroviral therapy in Eastern and Southern Africa, and their disease course and program effectiveness could be significantly affected by the concurrent use of alcohol. Screening for alcohol use may be important to assess the prevalence of alcohol consumption and its impact on patient and programmatic outcomes.

Methods

As part of this observational study, data on patient characteristics and alcohol consumption were collected on a cohort of 765 adult patients enrolling in HIV care in East Africa. Alcohol consumption was assessed with the AUDIT questionnaire at enrollment. Subjects were classified as consuming any alcohol (AUDIT score >0), hazardous drinkers (AUDIT score ≥8) and hyper drinkers (AUDIT score ≥16). The effects of alcohol consumption on retention in care, death and delays in antiretroviral therapy (ART) initiation were assessed through competing risk (Fine & Gray) models.

Results

Of all study participants, 41.6% consumed alcohol, 26.7% were classified as hazardous drinkers, and 16.0% as hyper drinkers. Depending on alcohol consumption classification, men were 3–4 times more likely to consume alcohol compared to women. Hazardous drinkers (median age 32.8 years) and hyper drinkers (32.7 years) were slightly older compared to non-hazardous drinkers (30.7 years) and non-hyper drinkers (30.8 years), (p-values = 0.014 and 0.053 respectively). Median CD4 at enrollment was 330 cells/μl and 16% were classified World Health Organization (WHO) stage 3 or 4. There was no association between alcohol consumption and CD4 count or WHO stage at enrollment. Alcohol consumption was associated with significantly lower probability of ART initiation (adjusted sub-distribution hazard ratio aSHR = 0.77 between alcohol consumers versus non-consumers; p-value = 0.008), and higher patient non-retention in care (aSHR = 1.77, p-value = 0.023).

Discussion

Alcohol consumption is associated with significant delays in ART initiation and reduced retention in care for patients enrolling in HIV care and treatment programs in East Africa. Consequently, interventions that target alcohol consumption may have a significant impact on the HIV care cascade.

Alcohol-Related Intentional Antiretroviral Nonadherence among People Living with HIV: Test of an Interactive Toxicity Beliefs Process Model

Beliefs that it is harmful to mix medications with alcohol (ie, interactive toxicity beliefs) are a known source of intentional antiretroviral therapy (ART) nonadherence. This study examined a serial process model of alcohol-ART interactive toxicity beliefs, alcohol-ART avoidance behaviors, and ART adherence in the association between alcohol use and HIV viral load. Participants were 198 patients receiving ART from a community clinic in the southeastern United States; 125 reported current alcohol use. Results showed that current alcohol use was associated with detectable HIV viral load, partially accounted for by alcohol-ART interactive toxicity beliefs, alcohol-ART avoidance behaviors, and ART adherence. There was a significant indirect effect of the serial chain of interactive toxicity beliefs-avoidance behaviors-adherence, indicating the 3 intermediating variables partially accounted for the relationship between alcohol use and HIV viral load. Addressing alcohol use as a barrier to ART adherence requires multipronged approaches that address intentional nonadherence.

Stigmatisation of alcohol use among people receiving antiretroviral therapy for HIV infection, Cape Town, South Africa

Antiretroviral therapy (ART) effectively treats HIV infection, with improved longevity and quality of life among people living with HIV. Alcohol use, however, remains a robust barrier to ART. This study, for the first time, examined the effects of the stigmatisation of alcohol use on ART adherence. Patients receiving ART in Cape Town, South Africa who currently drink alcohol (N = 187) and those who do not drink alcohol (N = 106) completed measures of alcohol use, alcohol-ART adherence, and alcohol-ART stigma. Participants also provided permission to access their most recent HIV viral load from clinic medical records. Results of a mediation model demonstrated significant detrimental effects of alcohol use on ART adherence. In addition, the indirect effects of alcohol use on ART adherence through alcohol-ART stigma was also significant, indicating that alcohol-ART stigma at least in part mediates the association between alcohol use and ART adherence. The same pattern of results was observed in relation to HIV viral load obtained from medical records. Interventions designed to address alcohol use as a barrier to ART adherence should incorporate alcohol-ART stigma as a barrier to adherence as well as a barrier to participating in adherence interventions.

