Hazardous alcohol consumption and alcohol-related problems are associated with unknown and HIV-positive status in fishing communities in Uganda

Associations Between Alcohol Use, Antiretroviral Therapy Use, and Viral Load Suppression Among People Living with HIV in Rural Central Uganda

Alcohol use among people living with HIV (PWH) is common and may negatively affect engagement in HIV care. We evaluated the relationships between alcohol use, ART use, and viral suppression among PWH in Uganda. PATH/Ekkubo was a trial evaluating a linkage to HIV care intervention in four Ugandan districts, Nov 2015-Sept 2021. Our analytical sample included: (1) baseline data from individuals not enrolled in the intervention trial (previously diagnosed HIV+); and 12-month follow-up data from the control group (newly diagnosed or previously diagnosed, but not in care). Level of alcohol use was categorized using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C): none (AUDIT-C = 0), low (women = 1-2, men = 1-3), medium (women = 3-5, men = 4-5), high/very high (6-12). Multivariable logistic regression models evaluated associations between alcohol use, ART use and viral suppression (a viral load of < 20); we also stratified by gender. Among 931 PWH, medium (OR: 0.43 [95% CI 0.25-0.72]) and high/very high (OR: 0.22 [95% CI 0.11-0.42]) levels of alcohol use were associated with lower odds of being on ART. In a sub-sample of 664, medium use (OR: 0.63 [95% CI 0.41-0.97]) was associated with lower odds of viral suppression. However, this association was not statistically significant when restricting to those on ART, suggesting the relationship between alcohol use and viral suppression is explained by ART use. Among men, high/very high, and among women, medium alcohol use levels were associated with lower odds of being on ART and being virally suppressed. Interventions for PWH who use higher levels of alcohol may be needed to optimize the benefits of Uganda's Universal Test and Treat strategy.

Epidemiology of alcohol use and alcohol use disorder among female sex workers in Mbeya City, Tanzania

Alcohol misuse is a global concern, contributing to 5.3% of total deaths and 132.6 million disability-adjusted life years worldwide. In Sub-Saharan African countries, the prevalence of Alcohol Use Disorder (AUD) has risen, especially among female sex workers, due to increased availability and advertising. However, there are limited studies on alcohol use and AUD among female sex workers in Tanzania. This study aimed to determine the prevalence, patterns, and factors associated with alcohol use and AUD among sex workers in Mbeya city, Tanzania. In this cross-sectional study, 212 female sex workers in Mbeya city, Tanzania, seeking enrolment in the National Institute for Medical Research Mbeya Medical Research Centre's registration cohort from July to November 2022. Structured interviews covered socio-demographics, alcohol screening (AUDIT-C and Timeline Follow Back Calendar), and sexual behaviours data. Data were analysed using Stata version 17. Descriptive analysis assessed alcohol consumption and AUD prevalence. Factors associated with alcohol use and AUD at bivariate analysis were identified using Chi-square/Fisher's exact tests. All variables with p-value ≤ 0.20 were entered into a multivariable logistic regression model to identify factors associated with alcohol use and AUD. Among 212 participants, 86.6% reported alcohol use in the past 12 months, 85% in the past 30 days, and 98.5% met AUD criteria. Factors linked to recent alcohol consumption included primary education or higher, income above the median, and more than 10 sexual partners. Education level, marital status, income, and having dependents were significantly associated with heavy drinking episodes. The prevalence of AUD, alcohol use, and heavy episodic drinking were high among female sex workers in Mbeya city. Socio-demographic factors and risky sexual behaviours were associated with alcohol use and heavy episodic drinking highlighting the need for targeted interventions to combat alcohol abuse among female sex workers within the HIV program.

