Alcohol use before sex and HIV acquisition: a longitudinal study in Rakai, Uganda

Alcohol Consumption Among Persons Living with HIV: Perceptions, Messages and Interventions-A Qualitative Study at an HIV Treatment Clinic in South Western Uganda

In Sub-Saharan Africa, efficacy trials of brief interventions to reduce unhealthy drinking among persons living with HIV (PLWH) have yielded mixed results. A better understanding of the perceptions of drinking, especially by PLWH, and how drinking is talked about at HIV treatment clinics in this setting, may guide more optimal designs for future trials. We conducted a qualitative study at an HIV treatment clinic in South Western Uganda to better understand perceptions of drinking, how drinking is talked about, and perceptions of interventions, especially a protocolled screening and brief intervention (SBI) for unhealthy drinking among PLWH. We conducted in-depth interviews with 17 PLWH who engaged in unhealthy drinking and 6 health workers, and one focus group discussion with 3 community advisory-board members. We performed manual preliminary data analysis and computer-assisted detailed thematic analysis to identify emergent themes. Four themes emerged: perceptions of alcohol use in the general population; perceptions of alcohol use in PLWH; interaction between PLWH and health workers about alcohol use; perceptions of interventions for unhealthy drinking including SBI. Unhealthy drinking was seen as a problem in the general population and among those with HIV, where it was negatively perceived. Communication about drinking was done by counselors, but doctors participated in screening for unhealthy alcohol use. Messages about drinking covered reduction and abstinence. Participants expressed positive attitudes towards SBI and preference for person-delivered SBI over technological alternatives. A protocolled SBI for unhealthy alcohol use among PLWH would be well-received but successful implementation may depend on mode of delivery.

The relationship between alcohol consumption and risk of HIV in married men in Sub-Saharan Africa

OBJECTIVE

A key factor for incidence of HIV is alcohol consumption. It impacts judgment and the probability to overlook risk-relevant information, which creates a pathway to reduced adherence to biomedical prevention and engagement in condomless sex. We strengthen the understanding of the link between alcohol consumption and risk of HIV among married men in sub-Saharan Africa (SSA), as we use comprehensive population-level data to provide robust evidence with high external validity.

DESIGN

Cross-sectional data analysis.

METHODS

Based on data from Demographic and Health Surveys (DHS) from 20 countries and over 30 000 observations, a minimally and a fully adjusted model with country fixed effects examined the relationship between the men's alcohol consumption (observed by wife) and HIV status (blood test) while accounting for survey weights and controlling for potential confounders.

RESULTS

The data comprised a total of 35 108 men. Minimally adjusted [risk ratio (RR) 1.25; 95% confidence interval (CI) 1.14-1.37; P  < 0.001] and fully adjusted (RR 1.26; 95% CI 1.15-1.38; P  < 0.001) models showed a positive association between the men's alcohol consumption and HIV status. Two sensitivity analyses confirmed the association.

CONCLUSION

In line with previous experimental studies and theoretical framework, this study confirms a risk relationship between alcohol consumption and HIV. Thus, modern HIV/AIDS programs must continue to address the relationship in implementation of prevention and treatment programs.

A Qualitative Exploration of Intimate Partner Violence Among HIV/TB Coinfected Persons With Problematic Alcohol Use Participating in an Incentive-Based Alcohol/Medication Adherence Intervention in Uganda During COVID-19

In Uganda, four in ten women report experiencing intimate partner violence (IPV) in the past year. Salient drivers of IPV in sub-Saharan Africa include stress related to household finances, alcohol use, and partner infidelity. We conducted 42 interviews with participants (n = 32) in the Drinkers' Intervention to Prevent Tuberculosis (DIPT) study which included economic incentives, and their partners (n = 10) to understand how participating in DIPT during COVID-19 lockdown restrictions impacted relationship dynamics in intimate partnerships. Our findings highlight the need to develop policies to address root causes of IPV and to ensure continuity of IPV services in future pandemics. Policy and programming recommendations based on study results are presented.

Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It?

This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.

Unhealthy alcohol use and intimate partner violence among men and women living with HIV in Uganda

Background

Intimate partner violence (IPV) and alcohol use are interrelated public health issues. Heavy and frequent alcohol use increase the risk of IPV, but the relationship between alcohol use and IPV (including recent and lifetime IPV victimization and perpetration) has not been well described among persons living with HIV (PWH) in sub-Saharan Africa.

Methods

We used baseline data from the Drinker’s Intervention to Prevent Tuberculosis study. All participants were PWH co-infected with tuberculosis and had an Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) positive score (hazardous drinking) and positive urine ethyl glucuronide test, indicating recent drinking. High-risk drinking was defined as AUDIT-C > 6 and/or alcohol biomarker phosphatidylethanol (PEth) ≥ 200 ng/mL. We measured IPV using the Conflict Tactics Scale. We estimated the association between alcohol use level and recent (prior six months) IPV victimization (recent perpetration was too low to study) using multivariable logistic regression models adjusted for gender, age, assets, education, spouse HIV status, religiosity, depressive symptoms, and social desirability. We additionally estimated the interaction of alcohol use and gender on IPV victimization and the association between alcohol use and lifetime victimization and perpetration.

Results

One-third of the 408 participants were women. Recent IPV victimization was reported by 18.9% of women and 9.4% of men; perpetration was reported by 3.1% and 3.6% of women and men. One-fifth (21.6%) of those reporting recent IPV victimization also reported perpetration. In multivariable models, alcohol use level was not significantly associated with recent IPV victimization (p = 0.115), nor was the interaction between alcohol use and gender (p = 0.696). Women had 2.34 times greater odds of recent IPV victimization than men (p = 0.016). Increasing age was significantly associated with decreased odds of recent IPV victimization (p = 0.004).

Conclusion

Prevalence of IPV victimization was comparable to estimates from a recent national survey, while perpetration among men was lower than expected. Alcohol use level was not associated with IPV victimization. It is possible that alcohol use in this sample was too high to detect differences in IPV. Our results suggest that women and younger PWH are priority populations for IPV prevention.

A Social-Ecological Study of Perceptions and Determinants of Sexual Enhancement Drug Use among Men and Women in Ghana

The use and sale of sexual enhancement drugs (particularly unapproved aphrodisiacs) have become a public health concern in Ghana and many other sub-Saharan African countries. While most studies have examined this phenomenon from the level of individual perspectives, this study investigates the multi-dimensional and multi-level factors (e.g., individual characteristics and behaviours, interpersonal factors, community norms and practices, institutional and public policy factors) that influence attitudes, perceptions, and use of aphrodisiacs among men and women in Ghana. Using a concurrent mixed-method design, we derived the data from a semi-structured interview and cross-sectional survey conducted across five administrative regions in Ghana. Interpretative phenomenological analysis and logistic regression techniques were used to analyse the qualitative and quantitative (survey) data, respectively. Approximately 12.6% of participants (17.6% among males and 7.2% among females) had used an aphrodisiac in the six months prior to the study. Approximately 23.4% of the participants had more than one partner during the same period. Among men, being religious (B = −0.238, p < 0.05) and having multiple sexual partners (B = 0.481, p < 0.01) were positively associated with the use of aphrodisiacs. For women, being employed (B = −1.539, p < 0.01), engaging in physical activities (exercising) (B = −0.658, p < 0.05), having good health (B = 0.869, p < 0.05), having multiple sexual partners (B = 1.191, p < 0.01), and taking alcohol (B = 1.041, p < 0.01) were associated with use of aphrodisiacs. Although many participants had used aphrodisiacs, women, in particular, held unfavourable views about the drugs due to perceived negative health implications for themselves and their partners. The findings also show that community-level factors (e.g., social norms and expectations), interpersonal factors (e.g., expectations of partners and friends), public policy (e.g., drug-related regulations), and organisational/institutional factors (e.g., health system arrangements about access and use of drugs) were critical to the sale and use of aphrodisiacs among both men and women in Ghana. A multi-level analysis of the use of sexual enhancement drugs among men and women is crucial to formulating social and public health policies that aim to improve public knowledge of these drugs, reduce uncontrolled production, and protect population health and well-being.