Alcohol-related beliefs and non-adherence to antiretroviral therapy in Cape Town, South Africa

The life-saving effects of antiretroviral therapy (ART) in treating HIV infection are compromised by alcohol use. A growing body of research shows that both unintentional (e.g., memory lapses) and intentional (e.g., forgoing ART to avoid mixing with alcohol) contribute to ART non-adherence. Beliefs that it is harmful to mix alcohol with ART (alcohol-ART interactive toxicity beliefs) contribute to intentional non-adherence, but their role in overall adherence is not clear. This study conducted a clinic-based survey with 100 men and 193 women (mean age = 36) to examine the prevalence of alcohol-ART interactive toxicity beliefs and whether they contribute to treatment non-adherence in South Africa. One in three (36%, n = 106) participants reported no current alcohol use and 64% (n = 187) reported current alcohol use. The majority of participants, including current alcohol drinkers, endorsed beliefs that it is harmful to mix ART and alcohol, with 57% who currently drink reporting that they forgo taking ART when they are drinking. Participants reported being warned not to mix alcohol and ART from family, friends, and health care providers. In addition, 62% of participants who do not drink, as well as 36% of those who do drink, tell others not to mix alcohol and ART. Mediation modelling found that alcohol use directly predicts ART adherence, and that this relationship is partially mediated by alcohol-ART interactive toxicity beliefs. Health care providers can play a critical role in disputing interactive toxicity beliefs and encouraging patients to take ART even when they are drinking.

Comparing Alcohol Use Disorders Identification Test (AUDIT) with Timeline Follow Back (TLFB), DSM-5 and Phosphatidylethanol (PEth) for the assessment of alcohol misuse among young people in Ugandan fishing communities

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Validated tools are needed to evaluate alcohol-reduction interventions in low income countries.

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Among young Ugandans ACASI-administered 30-day and 12-month-AUDIT have good diagnostic properties.

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Self-reported AUDIT provides an efficient means of assessing alcohol misuse.

Background

Validated tools for assessing alcohol use among young people in low-income countries are needed to estimate prevalence and evaluate alcohol-reduction interventions. We validated Alcohol Use Disorders Identification Test (AUDIT) against Timeline Follow Back (TLFB), Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and phosphatidylethanol (PEth); and the 30-day-AUDIT against the 12-months-AUDIT among young Ugandans.

Methods

In 2018, we collected retrospective data on 30-day and 12-month AUDIT, TLFB and DSM-5 in a cross-sectional study of 15–24 year old residents of Ugandan fishing communities. AUDIT was administered by Audio Computer Assisted Self-Interviewing (ACASI) and DSM-5 and TLFB by psychiatric nurses. We determined PEth16:0/18:1 levels from dried blood spots using liquid chromatography tandem-mass spectrometry (heavy usage, ≥210 ng/mL) and calculated sensitivity and specificity of AUDIT against the other measures.

Results

Among 1281 participants (52.7% male, mean age 20 years), half (n = 659; 51.4%) reported ever drinking alcohol, 19.4% had 12-month-AUDIT ≥ 8 (21.5% men; 17.0% women), and 24.2% had 30-day-AUDIT ≥ 8 (29.0% men; 18.9% women). Twenty percent of participants had detectable PEth with 55 (4.3%) classified as heavy drinkers; 50.7% reported ≥ 2 symptoms on DSM-5 and 6.3% reported binge drinking in the previous month based on TLFB (8.9% men, 3.5% women). The 30-day-AUDIT ≥ 8 had sensitivity 86.7%, 95%CI: 81.8%–90.7% and specificity 90.9%, 95%CI:89.0%–92.6% versus 12-month-AUDIT ≥ 8. Both 30-day and 12-month-AUDIT ≥ 8 were sensitive and specific markers of heavy drinking by PEth (12-month-AUDIT sensitivity = 80.0%; 95%CI:67.0%–89.6%; specificity = 83.3%; 95%CI:81.1%–85.3%). The 30-day-AUDIT was a sensitive and specific marker of binge drinking based on TLFB (sensitivity = 82.7%; 95%CI:72.7%–90.2%, specificity = 79.8%; 95%CI:77.4%–82.1%); 12-month-AUDIT had lower sensitivity. Both 30-day and 12-month AUDIT ≥ 8 were highly specific but insensitive markers of having DSM-5 ≥ 2 symptoms.