Heavy alcohol use and the HIV care continuum in Kenya: a population-based study

Heavy alcohol use (HAU) can destabilize engagement along the HIV care continuum. Population-based studies assessing associations of HAU with HIV treatment outcomes are lacking, especially in sub-Saharan Africa. We leveraged data from the Kenya Population-based HIV Impact Assessment to identify associations of self-reported HAU, assessed using two items measuring the frequency and quantity of past-year alcohol consumption, with serum biomarkers for HIV serostatus unawareness, antiretroviral therapy (ART) non-use, and HIV viremia (≥1000 RNA copies/mL). Overall and sex-stratified survey-weighted logistic regression with jackknife variance estimation modeled adjusted odds ratios (adjOR) of HIV treatment indicators by HAU. Overall, 1491 persons living with HIV aged 15-64 years (68.4% female) were included. The prevalence of HAU was 8.9% (95% confidence interval [95%CI]: 6.8-11.0%) and was significantly more pronounced in males than females (19.6% vs. 4.0%, p < 0.001). In multivariable analysis, HAU was significantly (p < 0.001) associated with HIV serostatus unawareness (adjOR = 3.65, 95%CI: 2.14-6.23), ART non-use (adjOR = 3.81, 95%CI: 2.25-6.43), and HIV viremia (adjOR = 3.13, 95%CI: 1.85-5.32). Incorporating sex-specific alcohol use screening into HIV testing and treatment services in populations where HAU is prevalent could optimize clinical outcomes along the HIV care continuum.

Prevalence and Correlates of Substance Use Among Youth Living with HIV in Fishing Communities in Uganda

Alcohol and drug use (ADU) poses a significant barrier to optimal HIV treatment outcomes for adolescents and youths living with HIV (AYLHIV). We aimed to investigate the prevalence and correlates of ADU among ALHIV in Ugandan fishing communities, areas characterized by high HIV and poverty rates. AYLHIV aged 18-24, who knew they were HIV-positive, were selected from six HIV clinics. Substance use was determined through self-report in the last 12 months and urine tests for illicit substances. Utilizing a socioecological framework, the study structured variables into a hierarchical logistic regression analysis to understand the multi-layered factors influencing ADU. Self-reported past 12 months substance use was 42%, and 18.5% of participants had a positive urine test for one or more substances, with alcohol, benzodiazepines, and marijuana being the most commonly used. With the addition of individual-level socio-demographics, indicators of mental health functioning, interpersonal relationships, and community factors, the logistic regression analysis revealed greater exposure to adverse childhood experiences increased the odds of substance use (Odds Ratio [OR] = 1.24; 95% Confidence Interval [CI]: 1.03-1.55). Additionally, exposure to alcohol advertisements at community events significantly raised the odds of substance use (OR = 3.55; 95% CI: 1.43-8.83). The results underscore the high prevalence among AYLHIV and emphasize the need for comprehensive interventions targeting individual (e.g., life skills education and mental health supports), interpersonal (e.g., peer support and family-based interventions), community (e.g., community engagement programs, restricted alcohol advertisements and illicit drug access), and policies (e.g., integrated care models and a national drug use strategy), to address ADU.

Stakeholder perspectives on the Kisoboka intervention: A behavioral and structural intervention to reduce hazardous alcohol use and improve HIV care engagement among men living with HIV in Ugandan fishing communities

BACKGROUND

East Africa's fishing communities experience a high burden of two interrelated and frequently co-occurring health issues: HIV and hazardous alcohol use. Nearly two-thirds of Ugandan fisherfolk men meet the criteria for harmful alcohol use. We developed a multilevel intervention to reduce hazardous alcohol use and improve HIV care engagement among fisherfolk men living with HIV (LWHIV) in Wakiso district, Uganda.

METHODS

This is a qualitative study of stakeholder perspectives on the appropriateness, acceptability, and feasibility of a multilevel intervention for fisherfolk men LWHIV. The proposed intervention, Kisoboka ("It is possible!"), combines a structural component [changing the mode of work payments from cash to mobile money] with a behavioral component [motivational interviewing-based counseling combined with content using behavioral economic principles to promote behavior change]. We conducted one focus group (n=7) and eight in-depth interviews with fisherfolk men LWHIV and 19 key informant (KI) interviews with health workers, employers, and community leaders. These explored the appropriateness, acceptability, and feasibility of specific key intervention components.