Perspectives of Women Living With HIV on Addressing Violence and Use of Alcohol During HIV Services: Qualitative Findings From Fishing Communities in Uganda

The syndemic relationship between harmful alcohol use, intimate partner violence (IPV), and HIV is well established across international settings. Less is known about how these health issues are perceived by women living with HIV (WLWH), who are disproportionately affected by these intertwined epidemics. A qualitative study was undertaken with 20 WLWH in Rakai, Uganda, to assess their perceptions of how these issues have affected their lives and their communities and to assess the acceptability of integrating a screening and brief intervention for alcohol use and IPV into HIV posttest counseling. Recommendations for intervention programming arising from the results are discussed.

Predictors of HIV Among 1 Million Clients in High-Risk Male Populations in Tanzania

The World Health Organization identified men as an essential group to target with HIV testing and treatment strategies;: men who have sex with men (MSM) and male clients of female sex workers (CFSW) account for 35% of new HIV infections globally. Using a cross-sectional design from a community-based HIV prevention project in Tanzania (October 2015-September 2018) and multivariable logistic regression, we identified predictors of HIV seropositivity among men. Of 1,041,343 men on their initial visit to the project, 36,905 (3.5%) were MSM; 567,005 (54.5%) were CFSW; and 437,343 (42.0%) were other men living near hotspots (OMHA). Three predictors of HIV seropositivity emerged across all three groups: being uncircumcised, having sexually transmitted infection symptoms, and harmful drinking of alcohol before sex. Any reported form of gender-based violence among MSM and OMHA and inconsistent condom use among CFSW were associated with HIV seropositivity. These findings may inform community HIV strategies like self-testing, delivery of pre-exposure prophylaxis and antiretroviral therapy, and behavioral change communication targeting men at higher risk of infection.

The Role of Alcohol-Related Behavioral Research in the Design of HIV Secondary Prevention Interventions in the Era of Antiretroviral Therapy: Targeted Research Priorities Moving Forward

HIV secondary prevention focuses on averting onward HIV transmission, which can be realized when people living with HIV enact requisite HIV care continuum-related behaviors to achieve viral suppression, and engage in condom-protected sex when virally unsuppressed. Alcohol has been detrimentally linked to all aspects of HIV secondary prevention, and although a growing number of behavioral interventions account for and address alcohol use within this realm, further efforts are needed to fully realize the potential of such initiatives. The present article proposes a series of targeted priorities to inform the future design, implementation, and evaluation of alcohol-related behavioral intervention research within the scope of HIV secondary prevention. These priorities and corresponding approaches account for the challenges of resource-constrained clinic environments; capitalize on technology; and address key comorbidities. This framework provides the foundation for a range of alcohol-related behavioral interventions that could potentially enhance global HIV secondary prevention efforts in the years ahead.

Alcohol use during pregnancy in Rakai, Uganda

Introduction

Antenatal alcohol use is linked to adverse maternal and neonatal outcomes. Uganda has one of the highest rates of alcohol use in sub-Saharan Africa, but the prevalence of antenatal alcohol use has not been reported in the Rakai region.

Methods

We used cross-sectional data from pregnant women in the Rakai Community Cohort Study between March 2017 and September 2018. Using bivariate and multivariable analyses, we assessed associations between self-reported antenatal alcohol use and sociodemographic characteristics, intimate partner violence (IPV), and HIV status.

Results

Among 960 pregnant women, the median age was 26 years, 35% experienced IPV in the past 12 months, 13% were living with HIV, and 33% reported alcohol use during their current pregnancy. After adjusting for marital status, education, smoking, and HIV status; Catholic religion (AOR: 3.54; 95% CI: 1.89–6.64; compared to other), bar/restaurant work (AOR: 2.40; 95% CI: 1.17–4.92; compared to agriculture), >one sex partner in past year (AOR: 1.92; 95% CI: 1.17–3.16), a partner that drank before sex in past year (AOR: 2.01; 95% CI: 1.48–2.74), and past year IPV (AOR: 1.55; 95% CI: 1.14–2.11) were associated with antenatal alcohol use.

Conclusion

We found that alcohol use during pregnancy was common and associated with religion, occupation, higher numbers of past year sex partners, having a partner who drank before sex in the past 12 months, and IPV experience. More research is needed to understand the quantity, frequency, and timing of antenatal alcohol use; and potential impacts on neonates; and to identify services that are acceptable and effective among pregnant women.

Transactional Sex, Alcohol Use and Intimate Partner Violence Against Women in the Rakai Region of Uganda

Transactional sex (TS) is prevalent in sub-Saharan Africa. Women's engagement in TS is linked with HIV infection; little is known about the relationship between TS, intimate partner violence (IPV) and alcohol use-established HIV risk behaviors. Using modified Poisson regression, we assessed associations between TS and physical, verbal and sexual IPV among 8248 women (15-49 years) who participated in the Rakai Community Cohort Study across forty communities in Uganda. An interaction term assessed moderation between alcohol use and TS and no significant interaction effects were found. In adjusted analysis, alcohol use and TS were significantly associated with all forms of IPV. In stratified analysis, TS was only associated with IPV in agrarian communities; alcohol use was not associated with physical IPV in trade communities or sexual IPV in trade and fishing communities. Identifying differences in IPV risk factors by community type is critical for the development of tailored interventions.

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.

Development and Validation of a Sociodemographic and Behavioral Characteristics-Based Risk-Score Algorithm for Targeting HIV Testing Among Adults in Kenya

To inform targeted HIV testing, we developed and externally validated a risk-score algorithm that incorporated behavioral characteristics. Outpatient data from five health facilities in western Kenya, comprising 19,458 adults ≥ 15 years tested for HIV from September 2017 to May 2018, were included in univariable and multivariable analyses used for algorithm development. Data for 11,330 adults attending one high-volume facility were used for validation. Using the final algorithm, patients were grouped into four risk-score categories: ≤ 9, 10-15, 16-29 and ≥ 30, with increasing HIV prevalence of 0.6% [95% confidence interval (CI) 0.46-0.75], 1.35% (95% CI 0.85-1.84), 2.65% (95% CI 1.8-3.51), and 15.15% (95% CI 9.03-21.27), respectively. The algorithm's discrimination performance was modest, with an area under the receiver-operating-curve of 0.69 (95% CI 0.53-0.84). In settings where universal testing is not feasible, a risk-score algorithm can identify sub-populations with higher HIV-risk to be prioritized for HIV testing.

Social and structural determinants of youth alcohol use in Tanzania: The role of gender, social vulnerability and stigma

Adolescent alcohol use remains an under-addressed population health issue across Africa. Although the literature explores the intersection of alcohol use and vulnerability to HIV and AIDS, there is limited evidence on the gendered uptake and use of alcohol among adolescents. Capturing adolescents' voiced experiences about the societal influences shaping their alcohol usage is essential for identifying contextually relevant interventions to reduce their vulnerability to alcohol and related risky behaviours, such as unsafe sex. We conducted qualitative research in urban Tanzania, including key informant interviews, systematic mapping of alcohol availability, in-depth interviews with adolescents in and out of school and adults, and participatory methodologies with adolescents ages 15-19. The findings described here were drawn from the participatory methodologies (n = 177); and in-depth interviews with adolescents (n = 24) and adults (n = 24). Three key themes emerged: (1) boys' increased social vulnerability to alcohol consumption; (2) the ways in which stigma shapes girls' alcohol usage; and (3) how gendered perceptions of alcohol use reinforce societal inequalities. There exists an urgent need to address the social and gendered vulnerabilities of youth in Africa to the uptake and use of alcohol, and identify interventions that reshape notions of masculinity increasing boy's vulnerability to use.

