Prevention Science

, 8:141

Alcohol Use and Sexual Risks for HIV/AIDS in Sub-Saharan Africa: Systematic Review of Empirical Findings

Authors

    • Department of PsychologyUniversity of Connecticut
  • Leickness C. Simbayi
    • Human Sciences Research Council
  • Michelle Kaufman
    • Department of PsychologyUniversity of Connecticut
  • Demetria Cain
    • Department of PsychologyUniversity of Connecticut
  • Sean Jooste
    • Human Sciences Research Council
Review Paper

DOI: 10.1007/s11121-006-0061-2

Cite this article as:
Kalichman, S.C., Simbayi, L.C., Kaufman, M. et al. Prev Sci (2007) 8: 141. doi:10.1007/s11121-006-0061-2

Abstract

Alcohol consumption is associated with risks for sexually transmitted infections (STI), including HIV/AIDS. In this paper, we systematically review the literature on alcohol use and sexual risk behavior in southern Africa, the region of the world with the greatest HIV/AIDS burden. Studies show a consistent association between alcohol use and sexual risks for HIV infection. Among people who drink, greater quantities of alcohol consumption predict greater sexual risks than does frequency of drinking. In addition, there are clear gender differences in alcohol use and sexual risks; men are more likely to drink and engage in higher risk behavior whereas women's risks are often associated with their male sex partners' drinking. Factors that are most closely related to alcohol and sexual risks include drinking venues and alcohol serving establishments, sexual coercion, and poverty. Research conducted in southern Africa therefore confirms an association between alcohol use and sexual risks for HIV. Sexual risk reduction interventions are needed for men and women who drink and interventions should be targeted to alcohol serving establishments.

Keyword

Alchohol and sexul risksHIV/AIDS PreventionSouthern Africa

Introduction

Alcohol is the most commonly used psychoactive substance and alcohol is among the most prevalent behaviors associated with sexual risks for HIV and other sexually transmitted infections (STI). Research conducted since the middle 1980s has repeatedly shown that alcohol use is related to sexual risks in several populations, especially among those with the highest rates of HIV infections (Weinhardt & Carey, 2001). Alcohol elevates sexual risks through multiple channels, including risk-taking personality characteristics, drinking environments, expectations regarding the effects of alcohol on risk-taking and the psychogenic effects of alcohol on decision making (Cook & Clark, 2005). The association between drinking and sexual risk behaviors has lead to interventions that address alcohol use for sexual risk reduction (Palepu et al., 2005) and there are HIV prevention interventions that specifically target people who drink (Kelly et al., 1991, 1992).
https://static-content.springer.com/image/art%3A10.1007%2Fs11121-006-0061-2/MediaObjects/11121_2006_61_Fig1_HTML.gif
Fig. 1

Model of alcohol use and sexual risk behavior, adapted from Morojele et al. (2006)

Among the more than 40 million people in the world who are infected with HIV, two out of three live in sub-Saharan Africa (UNAIDS, 2006). Coinciding with the world's greatest HIV/AIDS burden, southern Africa also consumes great quantities of alcohol. Alcohol use has a long history in southern Africa, dating back hundreds of years and spanning social, cultural, and economic spectrums (Nielsen et al., 1989). In the Republic of South Africa, for example, individuals who drink consume an average of 20 liters of alcohol per year, representing one of the highest volumes of per capita alcohol consumption in the world (Parry, 2005). Forty percent of South African men and 15% of women drink alcohol, with significant numbers drinking heavily (Shisana et al., 2005). There is also evidence that alcohol consumption in southern Africa is increasing over time (Parry et al., 2004).

Like elsewhere in the world, alcohol use is often associated with sexual risks in southern Africa.1 However, unlike anywhere else, the implications of alcohol use on risks for HIV infection are greatest in southern Africa because HIV prevalence rates are highest. This article reviews the current state of knowledge on the association between alcohol use and HIV risk behavior in southern Africa. To guide our review, we have adopted a conceptual model of the association between alcohol use and sexual risks (Morojele et al., 2006, described below). We also critically review the methodological issues that should be considered when interpreting results in the existing literature. Finally, we conclude by discussing the implications of the major study findings for future research and developing HIV prevention interventions in southern Africa.