RESULTS

Overall, stakeholders' perspectives supported high intervention acceptability and perceived appropriateness of the proposed intervention. It was perceived to be feasible with some caveats of recommendations for overcoming potential implementation challenges identified (e.g., having a friend assist with documenting savings and alcohol use if an individual was unable to write themselves) which are discussed.

CONCLUSION

This work highlights the potential of the Kisoboka intervention and the importance of early engagement of key stakeholders in the intervention development process to ensure appropriateness, acceptability, feasibility, and socio-cultural fit.

Alcohol consumption and utilization of HIV prevention services among men who have casual sex with women in China

Men who have casual sex with women (MCSW) have played an important role in HIV new infections in China. Research studies have shown that heavy alcohol consumption can increase the risk of HIV infection. The cross-sectional study was conducted in two cities in China from December 2018 to May 2019 to examine the association between alcohol consumption and utilization of HIV prevention services among MCSW. Convenience sampling was used to recruit participants and 400 MCSW were recruited in this study. There were 238 (59.6%), 213 (53.4%) and 129 (32.4%) participants having utilized HIV prevention services, condom promotion and distribution or HIV counseling and testing (CPD/HCT) services, and peer education services in the past 12 months, respectively. MCSW who were identified as heavy drinkers were less likely to utilize HIV prevention services and CPD/HCT services compared with non-drinkers. For youngsters, those who are in the local household and those who are married/cohabitating, heavy drinkers was less likely to utilize HIV prevention services. This study highlights the significance of intensive education on heavy drinkers of MCSW, particularly for high-risk subgroups. Targeting resources for integrated HIV prevention efforts with alcohol-using MCSW should be considered by public health policymakers.

Violence Exposure, Self-Reported Mental Health Concerns and Use of Alcohol and Drugs for Coping among Youth in the Slums of Kampala, Uganda

This study aimed to a) compute the prevalence of violence exposure types, polyvictimization, and self-reported depression, anxiety, and using substances to cope among youth ages 12 to 18 years living on the streets or in the slums of Kampala, Uganda, (b) examine the independent associations among orphan status, violence exposure types, and self-reported mental health concerns, and c) explore the association between polyvictimization and mental health concerns. Data are from a 2014 cross-sectional survey of service-seeking youth ages 12 to 18 years (N = 1134) in Kampala, Uganda. Violence exposure types explored in this study were: witnessing family physical violence, direct physical abuse by a parent, any rape history, and physical dating violence. We used descriptive statistics and multivariable logistic regression to test study objectives. Over half of the sample (60.5%) reported experiencing at least one type of violence exposure; many youth endorsed self-reported depression (57.8%), anxiety (76.8%), and substance use to cope (37.0%). Exposure to violence was associated with higher odds for self-reported depression, anxiety, and using substances to cope. These findings underscore the urgent need to implement evidence-based interventions among this young, underserved population and their families to prevent violence, improve mental health outcomes, and promote resilience.

Drug users' awareness of and willingness to use HIV non-occupational post-exposure prophylaxis (nPEP) services in China: a mixed methods study

Background

Drug users are regarded as a high-risk population for HIV infection. Non-occupational post-exposure prophylaxis (nPEP) is internationally regarded as an effective biomedical prevention against HIV but still a small-scale pilot project in China at present. The aim of this study was to understand drug users’ awareness of and willingness to use nPEP service in China.

Methods

This mixed methods study consisting of a qualitative study and a cross-sectional survey was conducted in two cities of China from 2018 to 2019. The in-depth interviews were audio-taped, transcribed verbatim and analyzed using thematic framework analysis. Univariate and multivariate logistic regressions were used to examine factors associated with drug users’ awareness of and willingness to use nPEP.

Results

There were 401 and 19 participants included in quantitative and qualitative study respectively. Among participants in quantitative study, 30.2% had heard of nPEP and 56.7% reported willingness to use nPEP in future HIV exposure. In multivariate analyses, nPEP awareness was associated with age, sex, education level, AIDS knowledge score and HIV risk perception. nPEP willingness was associated with AIDS knowledge score, HIV risk perception, alcohol use, monthly income and awareness of nPEP. The qualitative results showed the barriers to nPEP willingness included the fatigue after taking drugs, high cost and side effects of nPEP medication, long nPEP course, and fear of privacy disclosure.

