Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene

Incidence, risk factors, and temporal trends of penile cancer: a global population-based study

OBJECTIVES

To examine the global disease burden and country-specific trends of penile cancer incidence by age group and investigate its associations with several factors.

MATERIALS AND METHODS

The Global Cancer Observatory database was interrogated for penile cancer incidence. The 10-year cancer incidence rates were collected from the Cancer Incidence in Five Continents Plus. The country-specific data were extracted from the World Health Organization Global Health Observatory and Global Burden of Disease databases for conducting risk factors analysis. The penile cancer incidence was presented using age-standardised rates. Its associations with various factors were examined by linear regression, while the incidence trend was estimated using joinpoint regression and presented as average annual percentage change with 95% confidence intervals in different age groups.

RESULTS

There were an estimated 36 068 new cases of penile cancer in 2020. There was a considerable geographical disparity in the disease burden of penile cancer, with South America reporting the highest incidence. Overall, alcohol drinking, human immunodeficiency virus (HIV) infection, and unsafe sex were positively associated with a higher penile cancer incidence, while circumcision was found to be a protective factor. There has been a mixed trend in penile cancer incidence overall, but an increasing trend was found among younger males.

CONCLUSIONS

There was a global variation in the penile cancer burden associated with prevalence of alcohol drinking, HIV infection, unsafe sex, and circumcision. The increasing penile cancer incidence in the younger population is worrying and calls for early detection and preventive interventions.

Mapping Studies of Alcohol Use Among People Living with HIV/AIDS During 1990-2019 (GAPRESEARCH)

Alcohol drinking has long been reported to be common in people living with HIV/AIDS, having biological and behavioral impacts on the transmission, progression, and prevention of HIV/AIDS. A total of 7059 eligible articles and reviews published in English from 1990 to 2019 were extracted from the WOS. Results show an increase in publication volume, while citations peak for papers published in 2006. Content analysis reveals a wide-ranging coverage of topics, with the most popular being effects of alcohol consumption on ART adherence and outcomes, alcohol-related sexual behaviors, TB co-infection, and psycho-socio-cultural considerations in examining and designing measures targeting alcohol use and interventions to reduce alcohol dependence in PLWHA. This calls for more active engagement of governments in research and in designing and implementing interventions, as well as collaborations and knowledge transfer from high-income countries to developing counterparts, to effectively address alcohol use-related issues in PLWHA, moving toward the HIV/AIDS eradication target.

Lay counsellors' experiences of administering the AUDIT-C as a brief screening tool in a South African township

BACKGROUND

South Africa presents one of the riskiest patterns of alcohol consumption, with per capita consumption above the African regional average. Globally, there has been an increased focus on the potential of appointing lay counsellors to administer alcohol intervention strategies in resource-limited contexts. Given the increasing need for relevant and efficient intervention strategies in response to high-risk alcohol consumption, screening instruments such as the AUDIT-C have gained increased attention.

METHODS

This paper explores the experiences of 15 lay counsellors in response to the training received on how to administer the AUDIT-C instrument, as well as provide interventions such as brief advice or an appropriate referral, in the resource-limited South African township of Alexandra, Johannesburg. A focus group was facilitated for this purpose and, thereafter, a thematic content analysis was applied to identify the themes most central to the lay counsellors' experiences.

RESULTS

The research findings suggest that the lay counsellors perceived the training to be adequate in preparing them for administrating the AUDIT-C and for providing any relevant interventions, and that their confidence in administering the instrument developed as the project progressed. However, recruitment and administration challenges were experienced in primary healthcare and community settings, and lay counsellors perceived home visits to be more appropriate with respect to issues related to confidentiality and stigmatisation.

CONCLUSION

Overall, while lay counsellors feel that the training they received on the tool and the tool itself is useful for effectively implementing the AUDIT-C in low-resource communities, the availability and efficiency of alcohol treatment services in Alexandra Township need to be improved.

Dyspareunia, signs of epithelial disruption, sexual abstinence, and HIV status in female sex workers in Nairobi: a cross-sectional study

BACKGROUND

Epithelial trauma is a risk factor of HIV infection in men who have sex with men (MSM) and female sex workers (FSWs). Painful intercourse may be indicative of epithelial tissue disruption. Previous studies on a cohort of Kenyan FSWs established an association between prolonged sexual abstinence and late HIV seroconversion. Our research objective was to establish whether there is a relationship between HIV serostatus and signs of epithelial disruption and between HIV serostatus and sexual abstinence behaviour.

METHODS

Participants were selected from a Nairobi health facility. A structured questionnaire was administered to 322 FSWs, who provided data on HIV status, sexual behaviour, abstinence intervals and the level of sexual dysfunction. Sexual dysfunction scores were created using parts of the Female Sexual Function Index (FSFI-19). Additional questions addressed epithelial trauma signs. Descriptive data analysis, bivariate and multivariate logistic regression were used to describe the study population and determine factors associated with living with HIV. Potential factors influencing sexual dysfunction were assessed by FSWs via self-rating.

RESULTS

36% of FSWs reported discomfort or pain during vaginal penetration half the time. 44% noticed genital bleeding half the time. Vaginal tenderness was experienced by 70.6% half the time during or after intercourse. Variables predictive of living with HIV on multivariate analysis included a medium and high score of discomfort or pain during and following vaginal penetration (medium: AOR 2.288, p-value 0.032, 95% CI 1.075-4.871; high: AOR 3.044, p-value 0.031, 95% CI 1.110-8.348). No significant association of HIV status with past abstinence durations as reported by participants could be established in the multivariate analysis. A majority of FSWs agreed that steady partnerships (81% agreement), regularity of intercourse (74%), foreplay (72%) and lubricants (65%) alleviated dyspareunia.

CONCLUSIONS

Recurrent exposure to blood during sex was highly prevalent in FSWs, as was sexual dysfunction. Complaint levels were associated with living with HIV, providing evidence that reducing sexual dysfunctions may prevent HIV transmission. Preventive initiatives may be created that address sexual dysfunction in key populations and general populations with a high HIV prevalence. Subjective assessments indicate that prevention may include the promotion of sexual intercourse regularity, foreplay, and lubricant use.

Rate and Predictors of Ineffective HIV Protection in African Men Who Have Sex with Men Taking Pre-Exposure Prophylaxis

We investigated the rate and predictors of ineffective HIV protection in men who have sex with men (MSM) taking pre-exposure prophylaxis (PrEP) in a prospective cohort study from November 2017 to November 2020 in Mali, Côte d'Ivoire, Burkina Faso, and Togo. MSM had to be 18 years or older and at high risk of HIV infection to participate. They also received a comprehensive sexual health prevention package, including PrEP, in community-based clinics as part of the cohort study. Using socio-behavioral/clinical data, HIV protection during their most recent anal intercourse with a male partner was categorized as effective or ineffective (i.e., incorrect PrEP adherence and no condom use). Seventeen percent (500/2839) of intercourses were ineffectively protected for the 520 study participants. Predictors of ineffective HIV protection included being an event-driven user with financial difficulties, having a high alcohol misuse score, and not being a member of a community association. PrEP programs in West Africa must be tailored to socially vulnerable MSM who struggle to adopt PrEP.

Sociodemographic factors associated with daily tobacco smoking and binge drinking among Zambians: evidence from the 2017 STEPS survey

BACKGROUND

The burden of disease attributable to tobacco smoking and harmful alcohol consumption poses a major threat to sustainable development in most low- and middle-income countries. However, evidence on tobacco use and harmful alcohol consumption to inform context-specific interventions addressing these harmful social behaviours is limited in the African context. This study aimed to determine the sociodemographic factors associated with daily tobacco smoking and binge drinking in Zambia.