Conclusion

Among young people in Uganda, ACASI-administered 30-day and 12-month-AUDIT have good diagnostic properties compared to PEth, DSM-5 and TLFB. Self-reported AUDIT provides a quick and valid means of assessing alcohol misuse in these communities.

Is physician assessment of alcohol consumption useful in predicting risk of severe liver disease among people with HIV and HIV/HCV co-infection?

BACKGROUND

Alcohol consumption is a known risk factor for liver disease in HIV-infected populations. Therefore, knowledge of alcohol consumption behaviour and risk of disease progression associated with hazardous drinking are important in the overall management of HIV disease. We aimed at assessing the usefulness of routine data collected on alcohol consumption in predicting risk of severe liver disease (SLD) among people living with HIV (PLWHIV) with or without hepatitis C infection seen for routine clinical care in Italy.

METHODS

We included PLWHIV from two observational cohorts in Italy (ICONA and HepaICONA). Alcohol consumption was assessed by physician interview and categorized according to the National Institute for Food and Nutrition Italian guidelines into four categories: abstainer; moderate; hazardous and unknown. SLD was defined as presence of FIB4 > 3.25 or a clinical diagnosis of liver disease or liver-related death. Cox regression analysis was used to evaluate the association between level of alcohol consumption at baseline and risk of SLD.

RESULTS

Among 9542 included PLWHIV the distribution of alcohol consumption categories was: abstainers 3422 (36%), moderate drinkers 2279 (23%), hazardous drinkers 637 (7%) and unknown 3204 (34%). Compared to moderate drinkers, hazardous drinking was associated with higher risk of SLD (adjusted hazard ratio, aHR = 1.45; 95% CI: 1.03-2.03). After additionally controlling for mode of HIV transmission, HCV infection and smoking, the association was attenuated (aHR = 1.32; 95% CI: 0.94-1.85). There was no evidence that the association was stronger when restricting to the HIV/HCV co-infected population.

CONCLUSIONS

Using a brief physician interview, we found evidence for an association between hazardous alcohol consumption and subsequent risk of SLD among PLWHIV, but this was not independent of HIV mode of transmission, HCV-infection and smoking. More efforts should be made to improve quality and validity of data on alcohol consumption in cohorts of HIV/HCV-infected individuals.

Biomarker-Measured Unhealthy Alcohol Use in Relation to CD4 Count Among Individuals Starting ART in Sub-Saharan Africa

Individuals are initiating antiretroviral therapy (ART) at earlier HIV disease stages. Unhealthy alcohol use is a known barrier to successful HIV treatment outcomes, yet it is unclear whether the problem varies by disease stage. We measured alcohol use with an objective biomarker (phosphatidylethanol [PEth]), comparing individuals (n = 401) with early (CD4 > 350 cells/mL, WHO Stage 1) versus late (CD4 < 200 cells/mL) ART initiation in HIV care in Uganda and South Africa (SA). We examined the association between CD4 count and biomarker results using multivariable regression modeling, and compared PEth results to self-report to assess underreporting. Overall, 32.2% (n = 129) had unhealthy alcohol use (PEth ≥ 50 ng/ml). Early ART initiation was significantly associated with unhealthy alcohol use in Uganda (AOR 2.65; 95% CI: 1.05–6.72), but not SA (AOR 1.00; 95% CI: 0.46–2.17). In Uganda, 23.2% underreported unhealthy alcohol use versus 11.6% in SA (χ² = 9.30; p < 0.01). Addressing unhealthy alcohol use is important as patients initiate ART earlier, yet challenging due to underreporting.

Alcohol-related intentional nonadherence to antiretroviral therapy among people living with HIV, Cape Town, South Africa

Alcohol use may have significant negative impacts on individuals' ability to remain adherent to antiretroviral therapy (ART), and may also yield other negative psychosocial, health-related, and behavioral outcomes. In addition, false beliefs about the consequences of mixing alcohol with ART use may cause individuals to avoid taking ART when drinking (alcohol-related ART avoidance). Although research conducted in the U.S. and Europe has reported on alcohol-ART avoidance, the current study presents among the first quantitative evidence of alcohol-related intentional ART nonadherence in South Africa. Patients receiving ART from a community clinic in Cape Town (N = 441) completed anonymous surveys of alcohol use, ART adherence, and alcohol-ART avoidance. Results showed that 292 (66%) participants reported current alcohol use; 25% who use alcohol believed that people who drink should stop taking ART when they are drinking and 24% stop their own ART when drinking. Alcohol-ART avoidance mediated the association between alcohol use and ART adherence. Results were robust when controlling for participant age, gender, current care status, and first- versus second-line ART. We found alcohol-ART avoidance may threaten successful ART in South Africa. Corrective messages that take a harm reduction approach to maximize ART adherence when drinking should be implemented in existing clinical services.