Conclusion

Drug users had low nPEP awareness and only about half participants reported willingness to use nPEP. It is essential to promote nPEP education campaigns among drug users, especially for elders, women and those with lower education level. Simultaneously, price regulation, side effect management, psychological support and privacy protection need to be managed well when nPEP is routinized.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07106-x.

HIV epidemic in fishing communities in Uganda: A scoping review

Background

Fishing communities in many Sub-Saharan African countries are a high-risk population group disproportionately affected by the HIV epidemic. In Uganda, literature on HIV in fishing communities has grown extensively since the first country’s documented case of HIV in a fishing community in 1985. The current study describes the status of the HIV burden, prevention, and treatment in Ugandan fishing communities.

Method

This scoping review was conducted based on the York Framework outlined by Arksey and O’Malley. We searched the PubMed, Embase, and Web of Science databases to identify relevant quantitative and qualitative studies on HIV incidence, HIV prevalence, HIV-related risk factors, HIV testing, antiretroviral therapy coverage and adherence, and interventions to improve treatment outcomes and reduce HIV risk factors.

Results & conclusion

We identified 52 papers and 2 reports. Thirty-four were quantitative, 17 qualitative, and 3 had a mixed-methods design. Eleven studies reported on the prevalence of HIV and 8 on HIV incidence; 9 studies documented factors associated with HIV incidence or HIV positive status; 10 studies reported on HIV testing coverage and/or associated factors; 7 reported on antiretroviral therapy coverage/adherence/outcomes; and 1 study reported on the impact of combination HIV interventions in fishing communities. This scoping review revealed a significant lack of evidence in terms of what works in HIV prevention and for improving adherence to ART, in contrast to the relatively large amount of evidence from observational quantitative and qualitative studies on HIV prevalence, incidence and related risk factors in Ugandan fishing communities. Intervention studies are urgently needed to fill the current evidence gaps in HIV prevention and ART adherence.

Understanding mobility and sexual risk behaviour among women in fishing communities of Lake Victoria in East Africa: a qualitative study

BACKGROUND

HIV-prevalence and incidence is high in many fishing communities around Lake Victoria in East Africa. In these settings, mobility among women is high and may contribute to increased risk of HIV infection and poor access to effective prevention and treatment services. Understanding the nature and patterns of this mobility is important for the design of interventions. We conducted an exploratory study to understand the nature and patterns of women's mobility to inform the design of HIV intervention trials in fishing communities of Lake Victoria.

METHODS

This was a cross-sectional formative qualitative study conducted in six purposively selected fishing communities in Kenya, Tanzania and Uganda. Potential participants were screened for eligibility on age (18+ years) and having stayed in the fishing community for more than 6 months. We collected data using introductory and focus group discussions, and in-depth interviews with key informants. Data focused on: history and patterns of mobility, migration in and out of fishing communities and the relationship between mobility and HIV infection. Since the interviews and discussions were not audio-recorded, detailed notes were taken and written up into full scripts for analysis. We conducted a thematic analysis using constant comparison analysis.

RESULTS

Participants reported that women in fishing communities were highly mobile for work-related activities. Overall, we categorized mobility as travels over long and short distances or periods depending on the kind of livelihood activity women were involved in. Participants reported that women often travelled to new places, away from familiar contacts and far from healthcare access. Some women were reported to engage in high risk sexual behaviour and disengaging from HIV care. However, participants reported that women often returned to the fishing communities they considered home, or followed a seasonal pattern of work, which would facilitate contact with service providers.

CONCLUSION

Women exhibited circular and seasonal mobility patterns over varying distances and duration away from their home communities. These mobility patterns may limit women's access to trial/health services and put them at risk of HIV-infection. Interventions should be tailored to take into account mobility patterns of seasonal work observed in this study.