METHODS

The study stems from nationwide population-based representative survey data collected using the World Health Organization's STEPwise approach for non-communicable disease risk factor surveillance in 2017 among 18-69-year-old Zambians. The main outcomes were daily tobacco smoking and binge drinking, and the demographic and socioeconomic variables included sex, marital status, age, residence, level of education and occupation. Prevalence ratios (PR) were calculated using log-binomial regression analysis.

RESULTS

Overall, 4302 individuals (weighted percentage 49.0% men and 51.0% women) participated in the survey. The prevalence of daily tobacco smoking was 9.0%, and 11.6% of participants engaged in binge drinking, both of which were higher among men than women (17.1% vs. 1.3% and 18.6% vs. 5.3%, respectively). The adjusted prevalence of daily tobacco smoking was 14.3 (95% CI: 9.74-21.01) times higher in men than women, and 1.44 (95% CI 1.03-1.99) times higher in the > 45-year-old group compared to the 18-29-year-old group. Significant positive associations with daily tobacco smoking were found among those with no education 2.70 (95% CI 1.79- 4.07) or primary education 1.86 (95% CI 1.22-2.83) compared to those with senior secondary or tertiary education. The adjusted prevalence of daily tobacco smoking was 0.37 times lower (95% CI 0.16-0.86) among students and homemakers compared to employed participants. The adjusted prevalence of binge drinking was 3.67 times higher (95% CI 2.83-4.76) in men than in women. Significantly lower adjusted prevalences of binge drinking were found in rural residents 0.59 (95% CI: 0.46-0.77) compared to urban residents and in students/homemakers 0.58 (95% CI: 0.35-0.94) compared to employed participants.

CONCLUSION

This study shows huge differences between men and women regarding tobacco smoking and binge drinking in Zambia. A high occurrence of tobacco smoking was observed among men, older members of society and those with lower levels of education, while binge drinking was more common in men and in those living in urban areas. There is a need to reshape and refine preventive and control interventions for tobacco smoking and binge drinking to target the most at-risk groups in the country.

Barriers to condom use in casual sexual relationships known as ukujola in KwaZulu-Natal, South Africa

South Africa has the largest number of people living with HIV in the world. Of the nine provinces in South Africa, KwaZulu-Natal is the worst affected. HIV is largely transmitted through unprotected penetrative sexual intercourse. Male latex condoms are central to HIV prevention because of their effectiveness in preventing HIV transmission in almost all sexual encounters if used consistently and correctly. There are, however, various barriers to condom use. This study sought to unpack barriers to condom use in the context of ukujola (casual or informal sexual relationships) in a South African, isiZulu-speaking community. A generic qualitative approach was used, drawing on a range of methods - four focus groups and twenty in-depth interviews. The study was conducted exclusively with isiZulu-speaking African participants, aged 21-34 years, from the uMgungundlovu district in KwaZulu-Natal, South Africa. Ukujola relationships encompass all casual relationships, i.e. those in which there has never been involvement of the families. The involvement of families in negotiating ilobolo (bride wealth) is a prerequisite for legitimate relationships, particularly marriage. Multiple concurrent sexual partnerships typically exist in ukujola relationships, and unprotected sex is common. The interviews suggest the existence of various barriers to condom use, including lack of trust, sexual pleasure and alcohol. There is a need for increased HIV prevention campaigns with particular emphasis on consistent condom use.

Alcohol use disorders in multidrug resistant tuberculosis (MDR-TB) patients and their non-tuberculosis family contacts in Nigeria

Introduction

the main aim of this study was to determine the prevalence and associated factors of alcohol use disorder (AUD) in patients with Multi-Drug Treatment-Resistant Tuberculosis (MDR-TB) compared with their non-tuberculosis control, and its association with disease pattern and associated medical comorbidities.

Methods

MDR-TB patients (128) and their respective caregivers were interviewed in a treatment unit in Nigeria. Diagnosis of AUD was made using the Structured Clinical Interview for DSM-IV Axis I Disorder, information was obtained on the severity of the TB and associated health problems.

Results

prevalence of AUD was (21.9%) and was significantly higher among cases than in controls (2.3%), p = 0.006. Severe TB, OR = 3.33 (1.56-6.83), hematological diseases, OR = 2.34 (1.06-4.33) and HIV/AIDS, OR = 3.01 (1.67-7.01) were the strongest predictors of AUD at 95% CI. Conclusion: AUD was highly prevalent in MDR-TB and was associated with certain medical comorbidities and increased severity of the illness.

Disability-adjusted life years and mortality rate attributed to unsafe sex and drug use for AIDS in the Middle East and North Africa countries

BACKGROUND

The Middle East and North Africa, is one of few regions where the number of new human immunodeficiency virus infections is increasing. The present study aimed to estimate the attributable burden of unsafe sex and drug use in Acquired immunodeficiency syndrome in the Middle East and North Africa countries.

METHODS

We used the Global Burden of Disease data 2017 to estimate the attributable mortality and disability-adjusted life-years to unsafe sex and drug use in Acquired immunodeficiency syndrome in the Middle East and North Africa countries (21 countries) from 1990 to 2017 by region, sex and age. The percent change was calculated at three time points by country and sex.

RESULTS

The rate of Disability-adjusted life years/100,000 attributed to drug use for Acquired immunodeficiency syndrome increased 1.10 (95% CI: 0.75-1.71) to 13.39 (95% CI: 9.98-18.17) in women of Middle East and North Africa countries from 1990 to 2017, and there is an increasing trend in Disability-adjusted life years attributable to drug use for Acquired immunodeficiency syndrome in men. The rate of Disability-adjusted life years/100,000 attributed to unsafe sex for Acquired immunodeficiency syndrome increased in women of Middle East and North Africa countries, 5.15 (95% CI: 3.34-8.07) to 53.44 (95% CI: 38.79-75.89); and 10.06 (95% CI: 6.61-16.18) to 46.16 (95% CI: 31.30-72.66) in men. Age-standardized mortality rate attributed to drug use and unsafe sex for Acquired immunodeficiency syndrome increased from 1990 to 2017 in both sex in Middle East and North Africa countries.

CONCLUSION

The rate of Disability-adjusted life years /100,000 and age-standardized mortality rate attributed to unsafe sex and drug use increased in Middle East and North Africa from 1990 to 2017. While most of such countries have traditional cultures with religious believes, such increase need to be addressed in more depth by all policy makers.

Prevalence and correlates of alcohol and tobacco use among key populations in Togo in 2017: a cross-sectional study

OBJECTIVES

The aim of this study was to estimate alcohol and tobacco use prevalence and their correlates among female sex workers (FSW), men who have sex with men (MSM) and drug users (DU) in Togo.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional bio-behavioural study was conducted among 2115 MSM, FSW and DU in 2017 using a respondent-driven sampling method, in the eight biggest towns of Togo. Selection criteria for the MSM were being male and having had oral or anal intercourse with a man in the previous 12 months; for FSW, being a female and having exchanged sex for money in the previous 12 months; and for DU, consuming heroin, cocaine or hashish for MSM, FSW and DU, respectively. All participants had to be at least 18 years old and residing in the territory for the past 3 months.

RESULTS

The prevalence of alcohol consumption, hazardous/harmful consumption and binge drinking was 64.8%, 38.4% and 45.5%, respectively. Current tobacco use was reported by 30.6% of participants and HIV prevalence was estimated at 12.5%. DU were more likely to engage in binge drinking compared with other key populations (adjusted odds ratio (aOR)=2.0; 95% CI 1.4 to 2.8; p=0.001). Participants who were identified as having hazardous/harmful alcohol consumption had almost three times the odds of tobacco consumption than those with no risky consumption (aOR=2.6; 95% CI 2.0 to 3.4; p=0.001). Hazardous/harmful alcohol consumption was three times more likely among participants with severe psychological distress compared with those with no psychological distress (aOR=3.3, 95% CI 2.2 to 5.1; p=0.001).

