Event-level association between alcohol use and unprotected sex during last sex: evidence from population-based surveys in sub-Saharan Africa

Prevalence of alcohol use by gender and HIV status in rural Uganda

BACKGROUND

Alcohol use is a major contributor to mortality and morbidity worldwide. Uganda has a high level of alcohol use per capita. Compared to men, women are less likely to consume alcohol globally; however, women who drink have increased risks for co-occurring conditions, including depression, intimate partner violence, and HIV. This study assessed the prevalence of alcohol use and correlates of harmful alcohol use by gender and HIV status in rural Uganda.

METHODS

We used cross-sectional data from a study among women and men aged 15-59 residing in rural, central Uganda and accepting home-based HIV testing (Nov 2017 to Dec 2020). We estimated the prevalence of levels of alcohol use (categorized as no alcohol use (score 0), low (score 1-3 for men; 1-2 for women), medium (score 4-5 for men; 3-5 for women), high (score 6-7), and very-high (score 8-12) use with the AUDIT-C), stratified by gender and HIV status. We assessed correlates of harmful alcohol use using multivariable logistic regression models for women and men.

RESULTS

Among 18,460 participants, 67% (95% CI: 66-67%) reported no alcohol use, 16% (95% CI: 16-17%) reported low, 5% (95% CI: 4.8-5%) reported medium, 5% (95% CI: 4-5%) reported high, and 3% (95% CI: 2.8-3) reported very high alcohol use. Compared to women, men were more likely to report alcohol use (Chi-squared p-value<0.0001). People diagnosed with HIV (both newly diagnosed and previously aware of their status prior to home-based HIV testing) were more likely to report low, medium, high, and very high alcohol use compared to those who were HIV negative (Chi-squared p-value<0.0001). Among women, those who were newly diagnosed were more likely report alcohol use, compared to those who were HIV negative. In multivariable models, being newly diagnosed with HIV (compared to HIV negative) increased the odds of harmful alcohol use among women, but not men.

CONCLUSION

While alcohol use was higher among men and people living with HIV, being newly diagnosed with HIV had a stronger relationship with harmful alcohol use among women than men. More research is needed to understand how alcohol use may increase the risks of HIV acquisition among women and to identify gender-responsive services to address harmful alcohol use and increase access to HIV testing and linkage to care for women who use harmful levels of alcohol.

Spatial Analysis of the Alcohol, Intimate Partner Violence, and HIV Syndemic Among Women in South Africa

The co-occurrence of and synergistic interactions between substance abuse, violence, and HIV, known as the "SAVA syndemic," is thought to be a driver of women's elevated risk for HIV in sub-Saharan Africa. This study uses data from the 2016 South African Demographic and Health Survey (DHS) and the 2016 South African Census to examine geospatial associations between alcohol use, intimate partner violence (IPV), unprotected sex, and HIV status among a population-based sample of 8528 South African women (age 15-49). Results support the geographic clustering of alcohol use, unprotected sex, and IPV, but not HIV, and geospatial clustering of HIV alone. This study highlights the need for geographically-tailored interventions to address syndemics through integrated interventions, such as those simultaneously focused on alcohol, IPV, and sexual risk reduction, and points to the need for more targeted research to link these factors to HIV from a place-based risk perspective.

Patterns of Event-Level Concurrent Substance Use During Sex Among Gay, Bisexual, and Other Men Who Have Sex with Men in Metro Vancouver

This study identified patterns of sexualized substance use among gay, bisexual, and other men who have sex with men (gbMSM) and examined associated risk factors for sexually transmitted and blood borne infections (STBBI). Data were from a longitudinal cohort recruited using respondent-driven sampling between Feb-2017 and Feb-2019. Participants reported on events with up to five of their most recent sexual partners. Latent class analysis examined patterns of concurrent substance use 2 h prior to or during sex. Multinomial regression identified demographic, partner-level, and event-level factors associated across 11,877 sexual events reported by 757 participants. Most combinations of substance use were rare, but most drugs were frequently combined with other drugs when they were used prior to or during a sexual event. Six latent classes of concurrent event-level substance use were identified. The referent class (58.8% of events) was characterized by limited use of any drugs. The Common Drug Use class (12.1%) was characterized by use of alcohol, cannabis, and poppers and the Licit Drug Use class (21.6%) was characterized by use of alcohol alone. The Party 'N' Play (PnP) class (2.3%) was characterized by use of crystal methamphetamine GHB, Poppers, and Erectile Drugs; The Multi-use (3.5%) class was characterized by the PnP substances plus alcohol and ecstasy; and the Cannabis + class was characterized by use of Cannabis, Erectile Drugs, and Ecstasy. Relative to the referent class, all other classes were associated with events with more behavioural and network risk factors for STBBIs-highlighting the need for harm reduction interventions for gbMSM who use these drugs.