The Alcohol Use Disorders Identification Test (AUDIT): Exploring the Factor Structure and Cutoff Thresholds in a Representative Post-Conflict Population in Northern Uganda

Aims

Despite increased use of the Alcohol Use Disorders Identification Test (AUDIT) in sub-Saharan Africa, few studies have assessed its underlying conceptual framework, and none have done so in post-conflict settings. Further, significant inconsistencies exist between definitions used for problematic consumption. Such is the case in Uganda, facing one of the highest per-capita alcohol consumption levels regionally, which is thought to be hindering rebuilding in the North after two decades of civil war. This study explores the impact of varying designation cutoff thresholds in the AUDIT as well as its conceptual factor structure in a representative sample of the population.

Methods

In all, 1720 Cango Lyec Project participants completed socio-economic and mental health questionnaires, provided blood samples and took the AUDIT. Participant characteristics and consumption designations were compared at AUDIT summary score thresholds of ≥3, ≥5 and ≥8. Confirmatory factor analyses (CFA) explored one-, two- and three-factor level models overall and by sex with relative and absolute fit indicators.

Results

There were no significant differences in participant demographic characteristics between thresholds. At higher cutoffs, the test increased in specificity to identify those with hazardous drinking, disordered drinking and suffering from alcohol-related harms. All conceptual models indicated good fit, with three-factor models superior overall and within both sexes.

Conclusion

In Northern Uganda, a three-factor AUDIT model best explores alcohol use in the population and is appropriate for use in both sexes. Lower cutoff thresholds are recommended to identify those with potentially disordered drinking to best plan effective interventions and treatments.

Short summary

A CFA of the AUDIT showed good fit for one-, two, and three-factor models overall and by sex in a representative sample in post-conflict Northern Uganda. A three-plus total AUDIT cutoff score is suggested to screen for hazardous drinking in this or similar populations.

The Relationship Between Spirituality/Religiousness and Unhealthy Alcohol Use Among HIV-Infected Adults in Southwestern Uganda

HIV and alcohol use are two serious and co-existing problems in sub-Saharan Africa. We examined the relationship between spirituality and/or religiousness (SR) and unhealthy alcohol use among treatment-naïve HIV-infected adults attending the HIV clinic in Mbarara, Uganda. Unhealthy alcohol was defined as having either an alcohol use disorders identification test-consumption score of ≥4 for men or ≥3 for women, or having a phosphatidylethanol level of ≥50 ng/ml based on analysis of dried bloodspot specimens. Of the 447 participants, 67.8% were female; the median age was 32 years (interquartile range [IQR] 27-40). About half reported being Protestant (49.2%), 35.1% Catholic, and 9.2% Muslim. The median SR score was high (103 [IQR 89-107]); 43.3% drank at unhealthy levels. Higher SR scores were associated with lower odds of unhealthy drinking (adjusted odds ratio [aOR]: 0.83 per standard deviation [SD] increase; 95% confidence interval [CI] 0.66-1.03). The "religious behavior" SR subscale was significantly associated with unhealthy alcohol use (aOR: 0.72 per SD increase; 95% CI 0.58-0.88). Religious institutions, which facilitate expression of religious behavior, may be helpful in promoting and maintaining lower levels of alcohol use.

Cross-sectional comparative study of risky sexual behaviours among HIV-infected persons initiated and waiting to start antiretroviral therapy in rural Rakai, Uganda

OBJECTIVES

To compare risky sexual behaviours between HIV-positive persons initiated on antiretroviral therapy (ART) (ART-experienced) and persons waiting to start on ART (ART-naive) and assess predictors of risky sexual behaviours among HIV-infected patients in rural Rakai district, Uganda.

STUDY DESIGN

This is a cross-sectional study that used data from the Rakai Community Cohort Study (RCCS) database between 2013 and 2014. A structured questionnaire was used for data collection. We used stepwise logistic regression as an index to estimate the adjusted ORs for the association between risky sexual behaviours and ART treatment status.