CONCLUSION

Findings from this study demonstrate the need for the integration of mental health and substance abuse reduction interventions into HIV prevention programme, particularly those geared towards key populations.

Changing sex risk behaviors, gender norms, and relationship dynamics among couples in Cape Town, South Africa: Efficacy of an intervention on the dyad

RATIONALE

South Africa continues to experience new HIV infections, with the highest risk among Black Africans living in poor communities. Most HIV prevention interventions target women or men separately and only a small number target couples jointly.

OBJECTIVE

This study examines varying strategies to engage women and men around HIV prevention and improved couple interactions.

METHODS

The study comprises three arms: (1) a couple-based intervention delivered to women and men jointly; (2) women and men both offered a gender-focused intervention that is delivered to them separately; and (3) an intervention offered to women only and their male partners receive standard HIV testing and counseling (comparison arm). Between June 2010 and April 2012, men were identified in and around drinking establishments in a large disadvantaged community in Cape Town and asked to participate in the study if they drink regularly, had recent unprotected sex with their partner, and have a female partner who was willing to participate in the study.

RESULTS

A total of 299 couples completed the baseline assessment and 276 were included in the analysis of sexual risk, partner communication, conflict resolution, and gender norm outcomes at baseline and six-month follow-up. Couples that participated in the couple-level intervention and couples where both partners received the intervention separately had better couple-level gender norms than couples in the comparison arm (women only receive intervention). Further, couples in the couple-level intervention and the both partners exposed separately arms were more likely to have the man only report consistent condom use than neither partner report consistent condom use than couples in the comparison arm.

CONCLUSION

Community-based HIV prevention intervention programs need to consider strategies to engage women and men and, if feasible, reach both partners jointly. Couple-level interventions are promising to improve gender norms and subsequently improve health outcomes, including reduced HIV risk among women, men, and couples.

Predictors and psychological pathways for binge drinking among South African men

OBJECTIVE

To develop targeted interventions for high-risk drinkers among South African men, we assessed whether sociodemographic factors and history of childhood sexual abuse predicted binge drinking at six-month follow-up assessment and their psychological pathways according to the extended Theory of Reasoned Action (TRA).

DESIGN

Survey responses with a sample of 1181 South African men from randomly selected neighbourhoods in Eastern Cape Province were collected at baseline and six-month follow-up. Multiple logistic regression analysis examined the baseline predictors of binge drinking. Serial multiple mediation analysis examined the psychological pathways.

MAIN OUTCOME MEASUREMENTS

Binge drinking at six-month follow-up.

RESULTS

Age (OR = 1.03, 95% CI: 1.01, 1.05), religious participation (OR = .73, CI: .65, .82) and history of childhood sexual abuse (OR = 1.82, CI: 1.32, 2.51) were significant predictors of binge drinking. Predictions of religious participation and history of childhood sexual abuse were partially mediated through attitude, subjective norm, descriptive norm and intention to binge drinking.

CONCLUSION

South African men with childhood sexual abuse experience and low religious participation were at higher risk for binge drinking. The extended TRA model explains the associations of these factors to binge drinking and can contribute to the design and evaluation of interventions.

An Empiric HIV Risk Scoring Tool to Predict HIV-1 Acquisition in African Women

Supplemental Digital Content is Available in the Text.

Objective:

To develop and validate an HIV risk assessment tool to predict HIV acquisition among African women.

Design:

Data were analyzed from 3 randomized trials of biomedical HIV prevention interventions among African women (VOICE, HPTN 035, and FEM-PrEP).

Methods:

We implemented standard methods for the development of clinical prediction rules to generate a risk-scoring tool to predict HIV acquisition over the course of 1 year. Performance of the score was assessed through internal and external validations.

Results:

The final risk score resulting from multivariable modeling included age, married/living with a partner, partner provides financial or material support, partner has other partners, alcohol use, detection of a curable sexually transmitted infection, and herpes simplex virus 2 serostatus. Point values for each factor ranged from 0 to 2, with a maximum possible total score of 11. Scores ≥5 were associated with HIV incidence >5 per 100 person-years and identified 91% of incident HIV infections from among only 64% of women. The area under the curve (AUC) for predictive ability of the score was 0.71 (95% confidence interval [CI]: 0.68 to 0.74), indicating good predictive ability. Risk score performance was generally similar with internal cross-validation (AUC = 0.69; 95% CI: 0.66 to 0.73) and external validation in HPTN 035 (AUC = 0.70; 95% CI: 0.65 to 0.75) and FEM-PrEP (AUC = 0.58; 95% CI: 0.51 to 0.65).

Conclusions:

A discrete set of characteristics that can be easily assessed in clinical and research settings was predictive of HIV acquisition over 1 year. The use of a validated risk score could improve efficiency of recruitment into HIV prevention research and inform scale-up of HIV prevention strategies in women at highest risk.

Alcohol use and sexual risk behaviour among men and women in inner-city Johannesburg, South Africa

BACKGROUND

Alcohol misuse is a key factor underlying the remarkable vulnerability to HIV infection among men and women in sub-Saharan Africa, especially within urban settings. Its effects, however, vary by type of drinking, population group and are modified by socio-cultural co-factors.

METHODS

We interviewed a random sample of 1465 men living in single-sex hostels and 1008 women in adjacent informal settlements in inner-city, Johannesburg, South Africa. Being drunk in the past week was used as an indicator of heavy episodic drinking, and frequency of drinking and number of alcohol units/week used as measures of volume. Associations between dimensions of alcohol use (current drinking, volume of alcohol consumed and heavy episodic drinking patterns) and sexual behaviours were assessed using multivariate logistic regression.

RESULTS

Most participants were internal migrants from KwaZulu Natal province. About half of men were current drinkers, as were 13% of women. Of current male drinkers, 18% drank daily and 23% were drunk in the past week (women: 14% and 29% respectively). Among men, associations between heavy episodic drinking and sexual behaviour were especially pronounced. Compared with non-drinkers, episodic ones were 2.6 fold more likely to have transactional sex (95%CI = 1.7-4.1) and 2.2 fold more likely to have a concurrent partner (95%CI = 1.5-3.2). Alcohol use in men, regardless of measure, was strongly associated with having used physical force to have sex. Overall effects of alcohol on sexual behaviour were larger in women than men, and associations were detected between all alcohol measures in women, and concurrency, transactional sex and having been forced to have sex.

CONCLUSIONS

Alcohol use and sexual behaviours are strongly linked among male and female migrant populations in inner-city Johannesburg. More rigorous interventions at both local and macro level are needed to alleviate alcohol harms and mitigate the alcohol-HIV nexus, especially among already vulnerable groups. These should target the specific dimensions of alcohol use that are harmful, assist women who drink to do so more safely and address the linkages between alcohol and sexual violence.

Alcohol Consumption in Ugandan HIV-Infected Household-Brewers Versus Non-Brewers

The brewing of alcohol in Ugandan households is common, yet little is known about its relationship with alcohol consumption in HIV-infected individuals. We performed a cross-sectional analysis to assess the association between household brewing and unhealthy alcohol consumption among 387 HIV-infected adults in a prospective study examining the association between alcohol consumption and HIV-disease progression. Household brewing was defined as participants reporting that they or a household member home-brewed alcohol. Logistic regression was used to assess the association between household brewing and unhealthy alcohol consumption, defined as phosphatidylethanol (PEth) level ≥50 ng/ml or AUDIT-C (modified to measure the prior 3 months) positive. Sixty-six (17.0 %) participants reported household brewing. Household brewers had higher odds of unhealthy alcohol consumption (AOR 2.27, 95 % CI 1.26-4.12). Among HIV-infected individuals, household brewing was associated with unhealthy alcohol consumption. Interventions to reduce alcohol consumption in this population could target household brewers.

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.

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.

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.