Challenges in measuring depression among Ugandan fisherfolk: a psychometric assessment of the Luganda version of the Center for Epidemiologic Studies Depression Scale (CES-D)

BACKGROUND

Depression is a prevalent and serious mood disorder and a major source of disability adjusted life years (DALY) in Uganda. Furthermore, evidence from Uganda and other countries throughout sub-Saharan Africa suggests that nearly a third of persons living with human immunodeficiency virus (HIV) suffer from depression and it adversely affects healthcare seeking behavior. The high burden of disease attributable to depression makes data on the prevalence of depression in Uganda, a country with a generalized HIV epidemic, a public health priority. This paper describes the psychometric properties of the Center for Epidemiologic Studies-Depression (CES-D) measure when administered to men and women residing in three fishing communities along the shore of Lake Victoria.

METHODS

We applied methods based on item response theory and classical test theory approaches to assess individual item characteristics, conducted exploratory factor analysis and assessed internal reliability, and construct and content validity of the measure. All analyses were performed in R Studio.

RESULTS

The study sample consisted of 300 residents of fishing communities in Wakiso District, Uganda. Fifty-six percent of the sample was female and 19.7% reported being HIV positive. Seven items of the measure that did not perform well, either because they could not differentiate between levels of the latent trait or because they did not map onto the primary factor, were removed from the scale. A single factor structure best fit our final set of 13-items and we found an overall coefficient alpha of 0.89, indicating high internal consistency in this population.

CONCLUSIONS

Based on our findings, we recommend that future use of the CES-D in this population utilize our revised scale with the final set of 13-items. The addition of other measures that can improve the rigor of CES-D validation efforts, such as inclusion of a clinical depression measure and administration in both a clinical and a general population sample in this setting are needed.

Exploring the Potential of Savings-Led Economic Strengthening HIV Interventions Among High-Risk Economically Vulnerable Fishing Communities in Uganda: Associations Between Use of Commitment Savings, Sexual Risk Behavior, and Problematic Alcohol Use

Fishing communities are a most-at-risk population for HIV in Uganda. Alcohol use and abuse and economic vulnerability fuel risky sexual practices and lead to increased risk of HIV infection in these communities. Economic strengthening is an emerging intervention approach and interventions promoting saving money via mechanisms with a "soft commitment" in the form of restricting or charging small fees for withdrawals, may serve to reduce spending on alcohol and spending that leads to HIV risk behaviors in cash-based economies. However, little research has been conducted to explore the potential for commitment savings-led economic strengthening interventions to address alcohol use and sexual risk behavior among fisherfolk. This cross-sectional study explored the associations between commitment savings, HIV sexual risk behavior, and problematic alcohol among fisherfolk. We also determined whether commitment savings moderated the associations between problematic alcohol use and risky sexual behaviors. 300 (132 male, 168 female) residents of fishing communities on Lake Victoria, Uganda completed a structured interviewer-assisted interview. Over half (55.3%) used commitment savings by saving money in a bank or savings cooperative or via mobile money. Having problematic alcohol use increased the rate of risky unprotected sex with: all partners (adjIRR 6.08, 95% CI 4.30-8.60) and with casual partners and CSWs/clients (adjIRR 4.90, 95% CI 3.09-7.78), and increased the odds of having met a sex partner at an alcohol venue (adjOR 2.84, 95% CI 1.46-5.51) compared to those without problematic alcohol use. Commitment savings was associated with lower odds of: problematic alcohol use (adjOR 0.50, 95% CI 0.26-0.96), meeting a sex partner at an alcohol venue (adjOR 0.43, 95% CI 0.24-0.78), as well as lower rates of risky unprotected sex with all partners (adjIRR 0.68, 95% CI 0.48-0.96), and with causal partners, CSWs/clients (adjIRR 0.38, 95% CI 0.17-0.85). Use of commitment savings moderated the associations between problematic alcohol use and unprotected sex. However, the moderating effects of commitment savings varied by gender. These findings suggest that promoting saving money in savings mechanisms which involve a commitment may be a potentially viable avenue for HIV prevention among fishing communities and may be particularly helpful for those who have problematic alcohol use.