STUDY SETTING

This study was conducted in Rakai district, located in south-western Uganda. The data for this study were extracted from the RCCS. RCCS is an open prospective cohort of approximately 15 000 consenting participants aged 15-49 years.

PARTICIPANTS

HIV-positive participants aged 18-49 years who had sex at least once a month with any partner prior to the start of the study.

MAIN OUTCOME MEASURES

Inconsistent/no condom use in the last 12 months, alcohol use at last sexual encounter, and two or more sexual partners.

RESULTS

ART-naive participants were more likely to report inconsistent condom use (OR=1.74, 95% CI 1.11 to 2.73) and more likely to drink alcohol at last sexual encounter (OR=1.65, 95% CI 1.11 to 2.46), compared with ART-experienced patients. ART treatment status (p<0.001) was a significant predictor of risky sexual behaviours. Both marital status (p=0.016) and occupation level (p=0.009) were positively associated with inconsistent condom use, while sex (p<0.001) correlated with alcohol use at last sexual encounter.

CONCLUSION

ART-naive participants were more likely to exhibit risky sexual behaviours than the ART-experienced participants. The intensity of risk reduction counselling should be increased for HIV-positive persons waiting to start ART but already in HIV care.

Declining and rebounding unhealthy alcohol consumption during the first year of HIV care in rural Uganda, using phosphatidylethanol to augment self-report

AIMS

We examined whether unhealthy alcohol consumption, which negatively impacts HIV outcomes, changes after HIV care entry overall and by several factors. We also compared using phosphatidylethanol (PEth, an alcohol biomarker) to augment self-report to using self-report alone.

DESIGN

A prospective 1-year observational cohort study with quarterly visits.

SETTING

Large rural HIV clinic in Mbarara, Uganda.

PARTICIPANTS

A total of 208 adults (89 women and 119 men) entering HIV care, reporting any prior year alcohol consumption.

MEASUREMENTS

Unhealthy drinking was PEth+ (≥ 50 ng/ml) or Alcohol Use Disorders Identification Test-Consumption+ (AUDIT-C+, over 3 months, women ≥ 3; men ≥ 4). We calculated adjusted odds ratios (AOR) for unhealthy drinking per month since baseline, and interactions of month since baseline with perceived health, number of HIV symptoms, antiretroviral therapy (ART), gender and self-reported prior unhealthy alcohol use.

FINDINGS

The majority of participants (64%) were unhealthy drinkers (PEth+ or AUDIT-C+) at baseline. There was no significant trend in unhealthy drinking overall [per-month AOR: 1.01; 95% confidence interval (CI) = 0.94-1.07], while the per-month AORs were 0.91 (95% CI = 0.83-1.00) and 1.11 (95% CI = 1.01-1.22) when participants were not yet on ART and on ART, respectively (interaction P-value < 0.01). In contrast, 44% were AUDIT-C+; the per-month AORs for being AUDIT-C+ were 0.89 (95% CI = 0.85-0.95) overall, and 0.84 (95% CI = 0.78-0.91) and 0.97 (95% CI = 0.89-1.05) when participants were not on and were on ART, respectively.

CONCLUSIONS

Unhealthy alcohol use among Ugandan adults entering HIV care declines prior to the start of anti-retroviral therapy but rebounds with time. Augmenting self-reported alcohol use with biomarkers increases the ability of current alcohol use measurements to detect unhealthy alcohol use.

Understanding the socio-structural context of high HIV transmission in kasensero fishing community, South Western Uganda

BACKGROUND

In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission remains high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44 %, reaching up to 74 % among female sex workers. We explored the social contextual factors for the high HIV transmission at Kasensero to inform future policy and preventive interventions.

METHODS

We conducted 20 in-depth interviews, including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community from April-September 2014. Content analysis was performed to identify recurrent themes.

RESULTS

Our findings suggest that the high HIV transmission in Kasensero is a complex function of eight themes including; positive/negative attitudes about HIV and combination HIV prevention such as the demand for services versus ART/circumcision disinhibition; HIV depository; Multiple partners; Frequent unprotected sex; Clothing; Parental behaviors; Pressure within the sex industry; and Cross generational sex.