Individual and poly-substance use and condomless sex among HIV-uninfected adults reporting heterosexual sex in a multi-site cohort

BACKGROUND

We analyzed the association between substance use (SU) and condomless sex (CS) among HIV-negative adults reporting heterosexual sex in the Seek, Test, Treat, and Retain (STTR) consortium. We describe the impact of SU as well as person/partner and context-related factors on CS, identifying combinations of factors that indicate the highest likelihood of CS.

METHODS

We analyzed data from four US-based STTR studies to examine the effect of SU on CS using two SU exposures: 1) recent SU (within 3 months) and 2) SU before/during sex. Behavioral data were collected via 1:1 or self-administered computerized interviews. Adjusted individual-study, multivariable relative risk regression was used to examine the relationship between CS and SU. We also examined interactions with type of sex and partner HIV status. Pooled effect estimates were calculated using traditional fixed-effects meta-analysis. We analyzed data for recent SU (n = 6781; 82% men, median age = 33 years) and SU before/during sex (n = 2915; 69% men, median age = 40 years).

RESULTS

For both exposure classifications, any SU other than cannabis increased the likelihood of CS relative to non-SU (8-16%, p-values< 0.001). In the recent SU group, however, polysubstance use did not increase the likelihood of CS compared to single-substance use. Cannabis use did not increase the likelihood of CS, regardless of frequency of use. Type of sex was associated with CS; those reporting vaginal and anal sex had a higher likelihood of CS compared to vaginal sex only for both exposure classifications (18-21%, p < 0.001). Recent SU increased likelihood of CS among those reporting vaginal sex only (9-10%, p < 0.001); results were similar for those reporting vaginal and anal sex (5-8%, p < 0.01). SU before/during sex increased the likelihood of CS among those reporting vaginal sex only (20%; p < 0.001) and among those reporting vaginal and anal sex (7%; p = 0.002). Single- and poly-SU before/during sex increased the likelihood of CS for those with exclusively HIV-negative partners (7-8%, p ≤ 0.02), and for those reporting HIV-negative and HIV-status unknown partners (9-13%, p ≤ 0.03).

CONCLUSION

Except for cannabis, any SU increased the likelihood of CS. CS was associated with having perceived HIV-negative partners and with having had both anal/vaginal sex.

"Condoms Are Boring": Navigating Relationship Dynamics, Gendered Power, and Motivations for Condomless Sex Amongst Adolescents and Young People in South Africa

Condoms remain an important method for preventing HIV prevention and unintentional pregnancies, however their use in South Africa is sub-optimal. We analyzed survey data on reported condom use among 3009 sexually active adolescent girls and young women (AGYW) aged 15-24 years, and qualitative data from interviews and focus group discussions with 237 AGYW and 38 male peers. Our findings describe the current condom use landscape among adolescents and young people in South Africa, illustrating relationship dynamics, gendered power and notions of masculinity which influence condom negotiation and use in young heterosexual South Africans' sexual encounters.

Psychosocial Factors, Condomless Sex, and Detectable Viral Load in HIV-Positive Women in Serodiscordant Couples in Nairobi, Kenya

This prospective study of HIV-positive Kenyan women in serodiscordant couples examined relationships between psychosocial factors, viral suppression, and condomless sex. Participants were screened for alcohol use disorders and intimate partner violence (IPV) annually and depressive symptoms every 6 months. Prostate specific antigen (PSA) detection was used as a marker for condomless sex. A total of 151 participants contributed 349 person-years of follow-up. Hazardous/harmful alcohol use was associated with increased risk of detecting PSA in vaginal secretions (aRR 1.99, 95%CI 1.08-3.66, χ2 = 4.85 (1)), while IPV and depression were not. Events representing HIV transmission potential, where there was biological evidence of condomless sex at a visit with a detectable plasma viral load, were observed at 2% of visits. The high prevalence of IPV and association between alcohol use and sexual risk suggest the need for monitoring and support for these conditions as part of comprehensive HIV care for women.

Drinking contexts and their association with acute alcohol-related harm: A systematic review of event-level studies on adults' drinking occasions

ISSUES

Event-level alcohol research can inform prevention efforts by determining whether drinking contexts-such as people or places-are associated with harmful outcomes. This review synthesises evidence on associations between characteristics of adults' drinking occasions and acute alcohol-related harm.

APPROACH

We systematically searched Ovid MEDLINE, Ovid PsycInfo and the Web of Science Social Sciences Citation Index. Eligible papers used quantitative designs and event-level data collection methods. They linked one or more drinking contexts to acute alcohol-related harm. Following extraction of study characteristics, methods and findings, we assessed study quality and narratively synthesised the findings.