Experiences of forced sex among female patrons of alcohol-serving venues in a South African township

South Africa has among the highest rates of forced sex worldwide, and alcohol use has consistently been associated with risk of forced sex in South Africa. However, methodological challenges affect the accuracy of forced sex measurements. This study explored the assessment of forced sex among South African women attending alcohol-serving venues and identified factors associated with reporting recent forced sex. Women (n = 785) were recruited from 12 alcohol-serving venues in a peri-urban township in Cape Town. Brief self-administered surveys included questions about lifetime and recent experiences of forced sex. Surveys included a single question about forced sex and detailed questions about sex by physical force, threats, verbal persuasion, trickery, and spiked drinks. We first compared the single question about forced sex to a composite variable of forced sex as unwanted sex by physical force, threats, or spiked drinks. We then examined potential predictors of recent forced sex (demographics, drinking behavior, relationship to the venue, abuse experiences). The single question about forced sex had low sensitivity (0.38); more than half of the respondents who reported on the detailed questions that they had experienced forced sex by physical force, threats, or spiked drinks reported on the single question item that they had not experienced forced sex. Using our composite variable, 18.6% of women reported lifetime and 10.8% reported recent experiences of forced sex. In our adjusted logistic regression model, recent forced sex using the composite variable was significantly associated with hazardous drinking (OR = 1.92), living farther from the venue (OR = 1.81), recent intimate partner violence (OR = 2.53), and a history of childhood sexual abuse (OR = 4.35). The findings support the need for additional work to refine the assessment of forced sex. Efforts to prevent forced sex should target alcohol-serving venues, where norms and behaviors may present particular risks for women who frequent these settings.

Male circumcision, alcohol use and unprotected sex among patrons of bars and taverns in rural areas of North-West province, South Africa

Strong research evidence has shown that medical male circumcision significantly reduces heterosexual HIV acquisition among men. However, its effectiveness is enhanced by behavioural factors such as condom use. Currently, little is known of unprotected sex associated with male circumcision (MC) among alcohol-drinking tavern-going men, or whether engagement in unprotected sex may differ between men who have been traditionally circumcised and those who have been medically circumcised. The study sought to determine the relative importance of alcohol consumption and MC as correlates of unprotected sex and to compare the risk of engaging in unprotected sex between traditionally circumcised and medically circumcised tavern-going men from two rural villages in North-West province, South Africa. Data from 314 adult men (≥18 years) were analysed. The men were recruited from four bars/taverns using systematic sampling. They responded to questions regarding their demographic characteristics, alcohol consumption, circumcision status and method (where applicable), and engagement in unprotected sex. Descriptive analyses and bivariate and multivariate logistic regression analyses were conducted. Age, education, relationship status, alcohol consumption and traditional male circumcision (TMC) were independently and significantly associated with unprotected sex. Specifically, probable alcohol dependence and traditional circumcision were independent risk factors for engaging in unprotected sex among tavern-going men. Traditionally circumcised men had a higher risk of engaging in unprotected sex than medically circumcised men. Interventions aimed at reducing alcohol consumption, encouraging protective behaviour among men who have undergone TMC, and increasing condom use are needed in bar/tavern settings. HIV prevention education must be urgently incorporated into TMC programmes.

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.

Alcohol use, sexual relationship power, and unprotected sex among patrons in bars and taverns in rural areas of North West province, South Africa

We examined the relative importance of alcohol consumption and sexual relationship power (SRP) in predicting unprotected sex among 406 bar patrons in North West province, South Africa. We assessed participants' demographic characteristics, alcohol consumption, SRP, and number of unprotected sexual episodes in the past 6 months. In correlational analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP was significantly associated with frequency of unprotected sex for males and marginally associated for females. In multivariate regression analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP's association was marginally significant for females and not significant for males. Alcohol consumption is more strongly associated with unprotected sex than is SRP among bar patrons. Combination HIV prevention approaches to curb problem drinking and increase condom accessibility, and regular and effective use are needed in tavern settings. SRP needs further examination among tavern populations.

HIV risks among injecting and non-injecting female partners of men who inject drugs in Almaty, Kazakhstan: implications for HIV prevention, research, and policy

BACKGROUND

Kazakhstan and other countries in Central Asia are experiencing a rapidly growing HIV epidemic, which has historically been driven by injection drug use, but is more recently being fueled by heterosexual transmission.

METHODS

This paper examines HIV and HCV infection, as well as sexual and drug-related risks among female partners of men who inject drugs (MWID), comparing females who inject drugs (FWID) to non-injecting female partners on socio-demographic, relationship context, and structural characteristics.

RESULTS

The prevalence rate of HIV was 30.1% among FWID and 10.4% among non-IDU female partners of MWID. The prevalence rate of HCV was 89.8% among FWID and 14.8% among female non-IDUs. Less than one-fifth of all female participants had access to HIV education and services or harm reduction programs. Although high rates of non-injection drug use and sexual risk behaviors were found among both FWID and non-injecting female partners of MWID, we found that FWID were more likely to be HIV seropositive (aRR=3.03; 95% CI=1.78, 5.18) and HCV seropositive than non-IDU females (aRR=6.05; 95% CI=4.05, 9.04), were more likely to have used alcohol or drugs before sex (aRR=1.67; 95% CI=1.40, 2.00), and were more likely to have used sedatives, barbiturates, tranquilizers, sleeping pills, or painkillers that were not prescribed by a physician (aRR=17.45; 95% CI=8.01, 38.01).

CONCLUSION

Given the spread of the HIV epidemic to heterosexual partners in Kazakhstan, more attention is needed in research, prevention, and policies regarding female partners of male injection drug users.

Adolescents' beliefs about forced sex in KwaZulu-Natal, South Africa

Gender-based violence has serious consequences for the psychological, physical, and sexual well-being of both men and women. Various gender roles, attitudes, and practices in South Africa create an environment that fosters submission and silence in females and hegemony and coercion in males. One of the expressions of this power inequity is a high prevalence of forced sex, which in its turn is associated with higher risk of HIV infection. This study therefore assessed potential gender differences in beliefs about forced sex and in prevalence of reported forced sex among high school students (N = 764) in KwaZulu-Natal. Results showed that significantly more boys were sexually active (26 %) than girls (12 %) and that boys experienced earlier sexual debut by over a year. Boys also held a more positive view about forced sex than girls since they associated it more often with signs of love, as an appropriate way to satisfy sexual urges, and as acceptable if the girl was financially dependent on the boy. The perception that peers and friends considered forced sex to be an effective way to punish a female partner was also more common among boys. On the other hand, boys were less knowledgeable about the health and legal consequences of forced sex, but no significant differences were found for other sociocognitive items, such as self-efficacy and behavioral intention items. Consequently, health education programs are needed to inform both boys and girls about the risks of forced sex, to convince boys and their friends about its inappropriateness and girls to empower themselves to avoid forced sex.

Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers

AIMS

To investigate putative links between alcohol use, and unsafe sex and incident HIV infection in sub-Saharan Africa.

METHODS

A cohort of 400 HIV-negative female sex workers was established in Mombasa, Kenya. Associations between categories of the Alcohol Use Disorders Identification Test (AUDIT) and the incidence at one year of unsafe sex, HIV and pregnancy were assessed using Cox proportional hazards models. Violence or STIs other than HIV measured at one year was compared across AUDIT categories using multivariate logistic regression.

RESULTS

Participants had high levels of hazardous (17.3%, 69/399) and harmful drinking (9.5%, 38/399), while 36.1% abstained from alcohol. Hazardous and harmful drinkers had more unprotected sex and higher partner numbers than abstainers. Sex while feeling drunk was frequent and associated with lower condom use. Occurrence of condom accidents rose step-wise with each increase in AUDIT category. Compared with non-drinkers, women with harmful drinking had 4.1-fold higher sexual violence (95% CI adjusted odds ratio [AOR] = 1.9-8.9) and 8.4 higher odds of physical violence (95% CI AOR = 3.9-18.0), while hazardous drinkers had 3.1-fold higher physical violence (95% CI AOR = 1.7-5.6). No association was detected between AUDIT category and pregnancy, or infection with Syphilis or Trichomonas vaginalis. The adjusted hazard ratio of HIV incidence was 9.6 comparing women with hazardous drinking to non-drinkers (95% CI = 1.1-87.9).