Prevalence and correlates of men's and women's alcohol use in agrarian, trading and fishing communities in Rakai, Uganda

INTRODUCTION

Uganda has one of the highest rates of alcohol use in sub-Saharan Africa but prevalence and correlates of drinking are undocumented in the Rakai region, one of the earliest epicenters of the HIV/AIDS epidemic in East Africa.

METHODS

We analyzed cross-sectional data from 18,700 persons (8,690 men, 10,010 women) aged 15-49 years, living in agrarian, trading and fishing communities and participating in the Rakai Community Cohort Study (RCCS) between March 2015 and September 2016. Logistic regression models assessed associations between past year alcohol use and sociodemographic characteristics, other drug use and HIV status, controlling for age, religion, education, occupation, marital status, and household socioeconomic status.

RESULTS

Past year alcohol prevalence was 45%. Odds of drinking were significantly higher in men (versus women) and fishing communities (versus agrarian areas). Odds of drinking increased with age, previous (versus current) marriage and past year drug use. By occupation, highest odds of drinking were among fishermen and (in women) bar/restaurant workers. Alcohol-related consequences were more commonly reported by male (vs. females) drinkers, among whom up to 35% reported alcohol dependence symptoms (e.g., unsteady gait). HIV status was strongly associated with alcohol use in unadjusted but not adjusted models.

CONCLUSIONS

Alcohol use differed by gender, community type and occupation. Being male, living in a fishing community and working as a fisherman or restaurant/bar worker (among women) were associated with higher odds of drinking. Alcohol reduction programs should be implemented in Uganda's fishing communities and among people working in high risk occupations (e.g., fishermen and restaurant/bar workers).

P, David JK, Rajan S, Adhikary R, Arumugam E. Substance use and risk of HIV infection among Men who have Sex with Men in India: Analysis of National IBBS data, India

HIV prevalence is higher among Men who have Sex with Men (MSM), owing to their unsafe sexual behavior. Further, MSM indulge in behaviors such as consumption of alcohol/oral drugs and/or injecting during/before sex that poses the risk of unsafe behaviors, thereby increasing their vulnerability to HIV. The study aims to analyze the factors associated with HIV infection among the multi-risk MSM using any substances with those MSM who do not use substances.Community-based cross-sectional survey design using probability-based sampling between October 2014 and November 2015.For the nation-wide Integrated Biological and Behavioral Surveillance (IBBS), 23,081 MSM were recruited from 4067 hotspots in 108 districts across India. Information on demographics, sexual behaviors, substance use, sexual partners, and awareness on HIV and its management was collected from the consented respondents using computer-assisted personal interview (CAPI) by trained personnel. Blood samples were tested for HIV. Statistical analyses were done, to study the associations between substance use and its influence on high-risk sexual behaviors and HIV infection.One in 3 MSM (33.88%) in India were substance users, thus exhibiting "multi-risk" (MR) behaviors. Significantly higher HIV prevalence (3.8%, P < .05) was reported among MR-MSM, despite 97.2% of them being aware of HIV. Higher HIV prevalence among MSM exhibiting homosexual behavior for ≤1 year is of specific concern, as this accounts to recent infections and indicates the increased vulnerability of the infection among the new entrants.Substance-use resulting in high-risk sexual behavior was significantly associated with higher HIV prevalence among MR-MSM. Integrated targeted interventions focusing on safe sex and safe-IDU practices among MR-MSM are required to end the disease transmission.

The incidence of HIV and associated risk factors among pregnant women in Kabarole District, Uganda

OBJECTIVES

The study attempted to determine the incidence of HIV among pregnant women in Kabarole District, Uganda, and to identify socio-demographic and behavioral risk factors for seroconversion during pregnancy.

METHODS

We carried out a retrospective cohort study among women for whom a documented HIV-negative test result from the first pregnancy trimester could be confirmed using available records, and who were HIV-retested in the third trimester or during delivery. In total, 1610 pregnant women from three different healthcare settings took part in the study. We captured the results of repeated HIV tests and conducted semi-structured interviews to explore participants' socio-demographic characteristics and sexual risk behavior. For HIV incidence rates, we calculated the number of seroconversions per 100 person-years. We used Fisher's exact test to test for potential associations. Penalized maximum likelihood logistic regression and Poisson regression were applied to adjust for potential confounders.

RESULTS

The overall HIV incidence rate among participants was 2.9/100 women-years. Among socio-demographic characteristics, the multivariable analysis showed a significant association of marital status with HIV incidence in pregnancy (IRR 8.78, 95%CI [1.13-68.33]). Risky sexual behaviors including higher number of sexual partners in pregnancy (IRR 2.78 [1.30-5.94]), unprotected sex with unknown persons (IRR 14.25 [4.52-44.93]), alcohol abuse (IRR 12.08 [4.18-34.90]) and sex under the influence of drugs or alcohol (IRR 6.33 [1.36-29.49]) were significantly associated with seroconversion in pregnancy (similar results in logistic regression).

CONCLUSIONS

HIV incidence was three times higher among our pregnant study population compared to the general female population in Uganda. This underlines the importance of HIV prevention and repeat testing during pregnancy. Identified risk groups should be considered for pre-exposure prophylaxis.

Alcohol use in fishing communities and men's willingness to participate in an alcohol, violence and HIV risk reduction intervention: qualitative findings from Rakai, Uganda

Alcohol use, intimate partner violence (IPV) and HIV infection are associated, but few programmes and interventions have addressed their synergistic relationship or been evaluated for effectiveness and acceptability. This is a critical gap in populations with high rates of alcohol use, HIV and IPV, such as Uganda's fishing communities. This study examined drinking norms, barriers and facilitators to engagement in a risk reduction programme, and ideas for tailoring. Results showed that alcohol use is common in fishing villages. While men and women drink, gendered notions of femininity deem alcohol largely unacceptable for women. Plastic sachets of liquor were the most common alcoholic drink. Participants did not understand the definition of 'hazardous drinking', but recognised connections between drinking, violence and sexual risk-taking. The idea of an alcohol, IPV and HIV risk reduction intervention was supported, but barriers need to be addressed, including how best to help those uninterested in reducing their drinking, addressing normalisation of drinking and how best to inform those who truly need intervention. Intervention to people living with HIV around the time of diagnosis and treatment may be warranted. Study findings highlight the potential to integrate alcohol and IPV reduction programmes into an HIV service provision.

Factors associated with alcohol use before sex among HIV-negative female sex workers in Zambia

Female sex workers (FSWs) are at high risk of HIV infection. Alcohol use prior to sex can compound this risk. We investigated the factors associated with having sex under the influence of alcohol among Zambian FSWs. Community health workers and peer FSWs recruited 331 HIV-negative FSWs in Lusaka and Ndola. In a cross-sectional survey, we asked FSWs how often they had sex under the influence of alcohol in the previous month and categorised responses as ‘always’ and ‘not always’. The adjusted odds ratios (AORs) of always having sex under the influence of alcohol were higher among FSWs who charged clients medium (AOR: 2.20, 95% confidence interval [CI]: 1.04–4.68) and low fees (AOR: 2.65, 95% CI: 1.26–5.60) for sex versus high fees; received 9–19 (AOR: 2.37, 95% CI: 1.15–4.91) and 20 or more clients per month (AOR: 3.06, 95% CI: 1.47–6.37) versus up to 8 clients per month; and never used condoms versus always used condoms with clients (AOR: 4.21, 95% CI: 1.53–11.55). FSWs who always used alcohol before sex appeared more likely to engage in riskier sex and charge clients lower fees. Interventions for financial empowerment and alcohol risk reduction should complement existing HIV prevention interventions for FSWs.