PROSPERO ID

CRD42018119701.

KEY FINDINGS

Searches identified 95 eligible papers, 65 (68%) of which study young adults and 62 (65%) of which are set in the United States, which limits generalisability to other populations. These papers studied a range of harms from assault to drink driving. Study quality is good overall although measures often lack validation. We found substantial evidence for direct effects of drinking context on harms. All of the contextual characteristics types studied (e.g. people, place, timing, psychological states, drink type) were consistently associated with harms. Certain contexts were frequently studied and associated with harms, in particular, weekend drinking, drinking in licensed premises and concurrent illicit drug use.

IMPLICATIONS

The findings of our review indicate target drinking contexts for prevention efforts that are consistently associated with increased acute alcohol-related harm.

CONCLUSION

A large range of contextual characteristics of drinking occasions are directly associated with acute alcohol-related harm, over and above levels of consumption.

Alcohol use and its association with sexual risk behaviors in the Armed Forces of the Republic of the Congo

Background

Previous research has shown alcohol misuse amplifies the risk of acquiring sexually transmitted infections [STIs], including HIV, by increasing high risk sexual behaviors. Military populations are particularly vulnerable to both alcohol misuse and STIs due to the unique conditions of military service. This study estimated the prevalence of probable hazardous and harmful alcohol use and examined associations with transactional sex, sex with a sex worker, and multiple sexual partners among military personnel in the Armed Forces of the Republic of the Congo (FAC).

Methods

A secondary analysis of data collected from a 2014 seroprevalence and behavioral epidemiology risk survey was performed. Participants included 703 active duty male service members 18 years of age or older who reported ever having sex. Patterns of harmful and hazardous drinking were measured with the Alcohol Use Disorders Identification Test (AUDIT). Participants with an AUDIT score ≥ 8 (indicative of probable hazardous and harmful alcohol use, and possible alcohol dependence) were compared to those with an AUDIT score ≤ 7.

Results

A total of 15.8% received a score of 8 or higher on the AUDIT. These participants were more likely to be lower educated and of lower military rank. In separate multivariable models, an AUDIT score ≥ 8 was significantly associated with higher odds of sex with a commercial sex worker and having multiple sexual partners.

Conclusions

Study results emphasize the need to address patterns of harmful and hazardous alcohol use in the FAC and integrate alcohol misuse education into the HIV prevention program. The development of military-specific interventions to reduce alcohol-related risky sexual behaviors are also needed. Lastly, implementing policies such as restricting alcohol availability and sales on military bases, and adding warning labels to advertisements and containers may provide a more comprehensive response to reduce problematic alcohol use.

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.

Substance use and universal access to HIV testing and treatment in sub-Saharan Africa: implications and research priorities

As universal testing and treatment for HIV, or 'treat all', expands across sub-Saharan Africa (SSA), substance use will likely have a negative impact on the success of scale-up efforts for antiretroviral treatment (ART). Overwhelming evidence highlights the negative impact of substance use on HIV care and treatment outcomes. Yet, as many countries in SSA expand ART, evidence of the extent of substance use, and its impact in the region, is more limited. Stigma, and the psychoactive effects of substance use, are barriers to seeking HIV treatment and adhering to ART regimens for persons with heavy alcohol use or substance use. As a result, we identified several implementation and operations research priorities and metrics for monitoring the impact of substance use and Treat All. Identifying barriers and facilitators to the integration of the prevention and treatment of substance use with HIV care, and assessing effects on HIV outcomes, through longitudinal studies are priorities that will determine the impacts of substance use on 'treat all' in SSA. Future research must use existing infrastructure, including large networks of HIV clinics, to enhance our understanding of the implementation and service delivery of substance use screening, referral and treatment. These networks will also inform robust and standardised substance use estimates and interventions within the 'treat all' era in SSA.

Alcohol Use and Unprotected Sex Among HIV-Infected Ugandan Adults: Findings from an Event-Level Study

While alcohol is a known risk factor for HIV infection in sub-Saharan Africa (SSA), studies designed to investigate the temporal relationship between alcohol use and unprotected sex are lacking. The purpose of this study was to determine whether alcohol used at the time of a sexual event is associated with unprotected sex at that same event. Data for this study were collected as part of two longitudinal studies of HIV-infected Ugandan adults. A structured questionnaire was administered at regularly scheduled cohort study visits in order to assess the circumstances (e.g., alcohol use, partner type) of the most recent sexual event (MRSE). Generalized estimating equation logistic regression models were used to examine the association between alcohol use (by the participant, the sexual partner, or both the participant and the partner) and the odds of unprotected sex at the sexual event while controlling for participant gender, age, months since HIV diagnosis, unhealthy alcohol use in the prior 3 months, partner type, and HIV status of partner. A total of 627 sexually active participants (57% women) reported 1817 sexual events. Of these events, 19% involved alcohol use and 53% were unprotected. Alcohol use by one's sexual partner (aOR 1.70; 95% CI 1.14, 2.54) or by both partners (aOR 1.78; 95% CI 1.07, 2.98) during the MRSE significantly increased the odds of unprotected sex at that same event. These results add to the growing event-level literature in SSA and support a temporal association between alcohol used prior to a sexual event and subsequent unprotected sex.