CONCLUSIONS

Unsafe sex, partner violence and HIV incidence were higher in women with alcohol use disorders. This prospective study, using validated alcohol measures, indicates that harmful or hazardous alcohol can influence sexual behaviour. Possible mechanisms include increased unprotected sex, condom accidents and exposure to sexual violence. Experimental evidence is required demonstrating that interventions to reduce alcohol use can avert unsafe sex.

Impact of interventions targeting unhealthy alcohol use in Kenya on HIV transmission and AIDS-related deaths

BACKGROUND

HIV remains a major cause of preventable morbidity and mortality in Kenya. The effects of behaviors that accompany unhealthy alcohol consumption are a pervasive risk factor for HIV transmission and progression. Our objective was to estimate the portion of HIV infections attributable to unhealthy alcohol use and to evaluate the impact of hypothetical interventions directed at unhealthy alcohol use on HIV infections and deaths.

METHODS

We estimated outcomes over a time horizon of 20 years using a computer simulation of the Kenyan population. This computer simulation integrates a compartmental model of HIV transmission with a mechanistic model of HIV progression that was previously validated in sub-Saharan Africa. Integration of the transmission and progression models allows simultaneous consideration of alcohol's effects on HIV transmission and progression (e.g., lowering antiretroviral adherence may increase transmission risk by elevating viral load, and may simultaneously increase progression by increasing the likelihood of AIDS). The simulation considers important aspects of heterogeneous sexual mixing patterns, including assortativeness of partners by age and activity level, age-discordant relationships, and high activity subgroups. Outcomes included number of new HIV infections, number of AIDS deaths, and infectivity (number of new infections per infected person per year).

RESULTS

Our model estimated that the effects of behaviors accompanying unhealthy alcohol consumption are responsible for 13.0% of new HIV infections in Kenya. An alcohol intervention with effectiveness similar to that observed in a published randomized controlled trial of a cognitive-behavioral therapy-based intervention in Kenya (45% reduction in unhealthy alcohol consumption) could prevent nearly half of these infections, reducing their number by 69,858 and reducing AIDS deaths by 17,824 over 20 years. Estimates were sensitive to assumptions with respect to the magnitude of alcohol's underlying effects on condom use, antiretroviral therapy adherence, and sexually transmitted infection prevalence.

CONCLUSIONS

A substantial number of new HIV infections in Kenya are attributable to unhealthy alcohol use. An alcohol intervention with the effectiveness observed in a published randomized controlled trial has the potential to reduce infections over 20 years by nearly 5% and avert nearly 18,000 deaths related to HIV.

Factors associated with problem drinking among women employed in food and recreational facilities in northern Tanzania

BACKGROUND

There is growing evidence that alcohol consumption is associated with increased risk of HIV infection. To determine factors associated with problem drinking, we analyzed data collected in two prospective cohorts of at-risk female food and recreational facility workers in northern Tanzania.

METHODS

We enrolled HIV seronegative women aged 18-44 years and employed in the towns of Geita, Kahama, Moshi, and Shinyanga. At enrolment, women were interviewed to obtain information about alcohol use, using CAGE and AUDIT screening scales, and risk factors for HIV infection. Blood and genital samples were collected for detection of HIV and sexually transmitted infections (STIs). We characterized alcohol use, concordance, and agreement of the scales, and examined the associations between characteristics of participants and problem drinking as defined by both scales using logistic regression. Lastly, we assessed problem drinking as a risk factor for recent sexual behavior and prevalent STIs.

RESULTS

Among enrollees, 68% women reported ever drinking alcohol; of these 76% reported drinking alcohol in the past 12 months. The prevalence of problem drinking was 20% using CAGE and 13% using AUDIT. Overall concordance between the scales was 75.0% with a Kappa statistic of 0.58. After adjusting for age, independent factors associated with problem drinking, on both scales, were marital status, occupation, facility type, increasing number of lifetime sexual partners, and transactional sex in the past 12 months. In addition, women who were problem drinkers on either scale were more likely to report having ≥ 1 sexual partner (CAGE: aOR = 1.56, 95% confidence interval, CI: 1.10-2.23;

AUDIT

aOR = 2.00, 95% CI: 1.34-3.00) and transactional sex (CAGE: aOR = 1.79, 95% CI: 1.26-2.56;

AUDIT

aOR = 1.51, 95% CI: 1.04-2.18), in the past 3 months.

CONCLUSION

These findings suggest that interventions to reduce problem drinking in this population may reduce high-risk sexual behaviors and contribute in lowering the risk of HIV infection.

Binge drinking prior to pregnancy detection in a nonhuman primate: behavioral evaluation of offspring

BACKGROUND

Minimal scientific information is available to inform public health policy on binge drinking prior to pregnancy detection. The nonhuman primate provides a valuable animal model for examining consequences to reproduction and offspring function that may result from this common pattern of alcohol abuse.

METHODS

Adult female rhesus monkeys were dosed with 1.5 g/kg per day ethanol (EtOH) by gavage 2 d/wk beginning 7 months prior to mating and continuing to pregnancy detection at 19 to 20 days gestation. Postnatal evaluation of control (n = 6) and EtOH-treated (n = 4) infants included a neonatal neurobehavioral assessment, a visual paired comparison (cognitive) test at 35 days of age, and mother-infant interaction at 100 to 112 days of age.

RESULTS

Alcohol-exposed neonates did not differ from controls in posture and reflex measures. Longer durations of visual fixation, suggesting slower visual processing, and greater novelty preference were seen in the alcohol group. At early weaning age, as infants spent more time away from their dams, more of the reunions between mother and infant were initiated by the mothers in the alcohol-exposed group, suggesting a more immature mother-infant interaction.

CONCLUSIONS

Intermittent high-dose alcohol exposure (binge drinking) discontinued at early pregnancy detection in rhesus monkey can result in altered behavioral function in the infant. Mediating effects on ovum, reproductive tract, and early embryo can be explored in this model. Studies of longer-term consequences in human populations and animal models are needed.

Prevalence and correlates of alcohol dependence disorder among TB and HIV infected patients in Zambia

Objectives

To determine the prevalence and correlates of alcohol dependence disorders in persons receiving treatment for HIV and Tuberculosis (TB) at 16 Primary Health Care centres (PHC) across Zambia.

Methods

649 adult patients receiving treatment for HIV and/or TB at PHCs in Zambia (363 males, 286 females) were recruited between 1st December 2009 and 31st January 2010. Data on socio-demographic variables, clinical disease features (TB and HIV), and psychopathological status were collected. The Mini International Neuropsychiatric Interview (MINI) was used to diagnose alcohol dependence disorder. Correlates of alcohol dependence were analyzed for men only, due to low prevalence in women. Univariable and multivariable logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI), using general estimating equations to allow for within-PHC clustering.

Results

The prevalence of alcohol dependence was 27.2% (95%CI: 17.7-39.5%) for men and 3.9% (95%CI: 1.4-0.1%) for women. Factors associated with alcohol dependence disorder in men included being single, divorced or widowed compared with married (adjusted OR = 1.47, 95%CI: 1.00-2.14) and being unemployed (adjusted OR=1.30, 95%CI: 1.01-1.67). The highest prevalence of alcohol dependence was among HIV-test unknown TB patients (34.7%), and lowest was among HIV positive patients on treatment but without TB (14.1%), although the difference was not statistically significant (p=0.38).