Factors associated with concurrent sexual partnerships among men who have sex with men in Yangon, Myanmar

Men who have sex with men (MSM) are considered to be one of the groups most at risk of contracting HIV. However, to date, information regarding MSM's sexual behaviors and the risk factors for their concurrent sexual partnerships (CSP) have not been known in Myanmar. This study aimed to identify factors associated with CSP among MSM.A cross-sectional study was conducted from September to October 2011 in Yangon, Myanmar. In total, 353 males who had self-reported sex with men were recruited using respondent-driven sampling method. Descriptive statistics and multivariate logistic regression analysis were performed. In total, 61.0% of the MSM reported having CSP. MSM who practiced sex trading in the past six months (adjusted odds ratio8.32; 95% confidence interval [CI]: 2.30-30.10), MSM who had diagnosed with STIs/HIV (AOR 6.71; 95% CI: 4.78-9.28), and MSM who engaged in unprotected insertive anal sex (AOR 1.27; 95% CI: 1.02-1.45) were more likely to have CSP. In contrast, MSM who used condoms consistently during the past six months (AOR = 0.27; 95% CI: 0.08-0.94), MSM who had a regular job (AOR = 0.21; 95% CI: 0.06-0.74), and MSM who initiated sexual activities later in their lives (AOR = 0.08; 95% CI: 0.03-0.25) were less likely to have CSP. Concurrent sexual partnerships are common among MSM in Myanmar. Findings suggest that interventions should focus on MSM who diagnosed with STIs/HIV, do not have regular jobs, and initiated their sexual activities at an early age.

Tobacco and Alcohol Use Among Youth in Low and Middle Income Countries: A Multi-Country Analysis on the Influence of Structural and Micro-Level Factors

BACKGROUND

The transition from adolescence to adulthood is a critical life phase as it is during this period that substance use and disorders typically emerge and escalate. Globally, few studies have examined the prevalence and correlates of alcohol and tobacco use among youth (ages 15-24). This study seeks to bridge this gap by assessing the influence of structural and micro-level factors on tobacco and alcohol use among youth in Low- and Middle-income countries (LMICs).

METHODS

Data are drawn from the Multiple Indicator Cluster Surveys (MICS) conducted in 29 countries or regions in Eastern Europe, Latin America, Asia and Africa between 2010 and 2015. Analyses focus on lifetime prevalence and age of onset for tobacco and alcohol use.

RESULTS

Descriptive analyses highlight regional variations in the prevalence and age of onset of tobacco and alcohol use: tobacco use is more concentrated among youth in Eastern Europe but alcohol use is generalized across the regions. Using multi-level analyses, we find statistically significant main effects for age, gender, educational attainment, rural residence, marital status and exposure to mass media on tobacco and alcohol use outcomes as well as interaction effects for age, gender and education on tobacco and alcohol use outcomes. Conclusions/importance: These findings highlight the need for structural interventions to control tobacco social marketing, and for gender considerations in tobacco and alcohol use prevention programs and policies.

"The Bottle Is My Wife": Exploring Reasons Why Men Drink Alcohol in Ugandan Fishing Communities

Fishing communities in Uganda have high rates of excessive alcohol consumption and negative health outcomes related to alcohol consumption, such as HIV acquisition and transmission and intimate partner violence victimization and perpetration. Research lacks understanding of alcohol use in Ugandan fishing communities, underlying reasons for excessive drinking among fishermen or how their community perceives negative health outcomes linked to excessive alcohol consumption. This qualitative study was conducted among Ugandan fisherfolk to determine why excessive alcohol consumption has overtaken their communities. Through analyzing in-depth interviews and focus group discussions, reasons for drinking and community perceptions of drinking were explored using the Socio Ecological Model and the Time Perspective Theory. Interviews were coded into two content themes: social influences on drinking and using alcohol to cope with stress. Participants acknowledged links between excessive alcohol consumption and negative health outcomes within their families and communities. These findings highlight the need for alcohol-related reduction interventions that are sensitive to contextual factors and self-identified contributors to problematic alcohol use within individuals and their communities. Such interventions must consider the social, ecological and economic conditions within fishing sites, focusing not only on individual-level behavioral change but also challenging the underlying structures that foster excessive alcohol consumption.

Alcohol use in a rural district in Uganda: findings from community-based and facility-based cross-sectional studies

Background

Uganda has one of the highest per capita alcohol consumption rates in sub-Saharan Africa. However, the prevalence of alcohol use disorders (AUD) remains unknown in many areas, especially in rural districts. This study aimed to estimate the prevalence of alcohol consumption and of alcohol use disorder among men, and to describe the distribution of drinking intensity, among men in in Kamuli District, Uganda.

Methods

Men attending primary care clinics in Kamuli District were consecutively interviewed in a facility-based cross-sectional study, and a separate group of men were interviewed in a population-based cross-sectional study. In both studies the men were administered a structured questionnaire, which included the alcohol use disorder identification test (AUDIT) to screen for AUD, as well as sections about demographic characteristics, depression screening, internalized stigma for alcohol problems and treatment-seeking.

Results

Among the 351 men enrolled in the Community study, 21.8% consumed alcohol in the past 12 months, compared to 39.6% of 778 men in the Facility Survey. The proportion of men who screened positive for AUD was 4.1% in the community study and 5.8% in the facility study. AUDIT scores were higher among older men, men with paid/self-employment status and higher PHQ-9 score (P < 0.05). Nearly half (47.5%) of the men with AUDIT-positive scores reported that alcohol use problems had ruined their lives. A majority (55.0%) of men with AUDIT-positive scores did not seek treatment because they did not think AUD was a problem that could be treated.

Conclusions

Internalized stigma beliefs among AUDIT-positive men impede treatment-seeking. As part of any efforts to increase detection and treatment services for alcohol use problems, routine screening and brief interventions for internalized stigma must be incorporated within the normal clinical routine of primary health care.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0191-5) contains supplementary material, which is available to authorized users.

HIV/AIDS mortality attributable to alcohol use in South Africa: a comparative risk assessment by socioeconomic status

OBJECTIVES

To quantify HIV/AIDS mortality attributable to alcohol use in the adult general population of South Africa in 2012 by socioeconomic status (SES).

DESIGN

Comparative risk assessment based on secondary individual data, aggregate data and risk relations reported in the literature.

SETTING

South African adult general population.

PARTICIPANTS

For metrics of alcohol use by SES, sex and age: 27 070 adults that participated in a nationally representative survey in 2012. For HRs of dying from HIV/AIDS by SES: 87 029 adults that participated in a cohort study (years 2000 to 2014) based out of the Umkhanyakude district, KwaZulu-Natal.

MAIN OUTCOME MEASURES

Alcohol-attributable fractions for HIV/AIDS mortality by SES, age and sex were calculated based on the risk of engaging in condom-unprotected sex under the influence of alcohol and interactions between SES and alcohol use. Age-standardised HIV/AIDS mortality rates attributable to alcohol by SES and sex were estimated using alcohol-attributable fractions and SES-specific and sex-specific death counts. Rate ratios were calculated comparing age-standardised rates in low versus high SES by sex.

RESULTS

The age-standardised HIV/AIDS mortality rate attributable to alcohol was 31.0 (95% uncertainty interval (UI) 21.6 to 41.3) and 229.6 (95% UI 108.8 to 351.6) deaths per 100 000 adults for men of high and low SES, respectively. For women the respective rates were 10.8 (95% UI 5.5 to 16.1) and 75.5 (95% UI 31.2 to 144.9). The rate ratio was 7.4 (95% UI 3.4 to 13.2) for men and 7.0 (95% UI 2.8 to 18.2) for women. Sensitivity analyses corroborated marked differences in alcohol-attributable HIV/AIDS mortality, with rate ratios between 2.7 (95% UI 0.8 to 7.6; women) and 15.1 (95% UI 6.8 to 27.7; men).

CONCLUSIONS

The present study showed that alcohol use contributed considerably to the socioeconomic differences in HIV/AIDS mortality. Targeting HIV infection under the influence of alcohol is a promising strategy for interventions to reduce the HIV/AIDS burden and related socioeconomic differences in South Africa.