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

In Uganda, alcohol consumption is associated with higher HIV prevalence. However, research is needed to better understand how different patterns of alcohol consumption and alcohol-related problems may drive this association. In this cross-sectional study, we examined how hazardous alcohol use and alcohol-related problems such as psychological, physical, and social harms are associated with HIV status in fishing communities in Uganda. 300 (132 male, 168 female) residents of fishing communities in Uganda (75 participants from each of the following occupational groups: fishmongers, alcohol sellers, commercial sex workers (CSW), and fishermen) completed an interviewer-assisted computerized interview. We captured information on sociodemographics and HIV testing history. Prior 12-month hazardous alcohol consumption patterns and alcohol-related problems were assessed with the AUDIT and AUDADIS. 19.7%, 58.0%, and 23.3% of the sample reported being HIV positive, being HIV negative from a test within the prior 12 months, and not knowing their HIV status respectively. 18.7% reported the co-occurrence of hazardous alcohol consumption patterns and alcohol-related problems. 7.7% reported either hazardous alcohol consumption patterns or alcohol-related problems. Compared to non-drinkers, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of being HIV positive (adjOR 2.75, 95% CI 1.17-6.43) and of unknown HIV status (adjOR 3.35, 95% CI 1.52-7.42). Reporting only hazardous consumption levels, only alcohol-related problems, or low-risk drinking, did not increase the odds of being HIV positive or of unknown status. Among those not HIV positive, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of never having had an HIV test (adjOR 3.78, 95% CI 1.63-8.68). The co-occurrence of hazardous alcohol use and alcohol related problems appears to be a prominent risk factor for HIV infection, not knowing one's HIV status, and never testing for HIV in this setting.

The intersection of intimate partner violence and HIV risk among women engaging in transactional sex in Ugandan fishing villages

Intimate partner violence (IPV) may increase risk for HIV/AIDS among women engaging in transactional sex in Ugandan fishing communities. In this cross-sectional study, 115 women reporting engaging in transactional sex in Lake Victoria fishing communities completed a computerized interview. We tested associations between IPV and other HIV risk factors, with unprotected sex and HIV status, and tested moderators of the IPV-HIV risk relationship. Women reporting recent sexual IPV reported 3.36 times more unprotected sex acts (AdjExp[B] = 3.36, 95% CI = 1.29-8.69, p = 0.07). The effect of sexual IPV on sexual risk was significantly greater among alcohol and fish sellers compared to sex workers (interaction: Exp[B] = 12.29, 95% CI = 5.06-29.85, p < 0.001). Women reporting any sexual IPV were nearly four times more likely to report being HIV positive than women reporting no sexual IPV (AOR = 3.94, 95% CI = 1.22-12.66, p = 0.02). Integrated IPV and HIV interventions are needed in this context, especially among alcohol and fish sellers engaging in transactional sex.

Daily associations between alcohol and sexual behavior in young adults

We tested within-person effects of alcohol on sexual behavior among young adults in a longitudinal burst design (N = 213, 6,487 days) using data collected from a previously published parent study. We differentiated effects of alcohol on likelihood of sexual activity versus use of protection against sexually transmitted diseases (STDs) or pregnancy on intercourse occasions by testing a multilevel multinomial model with 4 outcomes (no sex, oral sex without intercourse, protected intercourse, and unprotected intercourse). At the within-person level, effects of alcohol were hypothesized to be conditional upon level of intoxication (i.e., curvilinear effect). We also tested effects of four between-person moderators: gender, typical length of relationship with sexual partners, and two facets of self-control (effortful control and reactivity). Consistent with our hypothesis, low-level intoxication was associated with increased likelihood of engaging in oral sex or protected intercourse (relative to no sex) but was not related to likelihood of unprotected intercourse. The effect of intoxication on unprotected versus protected intercourse was an accelerating curve, significantly increasing likelihood of unprotected intercourse at high levels of intoxication. Between-person factors moderated associations between intoxication and sexual behavior. Effects of intoxication on both protected and unprotected intercourse were diminished for individuals with more familiar sexual partners. Effortful control exhibited a protective effect, reducing the effects of intoxication on likelihood of unprotected intercourse. Hypothesized effects of reactivity were not supported. Intoxication was a stronger predictor of oral sex and protected intercourse (but not unprotected intercourse) for women relative to men. Results highlight the inherent complexities of the alcohol-sexual behavior nexus. (PsycINFO Database Record