Conclusions

Male TB/HIV patients in this population have high prevalence of alcohol dependence disorder, and prevalence differs by HIV/TB status. Further work is needed to explore interventions to reduce harmful drinking in this population.

Substance use, gender inequity, violence and sexual risk among couples in Cape Town

Alcohol and other drug use, gender power inequities and violence are key contributors to sexual risks for HIV among South African men and women. Little is known about the intersection between these sex-risk behaviours among couples in established heterosexual relationships. We conducted 10 focus-group discussions with men and women in relationships of 1 year or longer recruited from shebeens (informal taverns) in Cape Town, South Africa. Participants described: high levels of alcohol consumption at shebeens; low levels of condom use with main and casual sex partners; gender roles disfavouring women's condom negotiating power that also promoted economic dependency on male partners; men often spending a portion of the household income on alcohol and other drugs and sex with others in shebeens; loss of household income driving women to trade sex to provide for their families; and sexual violence and the exploitation of women occurring in shebeens. Findings highlight how the social contexts of alcohol and other drug use, gender inequitable norms and gender violence promote HIV risk within established heterosexual relationships in South African communities. Evidence of this kind should inform the design of HIV-risk-reduction interventions tailored to heterosexual couples who drink alcohol in shebeens.

Intersecting epidemics among pregnant women: alcohol use, interpersonal violence, and HIV infection in South Africa

A critical factor for understanding negative health outcomes is acknowledging the synergistic quality that clusters of health problems create. An important step in addressing clusters of health problems involves gaining an awareness of the contextual factors that connect them. This paper considers the intersection of 3 mutually reinforcing health problems: alcohol use, interpersonal violence (IPV), and HIV infection among pregnant women residing in South Africa. We explore how SAVA (substance abuse, violence and AIDS) - a syndemics related theory - underscores the dire need to intervene in various areas of psycho-social health and general well-being. Based on World Health Organization data, we highlight the remarkably high rates of alcohol use, IPV, and HIV infection among South African women compared with women residing in other countries around the world. We conclude by highlighting the need for improved recognition of the intersection of these epidemics and for improved surveillance of the prevalence of alcohol use among pregnant women. Finally, based on the literature reviewed, we provide recommendations for future interventions.

Decreased injecting is associated with increased alcohol consumption among injecting drug users in northern Vietnam

BACKGROUND

Reducing injecting frequency may reduce the risk of HIV infection and improve health outcomes among injection drug users (IDUs). However, the reduction of one risk behavior may be associated with an increase in other risk behaviors, including the use of other risk-associated substances. Our objective was to determine if an association exists between a reduction in injecting and level of alcohol use among IDU.

METHODS

We conducted a longitudinal analysis of data collected for a randomized controlled trial examining the efficacy of a peer education intervention in reducing HIV risk among IDU and their network members in Thai Nguyen, Vietnam. Our analysis included active male injectors (n = 629) who were study participants and attended both baseline and 3-month visits. Frequency of alcohol consumption was assessed as the number of alcoholic drinks in the past 30 days. Change in risk and outcome behaviors was calculated as the difference in frequencies of behaviors between baseline and 3-month follow-up visits. The outcome of interest was concurrent decreased drug injection and increased alcohol consumption.

RESULTS

The mean difference between baseline and 3-month follow-up of alcohol consumption and injection frequency in the past 30 days was 19.03 drinks (93.68 SD) and 20.22 injections (35.66 SD), respectively. Participants who reported reduced injection frequency were almost three times as likely to report increased alcohol consumption (OR 2.8; 95% CI, 2.0, 4.0). The proportion that both decreased injecting and increased alcohol by any amount in the past 30 days was 35.6%. In multivariate analysis higher education was significantly associated with an increase in alcohol and decrease in injecting of any amount.

CONCLUSION

Male IDU may be at risk for increasing alcohol consumption when they reduce injection frequency. Interventions with male IDU that encourage reduction of injection may need to review specific strategies to limit alcohol consumption.

Mental health, childhood abuse and HIV sexual risk behaviour among university students in Ivory Coast

BACKGROUND

Little focus has been paid to the role of poor mental health and childhood abuse among young people with regard to human immunodeficiency virus (HIV) risk behaviour and HIV prevention in Africa. The aim of this study was to determine the association between mental health, childhood abuse and HIV sexual risk behaviour among a sample of university students in Ivory Coast.

METHODS

A cross-sectional survey was conducted with undergraduate students that were recruited randomly from classes at the Félix Houphouët Boigny University of Cocody. The sample included 824 university students (50% men and 50% women), with a mean age of 23.7 years (SD = 2.7).

RESULTS

Of the 824 university students who completed the survey, 17.6% reported depression, 10.8% screened positive for post-traumatic stress disorder, 8.3% reported at least monthly heavy episodic drinking, 13.5% reported childhood physical abuse and 4.7% sexual abuse, 33.9% had two or more sexual partners in the past 12 months, 66.3% had inconsistent condom use, 23.6% had alcohol use in the context of sex and 16.7% had a history of a sexually transmitted infection In multivariable analysis among men, lack of religiousness and alcohol use in the context of sex were associated with HIV risk behaviour, and among women, poorer family background, experience of sexual and physical partner violence, alcohol use in the context of sex and depression were associated with HIV risk behaviour.

CONCLUSIONS

Poor mental health (depression) including alcohol use and partner violence was found to be associated with HIV risk behaviour. Coordinated mental health and sexual and reproductive health services to meet the needs of university students would be desirable.

Alcohol production as an adaptive livelihood strategy for women farmers in Tanzania and its potential for unintended consequences on women's reproductive health

BACKGROUND

Although women occupy a central position in agriculture in many developing countries, they face numerous constraints to achieving their full potential including unequal access to assets and limited decision-making authority. We explore the intersection of agricultural livelihoods, food and economic security, and women's sexual and reproductive health in Iringa Region, Tanzania. Our goal was to understand whether the benefits of supporting women in the agricultural sector might also extend to more distal outcomes, including sexual and reproductive health.

METHODS

Using the Sustainable Livelihoods Framework to guide data collection, we conducted 13 focus group discussions (FGD) with female (n = 11) and male farmers (n = 2) and 20 in-depth interviews with agricultural extension officers (n = 10) and village agro-dealers (n = 10).

RESULTS

Despite providing the majority of agricultural labor, women have limited control over land and earned income and have little bargaining power. In response to these constraints, women adopt adaptive livelihood strategies, such as alcohol production, that allow them to retain control over income and support their households. However, women's central role in alcohol production, in concert with the ubiquitous nature of alcohol consumption, places them at risk by enhancing their vulnerability to unsafe or transactional sex. This represents a dangerous confluence of risk for female farmers, in which alcohol plays an important role in income generation and also facilitates high-risk sexual behavior.

CONCLUSIONS

Alcohol production and consumption has the potential to both directly and indirectly place women at risk for undesirable sexual and reproductive health outcomes. Group formation, better access to finance, and engaging with agricultural extension officers were identified as potential interventions for supporting women farmers and challenging harmful gender norms. In addition, joint, multi-sectoral approaches from health and agriculture and alternative income-generating strategies for women might better address the complexities of achieving safe and sustainable livelihoods for women in this context.

Prevalence of HIV and other sexually transmitted infections among female sex workers in Kisumu, Western Kenya, 1997 and 2008

Background

In 1997, a survey in Kisumu found a prevalence of HIV infection among female sex workers (FSW) of 75%. Only 50% reported using a condom with the last client. In 2008, we conducted another survey to collect data to inform an intervention targeting FSW in Kisumu.

Methods

In 2008 FSW were recruited by respondent-driven sampling. Women completed a questionnaire and were tested for HIV and other sexually transmitted infections (STIs). Multiple logistic regression analysis was done to explore factors associated with HIV-infection, and with condom use. Prevalence of HIV infection was compared in the two surveys from 1997 and 2008. Multivariate analysis was used to assess whether a change in HIV prevalence between the two surveys could be explained by changes in socio-demographic characteristics and/or behavioral factors.