HIV self-testing values and preferences among sex workers, fishermen, and mainland community members in Rakai, Uganda: A qualitative study

HIV self-testing may encourage greater uptake of testing, particularly among key populations and other high-risk groups, but local community perceptions will influence test uptake and use. We conducted 33 in-depth interviews and 6 focus group discussions with healthcare providers and community members in high-risk fishing communities (including sex workers and fishermen) and lower-risk mainland communities in rural Uganda to evaluate values and preferences around HIV self-testing. While most participants were unfamiliar with HIV self-testing, they cited a range of potential benefits, including privacy, convenience, and ability to test before sex. Concerns focused on the absence of a health professional, risks of careless kit disposal and limited linkage to care. Participants also discussed issues of kit distribution strategies and cost, among others. Ultimately, most participants concluded that benefits outweighed risks. Our findings suggest a potential role for HIV self-testing across populations in these settings, particularly among these key populations. Program implementers will need to consider how to balance HIV self-testing accessibility with necessary professional support.

Sex-related substance use and the externalizing spectrum

BACKGROUND

Substance use before and during sexual activity is associated with many negative health outcomes. Estimates suggest that at least 4.3 million American adults annually engage in regular sex-related alcohol consumption, indicating that the intersection of substance use and sexual behavior is of public health concern. However, it is likely that when considering broader sex-related substance use, estimates would be notably higher. While substance use disorders and antisocial personality disorder have been associated with sex-related alcohol consumption, no study has investigated how regular sex-related substance use is associated with the broader transdiagnostic externalizing spectrum. Further, no studies have assessed whether or not sexual risk-taking behaviors can be integrated into the externalizing spectrum.

METHODS

In a large internet sample (N=936), we used confirmatory factor analysis, item response theory, and logistic regression to link sex-related alcohol and drug use to an externalizing latent variable; identified psychometric characteristics of these behaviors; and determined the extent to which one's externalizing level was associated with changes in odds of regular sex-related substance use. We then replicated these findings in a nationally representative sample (N=34,653).

RESULTS

Results highlighted the close association between sex-related substance use and externalizing, with externalizing increases being associated with significantly increased odds of regular sex-related substance use.

CONCLUSIONS

These findings bear notable implications for conceptualization and treatment of sex-related substance use. Transdiagnostic intervention can be an efficient means of addressing this problematic behavior as well as other comorbid presentations. Results expand the current conceptualization of the externalizing spectrum.

Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic

BACKGROUND

Voluntary medical male circumcision (VMMC) is effective in decreasing the risk of HIV acquisition. As men resume sexual activity after circumcision, it will be important to study their satisfaction with the procedure, sexual pleasure and function, coital trauma, and risk compensation (RC), which can hamper or facilitate the long-term success of VMMC programs.

AIM

To assess men's satisfaction with VMMC, sexual pleasure and function, coital trauma, and RC after VMMC.

METHODS

This is a cohort study of circumcised men who presented for follow-up 6 to 24 months after VMMC. Logarithmic binomial regression was performed to explore factors associated with any increase in the number of sex partners after VMMC as a measurement of RC.

MAIN OUTCOME MEASURES

(i) Men's satisfaction with their VMMC; (ii) sexual pleasure and function after VMMC; (iii) coital trauma; and (iv) RC.

RESULTS

Of 454 circumcised men, 362 (80%) returned for a follow-up visit 6 to 24 months after VMMC. Almost all (98%) were satisfied with the outcome of their VMMC; most (95%) reported that their female partners were satisfied with their circumcision. Two thirds (67%) reported enjoying sex more after VMMC and most were very satisfied or somewhat satisfied (94%) with sexual intercourse after VMMC. Sexual function improved and reported sex-induced coital injuries decreased significantly in most men after VMMC. There was an increase in the proportion of men who reported at least two sexual partners after VMMC compared with baseline. In multivariate analysis, having sex with a woman they met the same day (adjusted relative risk = 1.7, 95% CI = 1.2-2.4) and having at least two sexual partners at baseline (adjusted relative risk = 0.5, 95% CI = 0.3-0.8) were associated with the outcome of any increase in the number of partners after VMMC.

CLINICAL IMPLICATIONS

VMMC can be offered to Dominican men for HIV prevention without adversely affecting sexual pleasure or function. The procedure substantially reduces coital trauma.

STRENGTHS & LIMITATIONS

This is the first report of long-term overall satisfaction, sexual pleasure/function and sex behaviors in the context of VMMC outside of Africa. Limitations of the study included the reliance on self-reported sex behaviors, the lack of physiologic measurement of penile sensitivity and the lack of follow up data beyond 24 months, which precludes the assessment of longer term RC.

CONCLUSION

The study confirmed men's long-term satisfaction with the outcome of their VMMC. VMMC improved sexual pleasure and function for most men and significantly decreased coital injuries. There was mixed evidence of RC. Brito MO, Khosla S, Pananookooln S, et al. Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic. J Sex Med 2017;14:526-534.

Population attributable fraction of incident HIV infections associated with alcohol consumption in fishing communities around Lake Victoria, Uganda

Background

Although the association between alcohol consumption and HIV risk is well documented, few studies have examined the magnitude of new HIV infections that could be prevented by controlling alcohol use. We report the population attributable fraction (PAF) of incident HIV infections due to alcohol consumption among the HIV high-risk population of fishing communities along Lake Victoria, Uganda.

Methods

In a community-based cohort study, 1607 HIV sero-negative participants aged 18–49 years were enrolled from eight fishing communities along Lake Victoria, Uganda. At follow up 12 months later, 1288 (80.1%) were seen and interviewed. At baseline and follow-up visits, participants completed interviewer-administered questionnaires on alcohol consumption, demographics, and sexual risk behavior, and were tested for HIV infection. HIV incidence and adjusted incident rate ratios (adjusted IRRs) were estimated using Poisson regression models; the crude and adjusted PAFs of incident HIV infections associated with alcohol consumption were calculated using the Greenland and Drescher method for cohort studies.

Results

Among the 1288 participants seen at follow up, 53.5% reported drinking alcohol of whom 24.4% drank occasionally (2 days a week or less) and 29.1% drank regularly (3–7 days a week). Forty eight incident HIV infections occurred giving an incidence rate of 3.39/100 person years at-risk (pyar) (95% CI, 2.55–4.49). Compared to non-drinkers, the adjusted IRR of HIV was 3.09 (1.13–8.46) among occasional drinkers and 5.34 (2.04–13.97) among regular drinkers. The overall adjusted PAF of incident HIV infections due alcohol was 64.1 (95% CI; 23.5–83.1); ranging from 52.3 (11.9–74.2) among Muslims to 71.2 (32.6–87.7) for participants who reported ≥ 2 sexual partners in the past 12 months.

Conclusion

In fishing communities along Lake Victoria, Uganda, 64% of new HIV infections can be attributed to drinking alcohol. Interventions to reduce alcohol consumption should be integrated in HIV/AIDS prevention activities for populations in whom both HIV and alcohol consumption are highly prevalent.

Depression, alcohol use, and intimate partner violence among outpatients in rural Uganda: vulnerabilities for HIV, STIs and high risk sexual behavior

Background

Intimate partner violence (IPV), alcohol use, and depression are key vulnerabilities for HIV in Uganda, and taken together may have a synergistic effect on risk. Our objective was to investigate the associations between depression, IPV, and alcohol use and HIV-risk indicators among a sample of outpatients in rural Uganda, and the effect of co-occurrence of these factors on HIV-risk indicators.

Methods

In a structured interview we collected data on high-risk sexual behavior, depression symptoms, emotional and physical IPV, and alcohol use, as well as a blood sample for HIV and syphilis tests and a urine sample for chlamydia and gonorrhea tests from 325 male and female outpatients receiving provider-initiated HIV testing and counseling (PITC) at a public hospital outpatient clinic in rural Uganda. We used logistic regression and generalized linear modeling to test independent associations between depression, IPV, and alcohol use and HIV-risk indicators, as well as the effect of co-occurrence on HIV-risk indicators.