Alcohol Use and Associations With Biological Markers and Self-Reported Indicators of Unprotected Sex in Human Immunodeficiency Virus-Positive Female Sex Workers in Mombasa, Kenya

BACKGROUND

Studies of alcohol use and sexual behavior in African populations have primarily been cross-sectional, used nonvalidated measures of alcohol use, or relied on self-reported sexual risk endpoints. Few have focused on human immunodeficiency virus (HIV)-positive women.

METHODS

Longitudinal data were collected from a cohort of HIV-positive Kenyan female sex workers. At enrollment and annual visits, participants were asked about past-year alcohol use using the Alcohol Use Disorders Identification Test (AUDIT). The primary endpoint was detection of prostate-specific antigen (PSA) in vaginal secretions at quarterly examinations. Associations between hazardous/harmful alcohol use (AUDIT score ≥7), PSA detection, and secondary measures of sexual risk were evaluated using generalized estimating equations with a log binomial regression model.

RESULTS

A total of 405 women contributed 2750 vaginal samples over 606 person-years of follow-up. Hazardous/harmful alcohol use was reported at 16.6% of AUDIT assessments and was associated with higher risk of PSA detection (relative risk 1.50; 95% confidence interval, 1.11-2.01) relative to no alcohol use. This association was attenuated and no longer statistically significant, after adjusting for age, work venue, intimate partner violence, depression, and partnership status (adjusted relative risk, 1.13; 95% confidence interval, 0.82-1.56). In exploratory analyses, alcohol use was associated with self-report of unprotected sex and with sexually transmitted infection acquisition.

CONCLUSIONS

Although hazardous/harmful alcohol use was not associated with detection of PSA in adjusted analysis, associations with secondary outcomes suggest that alcohol use is at least a marker of sexual risk behavior.

Triangular relationship among risky sexual behavior, addiction, and aggression: A systematic review

Background

Risky sexual behavior (RSB), addiction, and aggression are three important personal and social factors which influence each other.

Objective

To overview the potential relationship among RSB, addiction, and aggression to conduct an interactive model for the pathology and management of human behavior.

Methods

This review article was carried out by searching studies in PubMed, Medline, Web of Science, Ebsco, IEEE, Scopus, Springer, MagIran, and IranMedex databases from the year 1993 to 2013. The search terms were violence, aggression, drug abuse, substance abuse, illicit drug, psychoactive drug, intravenous drug users, addiction and high-risk sexual relationships, unprotected sex, high risk sexual behavior, and sexual risk-taking. In this study, forty-nine studies were accepted for further screening, and met all our inclusion criteria (in English or Persian, full text, and included the search terms).

Results

Forty-nine articles were included; 17 out of 26 studies showed a significant correlation between addiction and risky sexual behavior, 15 out of 19 articles indicated a statistically significant correlation between aggression and addiction, and 9 out of 10 articles reported significant correlation between aggression and risky sexual behavior.

Conclusion

According to the results, the triangle hypothesis of sex, addiction, and aggression led to the definition of the relationship among the variables of the hypothetical triangle based on the reviewed studies; and the proposed dual and triple relationship based on the conducted literature review was confirmed. This is not a meta-analysis, and there is no analysis of publication bias.

Is Cigarette and Alcohol Use Associated With High-Risk Sexual Behaviors Among Youth in China?

BACKGROUND

Very few studies have explored the association between cigarette or alcohol use and high-risk sexual behaviors (HRSBs) among Chinese youth.

AIM

To identify the associations between cigarette and/or alcohol use and HRSBs in unmarried youth 15 to 24 years old in China.

METHODS

Data were obtained from a nationally representative survey of youth 15 to 24 years old in China. Population numbers, prevalences, and proportions were calculated where appropriate. The χ² test was used to examine the different proportions of cigarette and alcohol use behaviors and HRSBs in female vs male youth. Logistic regression with propensity score-based weighting was used to elucidate the separate and combined associations of cigarette use and alcohol use with each HRSB.

OUTCOMES

The sexual behaviors of condom non-use during the first sexual experience, sexual activity with multiple partners, being forced to have sexual intercourse, taking part in casual sex, engaging in commercial sex, taking part in anal sex, and condom non-use during the most recent sexual encounter were classified as HRSBs.