Results

481 FSW participated in the 2008 study. HIV prevalence was 56.5% (95% CI 52.0–61.6). Factors independently associated with HIV were age older than 29 years; being a widow; STI treatment in the past year; herpes simplex virus Type-2 infection; bacterial vaginosis; and trichomoniasis. Condom use with last client was reported by 75.0% (95% CI 70.9–78.9). Predictors of condom use with the last client were age older than 29 years; higher price paid by last client; ever having been tested for HIV. Predictors of unprotected sex were being drunk during last sex act; usually having sex during menses; and STI treatment in the past year. The odds ratio of HIV infection associated with year of survey was 0.49 (95% CI 0.33–0.75) after adjusting for socio-demographic and behavioral factors.

Conclusions

The prevalence of HIV among FSW in Kisumu was found to be lower in 2008 than in 1997, while reported condom use was higher. However, access to HIV/STI prevention and care services needs to improve to further decrease HIV transmission between FSW and their clients.

Alcohol, HIV/AIDS, and Liver Disease

Globally, there are over 33 million persons living with HIV/AIDS resulting in 1.8 million deaths annually. While the rate of HIV transmission is slowing, it is estimated that 2.6 million new infections occur yearly [1]. In the United States, there are approximately 1.2 million living with HIV/AIDS, with 50,000 new HIV infections and 17,000 deaths from the disease annually [2]. For those who can obtain effective antiretroviral therapy (ART), HIV/AIDS has become a chronic disease with life expectancies over 30 years [3]. Research in the last 10 years has revealed the importance of alcohol in the HIV/AIDS epidemic. Alcohol use, in moderate or hazardous amounts, has been associated with increased acquisition of HIV infection, progression of HIV infection, deleterious effects on HIV treatment, and acceleration in the comorbidities of HIV infection [4–9]. Yet alcohol remains the “forgotten drug” of the HIV/AIDS epidemic [10].

Health in South Africa: changes and challenges since 2009

Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous administration are being transformed. The change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence; and maternal, neonatal, and child health. South Africa now has the world's largest programme of antiretroviral therapy, and some advances have been made in implementation of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention has received increased attention. Child mortality has benefited from progress in addressing HIV. However, more attention to postnatal feeding support is needed. Many risk factors for non-communicable diseases have increased substantially during the past two decades, but an ambitious government policy to address lifestyle risks such as consumption of salt and alcohol provide real potential for change. Although mortality due to injuries seems to be decreasing, high levels of interpersonal violence and accidents persist. An integrated strategic framework for prevention of injury and violence is in progress but its successful implementation will need high-level commitment, support for evidence-led prevention interventions, investment in surveillance systems and research, and improved human-resources and management capacities. A radical system of national health insurance and re-engineering of primary health care will be phased in for 14 years to enable universal, equitable, and affordable health-care coverage. Finally, national consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2·0% of national health spending. However, large racial differentials exist in social determinants of health, especially housing and sanitation for the poor and inequity between the sexes, although progress has been made in access to basic education, electricity, piped water, and social protection. Integration of the private and public sectors and of services for HIV, tuberculosis, and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered widely. Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.

Effects of acute nicotine and alcohol on the rating of attractiveness in social smokers and alcohol drinkers

BACKGROUND

Nicotine and alcohol are often consumed together. Previous research suggests that both can independently increase the perceived attractiveness of social stimuli, which may be a mechanism that drives continued use. This study examined whether there was an additive effect of nicotine and alcohol on perceived attractiveness of social and environmental stimuli.

METHODS

Male and female (n=96) social alcohol consumers and light cigarette smokers (no more than 14 cigarettes per week) were randomized to smoke either a nicotinized or denicotinized cigarette and drink either an alcoholic or non-alcoholic (placebo) beverage. The primary outcome was attractiveness ratings of facial and landscape stimuli. Secondary outcomes were self-report mood and craving.

RESULTS

There was a main effect of drink (p=.031) and a trend toward a main effect of cigarette (p=.057) with higher ratings of attractiveness after alcohol compared to placebo and after a nicotinized cigarette compared to a denicotinized cigarette. Nicotine and alcohol appeared to work additively on ratings of attractiveness, with the highest ratings in the nicotine/alcohol group. There were no interactions between drink, cigarette and stimulus type.

CONCLUSIONS

When co-administered, nicotine and alcohol consumption resulted in the highest perceptions of attractiveness across all stimulus types. This additive effect may be a mechanism by which administration of one drug reinforces use of the other, and which leads to an increased likelihood of habitual consumption and relapse.

Progress and challenges to male and female condom use in South Africa

South Africa has responded to the sexually transmissible infection and HIV epidemic with a rapid expansion of its national-level public sector condom program. Male condoms are available widely at no cost in the public sector, with expanded access via social marketing and the private sector. The female condom program is one of the largest and best established globally. National surveys show progressive increases in rates of condom use at last sex. However, inconsistent and incorrect condom use and the likelihood that condoms are discontinued in longer-term partnerships are some of the challenges impeding the condom program's successes in the fight against sexually transmissible infections and HIV. This article reviews the current condom program, related guidelines and policies, and the existing data on male and female condom use, including distribution and uptake. We discuss the main challenges to condom use, including both user and service-related issues and finally how these challenges could be addressed.

Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa

BACKGROUND

Alcohol-serving venues in South Africa provide a location for HIV prevention interventions due to risk factors of patrons in these establishments. Understanding the association between mental health and risk behaviors in these settings may inform interventions that address alcohol use and HIV prevention.

METHODS

Participants (n = 738) were surveyed in 6 alcohol-serving venues in Cape Town to assess post-traumatic stress disorder (PTSD) and depression symptoms, traumatic experiences, sexual behavior, and substance use. Logistic regression models examined whether traumatic experiences predicted PTSD and depression. Generalized linear models examined whether substance use, PTSD, and depressive symptoms predicted unprotected sexual intercourse. Men and women were analyzed separately.

RESULTS

Participants exhibited high rates of traumatic experiences, PTSD, depression, alcohol consumption, and HIV risk behaviors. For men, PTSD was associated with being hit by a sex partner, physical child abuse, sexual child abuse and HIV diagnosis; depression was associated with being hit by a sex partner, forced sex and physical child abuse. For women, both PTSD and depression were associated with being hit by a sex partner, forced sex, and physical child abuse. Unprotected sexual intercourse was associated with age, frequency and quantity of alcohol use, drug use, and PTSD for men and frequency and quantity of alcohol use, depression, and PTSD for women.

CONCLUSION

Mental health in this setting was poor and was associated with sexual risk behavior. Treating mental health and substance-use problems may aid in reducing HIV infection. Sexual assault prevention and treatment after sexual assault may strengthen HIV prevention efforts.

Everywhere you go, everyone is saying condom, condom. But are they being used consistently? Reflections of South African male students about male and female condom use

Young men in South Africa can play a critical role in preventing new human immunodeficiency virus (HIV) infections, yet are seldom targeted for HIV prevention. While reported condom use at last sex has increased considerably among young people, consistent condom use remains a challenge. In this study, 74 male higher education students gave their perspectives on male and female condoms in 10 focus group discussions. All believed that condoms should be used when wanting to prevent conception and protect against HIV, although many indicated that consistent condom use was seldom attained, if at all. Three possible situations for not using condoms were noted: (i) when sex happens in the heat of the moment and condoms are unavailable, (ii) when sexual partnerships have matured and (iii) when female partners implicitly accept unprotected sex. Men viewed it as their responsibility to have male condoms available, but attitudes about whose decision it was to initiate condom use were mixed. Almost all sexually active men had male condom experience; however, very few had used female condoms. Prevention initiatives should challenge traditional gendered norms that underpin poor condom uptake and continued use and build on the apparent shifts in these norms that are allowing women greater sexual agency.