Results

Twelve percent of men and 15% of women had two or more of the following conditions: depression, IPV, and alcohol use; another 29% of men and 33% of women had 1 condition. Each condition was independently associated with HIV risk behavior for men and women, and for women, depression was associated with testing positive for HIV or a sexually transmitted infection (STI). Men with one condition (AOR 2.32, 95% CI 1.95–2.77) and two or more conditions (AOR 12.77, 95% CI 7.97–20.47) reported more high risk sex acts compared to those with no potential co-occurring conditions. For men, experiencing two or more conditions increased risky sex more than one alone (χ² 24.68, p < 0.001). Women experiencing one condition (AOR 3.33, 95% CI 137–8.08) and two co-occurring conditions (AOR 5.87, 95% CI 1.99–17.35) were more likely to test positive for HIV or an STI and women with two co-occurring conditions were also at increased risk for risky sex (AOR 2.18, 95% CI 1.64–2.91). We also found preliminary evidence suggesting synergistic effects between depression and emotional IPV and between alcohol use and depression.

Conclusions

This study demonstrates the co-occurrence of depression, IPV, and alcohol use in men and women in an outpatient setting in rural Uganda. The co-occurrence of these factors was associated with greater HIV risk, highlighting the need for a more holistic approach to HIV prevention and care research and programming.

Alcohol Consumption and Risky Sexual Behavior Among Persons Attending Alcohol Consumption Venues in Gaborone, Botswana

Alcohol use is a known key risk factor associated with risky sexual behavior that contributes to HIV transmission. This cross-sectional study used time location sampling to investigate alcohol use and risky sexual behaviors that occurred after ingesting alcohol among 609 patrons of alcohol venues in Gaborone, Botswana. Alcohol Use Disorders Identification Test (AUDIT) scores were categorized as low (1-7), medium (8-15), and high (16+) for analysis. Logistic regression models stratified by gender assessed the association between alcohol use and condom use at last sex after drinking alcohol. Among females, the odds of condom use during last sex after drinking alcohol were significantly lower for high compared to low AUDIT scores (AOR = 0.17, 95% CI 0.06-0.54). Among males, factors significantly associated with condom use at last sex after alcohol use were low levels of education (primary level compared to university and above AOR = 0.13; 95% CI 0.03-0.55) and beliefs that alcohol use did not increase risky sexual behaviors (AOR = 0.26; 95% CI 0.11-0.62). HIV prevention interventions should target females and emphasize sexual risks associated with alcohol use.

Relationship Power and Sexual Violence Among HIV-Positive Women in Rural Uganda

Gender-based power imbalances place women at significant risk for sexual violence, however, little research has examined this association among women living with HIV/AIDS. We performed a cross-sectional analysis of relationship power and sexual violence among HIV-positive women on anti-retroviral therapy in rural Uganda. Relationship power was measured using the Sexual Relationship Power Scale (SRPS), a validated measure consisting of two subscales: relationship control (RC) and decision-making dominance. We used multivariable logistic regression to test for associations between the SRPS and two dependent variables: recent forced sex and transactional sex. Higher relationship power (full SRPS) was associated with reduced odds of forced sex (AOR = 0.24; 95 % CI 0.07-0.80; p = 0.020). The association between higher relationship power and transactional sex was strong and in the expected direction, but not statistically significant (AOR = 0.47; 95 % CI 0.18-1.22; p = 0.119). Higher RC was associated with reduced odds of both forced sex (AOR = 0.18; 95 % CI 0.06-0.59; p < 0.01) and transactional sex (AOR = 0.38; 95 % CI 0.15-0.99; p = 0.048). Violence prevention interventions with HIV-positive women should consider approaches that increase women's power in their relationships.

Alcohol use among adults in Uganda: findings from the countrywide non-communicable diseases risk factor cross-sectional survey

Background

There are limited data on levels of alcohol use in most sub-Saharan African countries.

Objective

We analyzed data from Uganda's non-communicable diseases risk factor survey conducted in 2014, to identify alcohol use prevalence and associated factors.

Design

The survey used the World Health Organization STEPS tool to collect data, including the history of alcohol use. Alcohol users were categorized into low-, medium-, and high-end users. Participants were also classified as having an alcohol-use-related disorder if, over the past 12 months, they were unable to stop drinking alcohol once they had started drinking, and/or failed to do what was normally expected of them because of drinking alcohol, and/or needed an alcoholic drink first in the morning to get going after a heavy drinking session the night before. Weighted logistic regression analysis was used to identify factors associated with medium- to high-end alcohol use.

Results

Of the 3,956 participants, 1,062 (26.8%) were current alcohol users, including 314 (7.9%) low-end, 246 (6.2%) medium-end, and 502 (12.7%) high-end users. A total of 386 (9.8%) were classified as having an alcohol-use-related disorder. Male participants were more likely to be medium- to high-end alcohol users compared to females; adjusted odds ratio (AOR)=2.34 [95% confidence interval (CI)=1.88–2.91]. Compared to residents in eastern Uganda, participants in central and western Uganda were more likely to be medium- to high-end users; AOR=1.47 (95% CI=1.01–2.12) and AOR=1.89 (95% CI=1.31–2.72), respectively. Participants aged 30–49 years and those aged 50–69 years were more likely to be medium- to high-end alcohol users, compared to those aged 18–29 years, AOR=1.49 (95% CI=1.16–1.91) and AOR=2.08 (95% CI=1.52–2.84), respectively.

Conclusions

The level of alcohol use among adults in Uganda is high, and 9.8% of the adult population has an alcohol-use-related disorder.

Gendered sexual uses of alcohol and associated risks: a qualitative study of Nigerian University students

Background

Alcohol misuse among young people is a global phenomenon. In many countries, young people engage in heavy drinking and this exacerbates risky sexual behaviour. In Nigeria, alcohol held multiple roles in the traditional era but was mainly consumed by adult males for pleasure. Adult females and young people were culturally constrained from drinking in most communities. In contemporary Nigeria, young people’s drinking is increasing, and many engage in sexual intercourse under the influence of alcohol.

Methods

This study draws on the traditional gender and social sexual scripts to explore the factors that motivate young people to use alcohol for sexual purposes. In-depth interviews were conducted with 19 to 23-year old male and female undergraduate students from a Nigerian university. Thematic analysis was conducted with the aid of NVivo 10 software.

Results

Men drink to become confident to initiate sexual relationships, stimulate sexual urges, prolong erection, increase sexual satisfaction and become more aggressive during sexual intercourse. Women also drink to be bold in initiating sexual relationships, for sexual arousal and to increase satisfaction. Relatedly, not every brand of alcohol is used for sexual purposes. For example, while men use ‘herbal’ alcoholic beverages and a mixture of locally-produced gin and marijuana, women use champagne and other flavoured alcoholic beverages. The results also revealed that young people use alcohol or salt in a bid to prevent conception after sexual intercourse.

Conclusions

Adherence to the traditional gender (masculinity) and social sexual scripts amongst men and the enactment of what appears to be a new form of femininity script amongst women contribute to a culturally specific understanding of the motivations to use alcohol for sexual purposes. Evidence-based strategies should be employed to distribute information about the consequences of sexual intercourse under the influence of alcohol.

HIV-Alcohol Risk Reduction Interventions in Sub-Saharan Africa: A Systematic Review of the Literature and Recommendations for a Way Forward

Sub-Saharan Africa bears 69 % of the global burden of HIV, and strong evidence indicates an association between alcohol consumption, HIV risk behavior, and HIV incidence. However, characteristics of efficacious HIV-alcohol risk reduction interventions are not well known. The purpose of this systematic review is to summarize the characteristics and synthesize the findings of HIV-alcohol risk reduction interventions implemented in the region and reported in peer-reviewed journals. Of 644 citations screened, 19 met the inclusion criteria for this review. A discussion of methodological challenges, research gaps, and recommendations for future interventions is included. Relatively few interventions were found, and evidence is mixed about the efficacy of HIV-alcohol risk reduction interventions. There is a need to further integrate HIV-alcohol risk reduction components into HIV prevention programming and to document results from such integration. Additionally, research on larger scale, multi-level interventions is needed to identify effective HIV-alcohol risk reduction strategies.