CONCLUSIONS

The current combination HIV prevention services by the RHSP need to be enhanced with more government involvement including ensuring sustainable supply of ART and circumcision services since they are reportedly highly demanded. Community involvement through the engagement of popular peers could also help in the campaign to change the HIV predisposing culture, misconceptions and risky social norms of the population. Social Context HIV Transmission Fishing Community.

Comparison of behavioral characteristics of dogs in the United States and Japan

This study examined the difference in dog owning between Japan and the United States, and the effect of these differences on dogs' behavioral characteristics. Behavioral evaluations of privately-owned dogs were obtained by using online questionnaire. We compared background and demographic information from the two countries and analyzed the effects of these differences on behavioral characteristics in dogs. The results indicated that there was a bias in the dog breeds kept in Japan compared to the United States and that Japanese dogs' body weight was lower than the US dogs. The main source of dog acquisition was pet stores in Japan and breeders and/or shelters in the United States. Multiple linear regression analysis found that Japanese dogs showed more aggression to household members and higher energy, restlessness and fear of non-social stimuli than US dogs, while US dogs showed more fear of unfamiliar persons, separation-related behavior and excitability. US dogs also showed higher levels of trainability and attachment to owners. The lower dog's body weight was, the higher the behavioral scores except for trainability were. When dogs that were obtained under 3 months of age were analyzed, the younger the dogs were when their owners obtained them, the higher the scores on some behavioral problem factors were. The higher rates of problem behaviors among Japanese dogs compared with US dogs suggest that the preference for small breed dogs and poor early development environment influenced the behavioral characteristics of dogs.

Alcohol Consumption among HIV-Infected Persons in a Large Urban HIV Clinic in Kampala Uganda: A Constellation of Harmful Behaviors

INTRODUCTION

Alcohol use by persons living with HIV/AIDS (PLWHA) negatively impacts the public health benefits of antiretroviral therapy (ART). Using a standardized alcohol assessment tool, we estimate the prevalence of alcohol use, identify associated factors, and test the association of alcohol misuse with sexual risk behaviors among PLWHA in Uganda.

METHODS

A cross-section of PLWHA in Kampala were interviewed regarding their sexual behavior and self-reported alcohol consumption in the previous 6 months. Alcohol use was assessed using the alcohol use disorders identification test (AUDIT). Gender-stratified log binomial regression analyses were used to identify independent factors associated with alcohol misuse and to test whether alcohol misuse was associated with risky sexual behaviors.

RESULTS

Of the 725 subjects enrolled, 235 (33%) reported any alcohol use and 135 (18.6%) reported alcohol misuse, while 38 (5.2%) drank hazardous levels of alcohol. Alcohol misuse was more likely among subjects not yet on ART (adjusted prevalence ratio [aPR] was 1.65 p=0.043 for males and 1.79, p=0.019 for females) and those with self-reported poor adherence (aPR for males=1.56, p=0.052, and for females=1.93, p=0.0189). Belonging to Pentecostal or Muslim religious denominations was protective against alcohol misuse compared to belonging to Anglican and Catholic denominations in both sexes (aPR=0.11 for men, p<0.001, and aPR=0.32 for women, p=0.003). Alcohol misuse was independently associated with reporting risky sexual behaviors (aPR=1.67; 95% CI: 1.07-2.60, p=0.023) among males, but not significant among females (aPR=1.29; 95% CI: 0.95-1.74, p=0.098). Non-disclosure of HIV positive status to sexual partner was significantly associated with risky sex in both males (aPR=1.69; p=0.014) and females (aPR 2.45; p<0.001).

CONCLUSION

Alcohol use among PLWHA was high, and was associated with self-reported medication non-adherence, non-disclosure of HIV positive status to sexual partner(s), and risky sexual behaviors among male subjects. Interventions targeting alcohol use and the associated negative behaviors should be tested in this setting.

Qualitative study of changes in alcohol use among HIV-infected adults entering care and treatment for HIV/AIDS in rural southwest Uganda

Alcohol has a substantial negative impact on the HIV epidemic in sub-Saharan Africa, particularly in Uganda, where heavy alcohol consumption is common. Using a content analytic approach, this qualitative study characterizes changes in alcohol use among 59 HIV-infected Ugandan adults (>18 years old), who reported any alcohol use in the previous year as they entered HIV care. Most participants reported attempting to cease or reduce alcohol intake over the study period. Reasons for decreased use included advice from clinicians, interference with social obligations, threats to financial security, and negative impact on social standing. Participants reported difficulty abstaining from alcohol, with incentives to continue drinking including desire for social inclusion, stress relief, and enjoyment of alcohol. These contrasting incentives created a moral quandary for some participants, who felt 'pulled' between 'good' and 'bad' influences. Results suggest brief interventions addressing self-identified obstacles to change may facilitate long-term reductions in drinking in this population.