RESULTS

Of youth 15 to 24 years old, 23.2% ever used cigarettes, 38.1% used alcohol, and 19.9% used cigarettes and alcohol. Compared with cigarette and alcohol non-use, cigarette and alcohol use showed a significantly increased risk of condom non-use during the first sexual experience (odds ratio = 2.9, 95% CI = 2.5-3.3), sexual activity with multiple partners (4.9, 3.8-6.2), forced sex (2.7, 1.1-6.9), casual sex (4.0, 3.1-5.3), commercial sex (2.9, 2.1-3.9), anal copulation (3.1, 2.1-4.6), condom non-use during the most recent sexual encounter (2.5, 2.1-3.0), and any HSRB (3.2, 2.8-3.6) among youth. The relations between cigarette and alcohol use and HRSBs were stronger among female youth than among male youth for all HRSBs.

CLINICAL IMPLICATIONS

More efforts should be made to implement HIV and AIDS prevention that consider the role of cigarette and alcohol use in precipitating HRSBs.

STRENGTHS AND LIMITATIONS

This study provided a more detailed evaluation with greater confidence of the association between cigarette and/or alcohol use and HRSBs with sex disparity taken into account using nationally representative data, although no detailed information about cigarette and alcohol use behaviors such as dependence and cessation was gathered in this survey.

CONCLUSION

Youth who use cigarette and alcohol are at greater risk of HRSBs, especially female youth. Guo C, Wen X, Li N, et al. Is Cigarette and Alcohol Use Associated With High-Risk Sexual Behaviors Among Youth in China? J Sex Med 2017:14:659-665.

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.

Does alcohol use have a causal effect on HIV incidence and disease progression? A review of the literature and a modeling strategy for quantifying the effect

In the first part of this review, the nature of the associations between alcohol use and HIV/AIDS is discussed. Alcohol use has been found to be strongly associated with incidence and progression of HIV/AIDS, but the extent to which this association is causal has traditionally remained in question. Experiments where alcohol use has been manipulated as the independent variable have since helped establish a causal effect of alcohol use on the intention to engage in condomless sex. As the intention to engage in condomless sex is a surrogate measure of actual condom use behavior, which itself is linked to HIV incidence and re-infection, the causal chain has been corroborated. Moreover, there are biological pathways between alcohol use and the course of HIV/AIDS, only in part being mediated by adherence to antiretroviral medication. In the second part of the contribution, we provide suggestions on the quantification of the link between alcohol use and HIV incidence, using risk relations derived from experimental data. The biological links between alcohol use and course of HIV/AIDS are difficult to quantify given the current state of knowledge, except for an operationalization for the link via adherence to medication based on meta-analyses. The suggested quantifications are exemplified for South Africa.

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.

"Such Behaviors Are Not in My Home Village, I Got Them Here": A Qualitative Study of the Influence of Contextual Factors on Alcohol and HIV Risk Behaviors in a Fishing Community on Lake Victoria, Uganda

In Uganda, elevated HIV prevalence in fishing communities along Lake Victoria have been attributed in part to heavy alcohol use, but qualitative research is needed to understand the contextual factors influencing alcohol and sexual risk. Eight focus group discussions were conducted (n = 50; 23 male, 27 female) in Gerenge, Uganda with five occupational groups: fishermen, fishmongers, alcohol-sellers, commercial sex workers, and restaurant owners. Data was analyzed using content analysis. Alcohol use was prevalent and said to influence risky sex. Sex-related alcohol expectancies and occupational factors influenced individuals to drink during sex and structural factors related to the built environment, economy, and policy were identified as key contributors to both alcohol use and sexual risk in general. The findings highlight alcohol reduction as an important component of HIV/AIDS prevention and suggest structural interventions should be prioritized in this context.

Risk factors for incident HIV infection among antenatal mothers in rural Eastern Cape, South Africa

BACKGROUND

The prevalence of HIV among antenatal clients in South Africa has remained at a very high rate of about 29% despite substantial decline in several sub-Saharan countries. There is a paucity of data on risk factors for incident HIV infection among antenatal mothers and women within the reproductive age bracket in local settings in the Eastern Cape, South Africa.

OBJECTIVE

To establish the risk factors for incident HIV infection among antenatal clients aged 18-49 years attending public antenatal clinics in rural Eastern Cape, South Africa.

DESIGN

This was an unmatched case-control study carried out in public health antenatal clinics of King Sabata District Municipality between January and March 2014. The cases comprised 100 clients with recent HIV infection; the controls were 200 HIV-negative antenatal clients. Socio-demographic, sexual, and behavioral data were collected using interviewer-administered questionnaires adapted from the standard DHS5 women's questionnaire. Multivariate logistic regression models were used to identify the independent risk factors for HIV infection. A p<0.05 was considered statistically significant.