Correlates of Alcohol Use Among Patrons of Alcohol Consumption Venues in Botswana

This study evaluated the correlates of three alcohol measures using a cross-sectional survey conducted among patrons of alcohol-serving venues in Gaborone, Botswana from October 2012 to February 2013. Using logistic regression, we found that engaging in higher levels of sexual risk behaviors was significantly associated with frequent drinking (at least 3 times a week), heavy episodic drinking (more than 6 standard units of alcohol at least weekly) and probable alcohol dependence (AUDIT score ≥20). Additionally, having higher levels of alcohol expectancies that increase the risk of HIV infection was significantly associated with probable alcohol dependence. Although HIV knowledge was generally high in this population, there is need for HIV prevention and alcohol harm reduction efforts to address the role of alcohol in increasing HIV risk and encourage the adoption of safer drinking patterns and the modification of alcohol expectancies.

Alcohol Use and Transactional Sex among Women in South Africa: Results from a Nationally Representative Survey

BACKGROUND

Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa.

METHODS

A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16-55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex.

RESULTS

About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1-4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5-6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex.

CONCLUSION

Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex.

HIV and alcohol knowledge, self-perceived risk for HIV, and risky sexual behavior among young HIV-negative men identified as harmful or hazardous drinkers in Katutura, Namibia

Background

Namibia’s HIV prevalence is 13.3 %. Alcohol is associated with sexual risk-taking, leading to increased HIV risk. Baseline sexual behaviors, HIV and alcohol knowledge, and self-perceived HIV risk were examined among men reporting high-risk drinking in Katutura, Namibia.

Methods

HIV negative men, ≥ 18 years, were screened for harmful or hazardous levels of drinking and >1 recent sex partner prior to randomization into control or intervention arm. SAS 9.3 and R 3.01 were used for descriptive baseline cohort analyses.

Results

A total of 501 participants who met criteria were included in analysis (mean Alcohol Use Disorders Identification Test [AUDIT] =12.4). HIV and alcohol knowledge were high with the majority (>85 and 89.8–98 %, respectively) of respondents correctly answering assessment questions. Despite high knowledge levels, 66.7 % of men felt they were at some or high risk of HIV acquisition. Among those respondents, 56.5 % stated often wanting to have sex after drinking and 40.3 % stated sex was better when drunk. Among respondents with non-steady partners [n = 188], 44.1 % of last sexual encounters occurred while the participant was drunk and condoms were not used 32.5 % of those times. Among persons who were not drunk condoms were not used 13.3 % of those times.

Conclusions

Sex with casual partners was high. Inconsistent condom use and alcohol use before sex were frequently reported. Increased emphasis on alcohol risk-reduction strategies, including drinking due to peer pressure and unsafe sexual behaviors, is needed.

Prevalence of Sexual Experience and Initiation of Sexual Intercourse Among Adolescents, Rakai District, Uganda, 1994-2011

PURPOSE

The purpose of the study was to identify risk factors and time trends for sexual experience and sexual debut in rural Uganda.

METHODS

Using population-based, longitudinal data from 15- to 19-year olds in Rakai, Uganda, we examined temporal trends in the prevalence of sexual experience and potential risk factors for sexual experience (n = 31,517 person-round observations) using logistic regression. We then identified factors associated with initiation of sex between survey rounds, using Poisson regression to estimate incidence rate ratios (IRR; n = 5,126 person-year observations).

RESULTS

Sexual experience was more common among adolescent women than men. The prevalence of sexual experience rose for most age-gender groups after 1994 and then declined after 2002. Factors associated with higher prevalence of sexual experience (without adjustment for other factors) included age, not enrolled in school, orphanhood, lower socioeconomic status, and drinking alcohol in the past 30 days; similar factors were associated with initiation of sex. Factors independently associated with initiation of sex included older age, nonenrollment in school (IRR = 1.7 for women and 1.8 for men), alcohol use (IRR = 1.3 for women and men), and being a double orphan among men (IRR = 1.2). Sexual experience began to decline around 2000, whereas increases in school enrollment began as early as 1994 and declines in orphanhood occurred after 2004 (as antiretroviral therapy became available).

CONCLUSIONS

Sexual experience among youth in Rakai was associated with social factors particularly school enrollment. Changes in these social factors also appear to influence change over time in sexual experience.

Sex-related alcohol expectancies and high-risk sexual behaviour among drinking adults in Kampala, Uganda

Alcohol consumption, a risk factor for HIV transmission in sub-Saharan Africa, is considered high in Uganda. A cross sectional study was conducted to determine whether sex-related expectations about the effects of alcohol explain the association between alcohol use and risky sexual behaviours in a population-based sample of adults in Kampala. Associations between alcohol use (current and higher risk drinking) and high-risk sexual behaviours (multiple regular partners and casual sex) were tested. In age-sex-adjusted models, having multiple regular partners was associated with current drinking (odds ratio [OR] = 2.76, 95% confidence intervals [CIs] = 1.15, 6.63) and higher risk drinking (OR = 3.35, 95% CI = 1.28, 8.71). Associations were similar but not statistically significant for having a causal sex partner. Sex-related alcohol outcome expectancy was associated with both alcohol use and high-risk sexual behaviour and attenuated relationships between multiple regular partners and both current drinking (OR = 1.94, 95% CI = 0.57, 6.73) and higher risk drinking (OR = 2.44, 95% CI = 0.68, 8.80). In this setting sexual behaviours related with alcohol consumption were explained, in part, by sex-related expectations about the effects of alcohol. These expectations could be an important component to target in HIV education campaigns.

Combined Intimate Partner Violence and HIV/AIDS Prevention in Rural Uganda: Design of the SHARE Intervention Strategy

Intimate partner violence (IPV) has a bidirectional relationship with HIV infection. Researchers from the Rakai Health Sciences Program (RHSP), an HIV research and services organization in rural Uganda, conducted a combination IPV and HIV prevention intervention called the Safe Homes and Respect for Everyone (SHARE) Project between 2005 and 2009. SHARE was associated with significant declines in physical and sexual IPV and overall HIV incidence, and its model could be adopted as a promising practice in other settings. In this article we describe how SHARE's IPV-prevention strategies were integrated into RHSP's existing HIV programming and provide recommendations for replication of the approach.

Time Since Release from Incarceration and HIV Risk Behaviors Among Women: The Potential Protective Role of Committed Partners During Re-entry

After release from incarceration, former female inmates face considerable stressors, which may influence drug use and other risk behaviors that increase risk for HIV infection. Involvement in a committed partnership may protect women against re-entry stressors that may lead to risky behaviors. This study measured the association between time since release from incarceration (1-6 months ago, and >6 months ago versus never incarcerated) and HIV risk behaviors and evaluated whether these associations differed by involvement in a committed partnership. Women released within the past 6 months were significantly more likely to have smoked crack cocaine, used injection drugs and engaged in transactional sex in the past month compared to never-incarcerated women and women released more distally. Stratified analyses indicated that incarceration within the past 6 months was associated with crack cocaine smoking, injection drug use and transactional sex among women without a committed partner yet unassociated with these risk behaviors among those with a committed partner.

Regularly Drinking Alcohol Before Sexual Activity in a Nationally Representative Sample: Prevalence, Sociodemographics, and Associations With Psychiatric and Substance Use Disorders

OBJECTIVES

We addressed regular drinking before sex and its associated risk factors.

METHODS

From the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative adult US sample (fielded 2004-2005), we determined the 12-month prevalence of regularly drinking alcohol before sexual activity. Among 17,491 sexually active drinkers, we determined the sociodemographic, psychiatric, and substance use correlates of regularly drinking before sex.