High prevalence of substance use among heterosexuals living in communities with high rates of AIDS and poverty in Washington, DC

OBJECTIVES

To assess the prevalence and patterns of substance use, HIV prevalence, and sexual risk behaviors in a community-based sample of heterosexuals recruited from areas at high risk for HIV/AIDS and poverty in Washington, DC.

METHODS

Community-recruited heterosexuals aged 18-50 from areas of high AIDS and poverty rates in DC were analyzed. Based on past 12 months use, participants were hierarchically classified into five groups: (1) ever injection drug use (IDU); (2) non-injection crack; (3) non-injection heroin and cocaine; (4) marijuana; and (5) no drug use. Sexual behaviors and HIV serology were also assessed.

RESULTS

Of 862 participants, 40% were men, most were Black and unemployed, and more than half had ever been incarcerated. Prevalence of past year substance use was high: binge drinking (59%); marijuana (50%); non-injection crack (28%); heroin and/or cocaine injection (28%), non-injection cocaine (13%); and ecstasy (13%). In the hierarchical classification, 25% were ever IDU, 15% non-injection crack users, 2% non-injection heroin and/or cocaine users, 31% marijuana users, and 27% reported no drug use. Overall HIV seroprevalence was 5.7% and differed by drug use group-9.5%, 11.1%, 1.8%, 1.6%, and 3.2%, respectively. Nearly half reported having ≥3 sex partners in the past year; 20% reported exchange partners, and 69% had concurrent sex partners.

CONCLUSION

Estimated prevalence of substance use in this heterosexual population was high. HIV prevalence among IDUs and non-injection crack users was higher than the estimated population prevalence in Washington, DC. Sexual behaviors above and beyond drug use are likely to be driving HIV transmission.

Modeling binge-like ethanol drinking by peri-adolescent and adult P rats

Alcohol binge-drinking, especially among adolescents and young adults, is a serious public health concern. The present study examined ethanol binge-like drinking by peri-adolescent [postnatal days (PNDs 30-72)] and adult (PNDs 90-132) alcohol-preferring (P) rats with a drinking-in-the-dark-multiple-scheduled-access (DID-MSA) procedure used by our laboratory. Male and female P rats were provided concurrent access to 15% and 30% ethanol for three 1-h sessions across the dark cycle 5 days/week. For the 1st week, adolescent and adult female P rats consumed 3.4 and 1.6g/kg of ethanol, respectively, during the 1st hour of access, whereas for male rats the values were 3.5 and 1.1g/kg of ethanol, respectively. Adult intakes increased to ~2.0 g/kg/h and adolescent intakes decreased to ~2.5 g/kg/h across the 6 weeks of ethanol access. The daily ethanol intake of adult DID-MSA rats approximated or modestly exceeded that seen in continuous access (CA) rats or the selection criterion for P rats (≥5 g/kg/day). However, in general, the daily ethanol intake of DID-MSA peri-adolescent rats significantly exceeded that of their CA counterparts. BELs were assessed at 15-min intervals across the 3rd hour of access during the 4th week. Ethanol intake was 1.7 g/kg vs. 2.7 g/kg and BELs were 57 mg% vs. 100mg% at 15- and 60-min, respectively. Intoxication induced by DID-MSA in female P rats was assessed during the 1st vs. 4th week of ethanol access. Level of impairment did not differ between the 2 weeks (106 vs. 97 s latency to fall, 120 s criterion) and was significant (vs. naïve controls) only during the 4th week. Overall, these findings support the use of the DID-MSA procedure in rats, and underscore the presence of age- and sex-dependent effects mediating ethanol binge-like drinking in P rats.

Use of AUDIT, and measures of drinking frequency and patterns to detect associations between alcohol and sexual behaviour in male sex workers in Kenya

BACKGROUND

Previous research has linked alcohol use with an increased number of sexual partners, inconsistent condom use and a raised incidence of sexually transmitted infections (STIs). However, alcohol measures have been poorly standardised, with many ill-suited to eliciting, with adequate precision, the relationship between alcohol use and sexual risk behaviour. This study investigates which alcohol indicator--single-item measures of frequency and patterns of drinking ( > = 6 drinks on 1 occasion), or the Alcohol Use Disorders Identification Test (AUDIT)--can detect associations between alcohol use and unsafe sexual behaviour among male sex workers.

METHODS

A cross-sectional survey in 2008 recruited male sex workers who sell sex to men from 65 venues in Mombasa district, Kenya, similar to a 2006 survey. Information was collected on socio-demographics, substance use, sexual behaviour, violence and STI symptoms. Multivariate models examined associations between the three measures of alcohol use and condom use, sexual violence, and penile or anal discharge.

RESULTS

The 442 participants reported a median 2 clients/week (IQR = 1-3), with half using condoms consistently in the last 30 days. Of the approximately 70% of men who drink alcohol, half (50.5%) drink two or more times a week. Binge drinking was common (38.9%). As defined by AUDIT, 35% of participants who drink had hazardous drinking, 15% harmful drinking and 21% alcohol dependence. Compared with abstinence, alcohol dependence was associated with inconsistent condom use (AOR = 2.5, 95%CI = 1.3-4.6), penile or anal discharge (AOR = 1.9, 95%CI = 1.0-3.8), and two-fold higher odds of sexual violence (AOR = 2.0, 95%CI = 0.9-4.9). Frequent drinking was associated with inconsistent condom use (AOR = 1.8, 95%CI = 1.1-3.0) and partner number, while binge drinking was only linked with inconsistent condom use (AOR = 1.6, 95%CI = 1.0-2.5).

CONCLUSIONS

Male sex workers have high levels of hazardous and harmful drinking, and require alcohol-reduction interventions. Compared with indicators of drinking frequency or pattern, the AUDIT measure has stronger associations with inconsistent condom use, STI symptoms and sexual violence. Increased use of the AUDIT tool in future studies may assist in delineating with greater precision the explanatory mechanisms which link alcohol use, drinking contexts, sexual behaviours and HIV transmission.

Risk factors of alcohol problem drinking among female bar/hotel workers in Moshi, Tanzania: a multi-level analysis

There is limited information on alcohol problem drinking, which has been associated with sexually transmitted infections (STIs), including HIV, among female bar/hotel workers in Africa. This paper aimed to identify the individual- and facility-level determinants of alcohol problem drinking in this setting. Problem drinking was defined based on the CAGE alcohol screening scale. Multi-level logistic regression was used to identify individual- and facility-level factors associated with problem drinking. About 37.3% of women (N = 1629) were classified as having probable or definite problem drinking. In multi-level analysis, main characteristics associated with problem drinking included: having 3-4 partners in the past 5 years compared to having 1-2, used a condom in the last sex comparing to non-use, history of transactional sex, having more pregnancies, and facilities whose employees do not live on the premises. Interventions which combine alcohol and sexual risk reduction counseling are urgently needed in this population.

Changing trends and the impact of alcohol on the HIV/AIDS epidemic in South Africa: review

The association between increased HIV infection and alcohol use has been extensively studied and is established. South Africa is among one of the sub-Saharan African countries with the highest prevalence and number of people living with HIV/AIDS in the world. Although recent evidence suggests that the epidemic has stabilised, infection rates remain unacceptably high. Alcohol use is on the increase, particularly in the groups most susceptible to HIV infection, namely women and young adults, and informs poor choices with respect to safer sexual practices. This paper reviews the association between alcohol and HIV. More specifically, however, it aims to explore the potential socio-politico-biological and cultural explanations as to the factors that intersect to drive these two epidemic diseases: alcoholism and HIV/AIDS in South Africa. Understanding some of the underlying factors will provide a framework to implement public health measures to curb HIV.