Comparison of self-reported alcohol consumption to phosphatidylethanol measurement among HIV-infected patients initiating antiretroviral treatment in southwestern Uganda

BACKGROUND

Alcohol consumption among HIV-infected patients may accelerate HIV disease progression or reduce antiretroviral therapy adherence. Self-reported alcohol use is frequently under-reported due to social desirability and recall bias. The aim of this study was to compare self-reported alcohol consumption to phosphatidylethanol (PEth), a biomarker of alcohol consumption, and to estimate the correlation between multiple measures of self-reported alcohol consumption with PEth.

METHODS

The Uganda AIDS Rural Treatment Outcomes (UARTO) cohort is located in southwestern Uganda and follows patients on ART to measure treatment outcomes. Patients complete standardized questionnaires quarterly including questions on demographics, health status and alcohol consumption. Baseline dried blood spots (DBS) were collected and retrieved to measure PEth.

RESULTS

One hundred fifty samples were tested, and 56 (37.3%) were PEth positive (≥8 ng/mL). Of those, 51.7% did not report alcohol use in the past month. Men were more likely to under-report compared to women, OR 2.9, 95% CI = 1.26, 6.65) and those in the higher economic asset categories were less likely to under-report compared to those in the lowest category (OR = 0.41 95% CI: 0.17, 0.94). Among self-reported drinkers (n = 31), PEth was highly correlated with the total number of drinking days in the last 30 (Spearman R = 0.73, p<0.001).

CONCLUSIONS

Approximately half of HIV infected patients initiating ART and consuming alcohol under-report their use of alcohol. Given the high prevalence, clinicians should assess all patients for alcohol use with more attention to males and those in lower economic asset categories who deny alcohol use. Among those reporting current drinking, self-reported drinking days is a useful quantitative measure.

Decreases in self-reported alcohol consumption following HIV counseling and testing at Mulago Hospital, Kampala, Uganda

BACKGROUND

Alcohol use has a detrimental impact on the HIV epidemic, especially in sub-Saharan Africa. HIV counseling and testing (HCT) may provide a contact opportunity to intervene with hazardous alcohol use; however, little is known about how alcohol consumption changes following HCT.

METHODS

We utilized data from 2056 participants of a randomized controlled trial comparing two methods of HCT and subsequent linkage to HIV care conducted at Mulago Hospital in Kampala, Uganda. Those who had not previously tested positive for HIV and whose last HIV test was at least one year in the past were eligible. Participants were asked at baseline when they last consumed alcohol, and prior three month alcohol consumption was measured using the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) at baseline and quarterly for one year. Hazardous alcohol consumption was defined as scoring ≥3 or ≥4 for women and men, respectively. We examined correlates of alcohol use at baseline, and of hazardous and non-hazardous drinking during the year of follow-up using multinomial logistic regression, clustered at the participant level to account for repeated measurements.

RESULTS

Prior to HCT, 30% were current drinkers (prior three months), 27% were past drinkers (>3 months ago), and 44% were lifetime abstainers. One-third (35%) of the current drinkers met criteria for hazardous drinking. Hazardous and non-hazardous self-reported alcohol consumption declined after HCT, with 16% of baseline current drinkers reporting hazardous alcohol use 3 months after HCT. Independent predictors (p < 0.05) of continuing non-hazardous and hazardous alcohol consumption after HCT were sex (male), alcohol consumption prior to HCT (hazardous), and HIV status (negative). Among those with HIV, non-hazardous drinking was less likely among those taking antiretroviral therapy (ART).

CONCLUSIONS

HCT may be an opportune time to intervene with alcohol consumption. Those with HIV experienced greater declines in alcohol consumption after HCT, and non-hazardous drinking decreased for those with HIV initiating ART. HCT and ART initiation may be ideal times to intervene with alcohol consumption. Screening and brief intervention (SBI) to reduce alcohol consumption should be considered for HCT and HIV treatment venues.