RESULTS

Regular presex drinking's 12-month prevalence was 1.8%. Significant bivariate sociodemographic correlates were age, gender, race/ethnicity, education, family income, marital status, and employment status. Generalized anxiety disorder and alcohol dependence were associated with significantly increased odds of being a regular presex drinker after controlling for covariates.

CONCLUSIONS

We estimate that 4.3 million American adults are regular presex drinkers. Future research should examine this public health issue at the population level, with particular focus on pathways that link it to psychopathology.

Risk behaviours and prevalence of sexually transmitted infections and HIV in a group of Dominican gay men, other men who have sex with men and transgender women

OBJECTIVES

The objectives of this study were to estimate the point prevalence of sexually transmitted infection (STI) and to investigate the sexual practices and behaviours associated with STIs in a group of gay men, other men who have sex with men and transgender women (GMT) in the province of La Romana, Dominican Republic.

DESIGN

A cross-sectional study of a convenience sample of GMT persons.

SETTING

The study was conducted in the province of La Romana, Dominican Republic, in June-July 2013.

PARTICIPANTS

Out of 117 GMT persons screened, a total of 100 completed the study. Participants had to be at least 18 years of age, reside in La Romana and have had sex with another man in the preceding 12 months. All participants were interviewed and tested for STI.

PRIMARY OUTCOME MEASURE

The main outcome of interest was the detection of any STI (HIV, herpes simplex virus type 2 (HSV-2), syphilis, hepatitis B or C) by serology.

RESULTS

Among 100 participants, the median age was 22 years (range 18-65). One-third had consumed illicit drugs the preceding year and only 43% consistently used condoms. Prevalence was 38% for HSV-2, 5% for HIV and 13% for syphilis. There were no cases of hepatitis B or C. Factors associated with the odds of a STI were age >22 years (OR=11.1, 95% CI 3.6 to 34.5), receptive anal intercourse (OR=4.2, 95% CI 1.3 to 13.6) and having ≥2 male sexual partners during the preceding month (OR=4, 95% CI 1.3 to 12.5).

CONCLUSIONS

In this group of GMT persons, seroprevalence of STI was high, and a number of risk behaviours were associated with STI. These preliminary data will help inform policy and programmes to prevent HIV/STI in GMT persons in the region.

Exploring the relationship between HIV and alcohol use in a remote Namibian mining community

In southern Africa, the use of alcohol is increasingly seen as creating a context of risk for HIV transmission. This qualitative study investigates the links between alcohol use and higher-risk sexual behaviours in a remote southern Namibian mining-town community. Using data from six focus groups and 16 in-depth interviews conducted in 2008, the researchers investigated knowledge of the link between alcohol consumption and HIV risk, focusing on the specific mechanisms related to drinking and higher-risk sexual behaviours. Although knowledge regarding HIV and alcohol was high among the mineworkers and other community members, the social structure of a remote mining town appears to lead to high levels of alcohol use and higher-risk sexual behaviours. The heavy use of alcohol acts as an accelerant to these behaviours, including as a source of fortitude for those with an intention to engage in casual sexual partnerships or multiple concurrent partnerships, and as a cause for those behaviours for people who may otherwise intend to avoid them. The findings suggest a need for HIV-prevention programmes that focus more holistically on HIV and AIDS and alcohol use, as well as the need for structural changes to mining-town communities in order to reduce the likelihood of both heavy alcohol use as well as a high prevalence of higher-risk sexual behaviours.

Alcohol consumption and high risk sexual behaviour among female sex workers in Uganda

Alcohol consumption has been associated with high risk sexual behaviour among key populations such as female sex workers. We explored the drivers of alcohol consumption and its relationship to high risk sexual behaviour. Participants were drawn from a cohort of 1027 women selected from 'hot spots' in the suburbs of Kampala city. We conducted 3 in-depth interviews with 40 female sex workers between 2010 and 2011. Data were analysed thematically, focusing on alcohol use within the context of sex work. Alcohol consumption was very high with only seven women reporting that they did not drink. Alcohol consumption was driven by the emotional and economic needs of the participants, but also promoted by clients who encouraged consumption. Many sex workers only started drinking alcohol when they joined sex work on the advice of more experienced peers, as a way to cope with the job. Alcohol was blamed for unsafe sex, acts of violence and poor decision making which increased sexual and physical violence. Alcohol was reported to affect medication adherence for HIV-positive women who forgot to take medicine. The findings suggest that the drivers of alcohol consumption are multifaceted in this group and require both individual and structural interventions. Alcohol reduction counselling can be supportive at the individual level and should be an integral part of HIV prevention programmes for female sex workers and others such as patrons in bars. The counselling should be addressed in a sensitive manner to bar owners and managers.

Barriers to and acceptability of provider-initiated HIV testing and counselling and adopting HIV-prevention behaviours in rural Uganda: a qualitative study

In Uganda, a nationwide scale-up of provider-initiated HIV testing and counselling presents an opportunity to deliver HIV-prevention services to large numbers of people. In a rural Ugandan hospital, focus group discussions and key informant interviews were conducted with outpatients receiving provider-initiated HIV testing and counselling and staff to explore the HIV-prevention information, motivation and behavioural skills strengths and weaknesses, and community-level and structural barriers to provider-initiated HIV testing and counselling acceptability and HIV prevention among this population. Strengths and weakness occurred at all levels, and results suggest brief client-centred interventions during provider-initiated HIV testing and counselling may be an effective approach to increase prevention behaviours in outpatient settings.

Inkwari: an emerging high-risk place potentiating hiv spread among young adults in a hyper-endemic South African setting

Young adults in South Africa are at the epicenter of the HIV epidemic. The prevalence of HIV among young people in the province of KwaZulu-Natal (KZN) is particularly high. This study characterizes inkwari (Zulu word for raves or weekend-long parties) in eThekwini District, KZN and explored how these place-based dynamics shape the risk environment for the young adult attendees. In 2011, 13 qualitative interviews were conducted with men and women between 18 and 30 years-old who reported unprotected sex with at least one casual partner in the prior 3 months and attended an inkwari in the same time period. Interviews were analyzed using qualitative content analysis. Nine key informant interviews helped to triangulate these data. Five women and eight men were interviewed and the mean age was 25 years (SD 3.24). Ten reported meeting a sexual partner at an inkwari. Inkwari were characterized as sexualized settings with limited adult supervision. Participants attended inkwari to socialize with peers, use drugs and alcohol, and meet sexual partners. Sexual and physical violence also occurred at inkwari. Given the convergence of social, sexual, and substance-using networks at inkwari, further inquiry is needed to determine how this place may potentiate HIV transmission risk in an endemic setting.

Regularly drinking alcohol before sex in the United States: effects of relationship status and alcohol use disorders

BACKGROUND

Drinking alcohol before sex increases the likelihood of engaging in sexual risk behaviors and risk for HIV infection. Relationship status (single versus partnered) and alcohol use disorders (AUD) are associated with each other and sexual risk behaviors, yet have not been examined as predictors of drinking alcohol before sex, using national data. This study examined whether relationship status and AUD increased the likelihood of regularly drinking alcohol before sex in a nationally representative sample.

METHODS

The main and additive interaction effects of relationship status and AUD on regularly drinking alcohol before sex were analyzed among sexually active drinkers (N=17,491) from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Regularly drinking alcohol before sex was defined as drinking alcohol most or all of the time before sex.

RESULTS

After adjustment for controls, relationship status (AOR=3.51; CI=2.59-4.75) and AUD (AOR=6.24; CI=5.16-7.53) increased the likelihood of regularly drinking alcohol before sex and interacted to differentially increase this risk, with the effect of being single on the likelihood of regularly drinking alcohol before sex increased among participants with AUD (p<.001).

CONCLUSIONS

This study reinforces the importance of relationship status and AUD to the risk for regularly drinking alcohol before sex. Public health efforts should target alcohol and HIV prevention messages to single adults, particularly those with AUD, highlighting their risk for regularly drinking alcohol before sex.