RESULTS

The independent risk factors for incident HIV infection were economic dependence on the partner, having older male partners especially among women aged ≤20 years, and sex under the influence of alcohol.

CONCLUSIONS

Therefore, effective prevention of HIV among antenatal mothers in KSDM must target the improvement of the economic status of women, thereby reducing economic dependence on their sexual partners; address the prevalent phenomenon of cross-generation sex among women aged <20 years; and regulate the brewing, marketing, and consumption of alcohol.

Alcohol Expectancies and Inhibition Conflict as Moderators of the Alcohol-Unprotected Sex Relationship: Event-Level Findings from a Daily Diary Study Among Individuals Living with HIV in Cape Town, South Africa

Literature from sub-Saharan Africa and elsewhere supports a global association between alcohol and HIV risk. However, more rigorous studies using multiple event-level methods find mixed support for this association, suggesting the importance of examining potential moderators of this relationship. The present study explores the assumptions of alcohol expectancy theory and alcohol myopia theory as possible moderators that help elucidate the circumstances under which alcohol may affect individuals' ability to use a condom. Participants were 82 individuals (58 women, 24 men) living with HIV who completed daily phone interviews for 42 days which assessed daily sexual behavior and alcohol consumption. Logistic generalized estimating equation models were used to examine the potential moderating effects of inhibition conflict and sex-related alcohol outcome expectancies. The data provided some support for both theories and in some cases the moderation effects were stronger when both partners consumed alcohol.

Sexually transmitted infections associated with alcohol use and HIV infection among men who have sex with men in Kampala, Uganda

OBJECTIVES

Few studies have been conducted in Africa to assess prevalence of sexually transmitted infections (STIs) and risk factors among men who have sex with men (MSM). We report findings from the first behavioural survey to include STI testing among MSM in Kampala, Uganda.

METHODS

Respondent-driven sampling (RDS) was used to recruit MSM for a biobehavioural survey. Eligible participants were men who reported anal sex with another man in the previous 3 months, were 18 years or older, and resided in Kampala. Information was collected on demographics, sexual behaviour, alcohol and drug use, and STI symptoms. Blood, urine and rectal specimens were tested for syphilis, HIV, rectal and urethral gonorrhoea, and chlamydia. Analyses weighted for RDS were conducted to assess associations with STI diagnosis.

RESULTS

A total of 295 MSM participated in the survey. Almost half (weighted percentage: 47.3%) reported STI symptoms in the last 6 months and 12.9% tested HIV-positive. Prevalence of non-HIV STI was 13.5%; syphilis prevalence was 9.0%. Adjusting for age and education, STI was associated with HIV (adjusted OR (AOR)=3.46, 95% CI 1.03 to 11.64), alcohol use before sex (AOR=4.99, 95% CI 1.86 to 13.38) and having sold sex in the last 3 months (AOR=3.17, 95% CI 1.25 to 8.07), and inversely associated with having anonymous sex partners (AOR=0.20, 95% CI 0.07 to 0.61).

CONCLUSIONS

We observed high levels of self-reported STI symptoms and STI prevalence associated with alcohol use and HIV among MSM in Kampala. Public health interventions supporting MSM are needed to address STI risk and facilitate access to diagnosis and treatment services.

Attitudes and Training Needs of New England HIV Care and Addiction Treatment Providers: Opportunities for Better Integration of HIV and Alcohol Treatment Services

OBJECTIVES

Unhealthy alcohol use is common among HIV-infected patients and contributes to co-morbidities, cognitive decline, unprotected sex, and poor medication adherence. Studies consistently show missed opportunities to address unhealthy alcohol use as part of care. Although treatment of other drug use has been integrated into HIV care in some settings, more information is needed regarding provider attitudes regarding the need for integration of alcohol treatment and HIV care.

METHODS

We surveyed 119 HIV and 159 addiction providers regarding the following domains: existing knowledge, desire for new knowledge (with subdomains relative advantage, compatibility, and complexity of integrating knowledge), and individual and program development needs. Scale scores for each domain were correlated with demographics to identify factors associated with training need.

RESULTS

Both HIV and addiction providers reported agreement with statements of existing knowledge and the need for additional skills. The priority attributed to training, however, was low for both groups. Knowledge and perceived prevalence of HIV and unhealthy alcohol use increased with years of experience. Perceived prevalence correlated with compatibility but not the relative advantage of training.

CONCLUSIONS

Though addressing alcohol use and HIV was acknowledged to be important, the priority of this was low, particularly early career providers. These providers may be important targets for training focusing on motivating coordination of care and skills related to assessment and counseling.

Intoxication at last sexual intercourse and unprotected sex among HIV-positive and HIV-negative individuals in Uganda: an event-level analysis

This study examined, for the first time, the association between intoxication at last sexual intercourse and unprotected sex separately among HIV-positive and HIV-negative individuals. Data were derived from a nationally-representative survey of Uganda in 2011. Multivariable logistic regression analyses of the intoxication-unprotected sex association included adjustment for sociodemographic and behavioral covariates that were also examined as moderators of the association. Among HIV-positive individuals, intoxication was associated with unprotected sex, whereas among HIV-negative individuals, the intoxication-unprotected sex association was moderated by knowledge that condoms prevent HIV transmission. The odds of unprotected sex was 2.67 times greater among HIV-negative individuals who were unaware that condoms prevent HIV, an association not observed among those who possessed such knowledge. The results suggest that the intoxication-unprotected sex link be incorporated within Ugandan National HIV Prevention Strategies among HIV-positive and HIV-negative individuals. HIV-negative individuals who are unaware that condoms prevent HIV should be targeted for interventions focusing on increasing HIV transmission knowledge especially on the role of condoms in preventing the disease. The latter interventions should also identify those sociocultural and political beliefs about condom use that may serve as barriers to consistent condom use.

Association between intoxication at last sexual intercourse and unprotected sex among men and women in Uganda

INTRODUCTION

This study examined the association between intoxication at last sexual intercourse and unprotected sex using data derived from a nationally representative survey conducted in Uganda in 2011.

METHODOLOGY

Multivariable logistic regression analyses were used to examine the intoxication-unprotected sex association separately among men and women, adjusted for sociodemographic and behavioral covariates that were also examined as moderators of the association.

RESULTS

Among men, intoxication at last sexual intercourse was almost entirely attributed to their own drinking, while women most frequently reported intoxication among their partners only. Among women, there was a significant association between their partner's intoxication and unprotected sex (adjusted odds ratio (AOR) = 1.36; 95% confidence interval (CI) = 1.07-1.73. Intoxication was associated with unprotected sex among unmarried men (AOR = 2.09; 95%; CI = 1.45-2.84), an association not observed among married men.

CONCLUSIONS

The results suggest that the alcohol-unprotected sex link should be incorporated within Ugandan National HIV Prevention Strategy. These interventions should be designed to target unmarried men. Programs that combine alcohol reduction and address structural factors that constrain women's ability to negotiate condom use are also needed.

Unmarried male migrants and sexual risk behavior: a cross-sectional study in Shanghai, China

Background

In China, there is increasing concern because of the rapid increase in HIV infection recorded over recent years. Migrant workers are recognized as one of the groups most affected. In this study, HIV/AIDS-related knowledge, attitudes, and behavior among unmarried migrant workers in Shanghai are investigated, with the aim of providing critical information for policy makers and sex educators to reinforce sexual health services and sex health education targeting the behavior and sexual health of unmarried male migrants.

Methods

A cross-sectional survey was conducted among unmarried male migrant workers in Shanghai, China’s largest city and housing the most migrants. A self-administered, anonymous questionnaire was used to collect information on knowledge, attitudes, and behavior associated with increased risk of HIV/AIDS.

Results

A total of 2254 subjects were questioned, with a response rate of 91.3%. Among those interviewed, 63.5% reported sexual activities. Misconceptions regarding HIV transmission, poor perception of HIV infection, and low use of condoms were not uncommon. Among those who had sexual intercourse, 73.7% had not used condoms in their last sexual intercourse, and 28.6% reported having engaged in sexual risk behavior (defined as having at least one non-regular partner). Multivariate logistic regression analyses identified several indicators of sexual risk behavior, including younger age at first sexual intercourse (OR: 0.67, 95% CI: 0.31–0.91 for older age at first sexual intercourse), more cities of migration (OR: 2.91, 95% CI: 2.17–3.81 for high level; OR: 1.15, 95% CI: 1.06–1.29 for medium level), poor perception of acquiring HIV/AIDS (OR: 1.52, 95% CI: 1.33–1.96 for unlikely; OR: 2.38, 95% CI: 1.61–3.70 for impossible), frequent exposure to pornography (OR: 0.33, 95% CI: 0.11–0.43 for never; OR: 0.69, 95% CI: 0.60–1.81 for less frequently), not knowing someone who had or had died of HIV/AIDS and related diseases (OR: 2.13, 95% CI: 1.70–2.53 for no), and having peers who engaged in sex with a non-regular sex partner (OR: 4.40, 95% CI: 3.37–5.56 for yes).

Conclusions

Today, it is necessary to reinforce sex health education among unmarried migrants and sexual health services should target vulnerable migrant young people.