Alcohol and risks for HIV infection in Southern Africa

Our literature review was performed using a combination of automated and manual search strategies. We searched PubMed and PsycInfo data bases for all journal dating back to 1985 using the key terms `Africa, alcohol, HIV, AIDS, risk behavior.' We also conducted manual searches of articles cited in reference sections of papers identified through automated search. In all, we located 84 articles. Using the criteria that studies had to have measured both alcohol use and sexual risks for HIV in the same timeframe and analyzed their associations, we retained 33 empirical papers. Table 1 presents a brief summary of findings and methodologies for the studies included in this review.
Table 1

Studies of alcohol use in relation to HIV transmission risks in southern Africa

   

HIV risk behaviors

 

Author

Sample

Alcohol measures

related to alcohol

Associations between alcohol and sexual risks

Botswana

    

Talbot, 2002

52 women, 83 men, TB patients Botswana

Number of drinks per day, Drinks before sex

HIV status

Drinking 3 or more drinks per day was not associated with HIV status. HIV status was related to alcohol use before sex in univariate and multivariate tests.

Campbell et al., 2003

663 young women, 461 young men, Botswana

Quantity and frequency of drinking

Frequency of sex in past month; ever had sex with casual partner when drinking; alcohol use by sex partner

Sexually active youth consume significantly more alcohol than their non-sexually active counterparts. Young men who drank at least once per week engaged in twice as much sexual risk behavior as non-drinking counterparts. Alcohol use accounted for 11% of the variance in sexual behavior for men and 26% for women.

Kenya

    

Ayisi et al., 2000

2844 women, antenatal clinic patients, Kenya

Current use of alcohol determined from interview

HIV Testing

Testing HIV+ was independently associated with current use of alcohol.

Feldblum, et al., 2000

1929 women plantation employees, Kenya

Currently drinking

Condom use; number of sex partners; STI testing

Current alcohol users had higher STD rates in stratified analysis.

Hargreaves et al., 2002

786 men, 1059 women Kenya

Drank in past month

Lifetime partners; condom use; STI and HIV testing

For men and women aged 25–49, alcohol use was associated with HIV infection.

Yadav et al., 2005

466 women sex workers, Kenya

Daily alcohol use

Condom use; STI

Women who drank daily were often based in night clubs and bars for their sex work and were more likely to engage in several high risk sex practices with clients; alcohol use was an independent risk factor for acquiring an STI

Malawi

    

Zachariah et al., 2003

1817 women, sex workers, Malawi

Any current alcohol use

Condom use with sex clients

37% of sex workers with symptomatic STIs who drank were four times more likely to not use condoms than were STI symptomatic women who did not drink (12%).

South Africa

    

Myer et al., 2002

384 persons who procure free condoms South Africa

Alcohol use before sex

Condom use, type of partner – regular / irregular

In an event level analysis of 3263 intercourse events, alcohol use before sex was more common with irregular partners and with not using condoms.

Taylor, 2003

514 women, 385 men, 10 to 22 year old students South Africa

Lifetime and current alcohol use

Currently sexually active

Drinking alcohol was significantly associated sexual activity; students who drank were 3 times more likely to be sexually active.

Zuma, Gouws, Willaims, Lurie, 2003

834 women South Africa

Alcohol use in past month

Number of lifetime partners, sex with non-regular partner, HIV and STI testing

Drinking in past month at least once a day as well as more frequent drinking were associated with HIV infection

Weir et al., 2003

3085 men, 1564 women in venues in townships and business districts, South Africa

Whether alcohol is served at the venues sampled

Number of new sex partners, condom use

People in townships and business districts meet sex partners in drinking establishments and sexual risk is closely associated with venues where drinking occurs.

Wechsberg et al., 2005

93 women sex workers, South Africa

Drinking frequency in past month, sex with client while intoxicated

Condom use with clients, STI symptoms and testing

24% of sex workers drank at least weekly and 51% had drank by the time they were 17 years old. Drinking was associated with history of physical abuse and with sexual risk behaviors.

Table 1

Continued.

   

HIV Risk behaviors

 

Author

Sample

Alcohol Measures

related to Alcohol

Associations between alcohol and sexual risks

Simbayi et al., 2005

113 men, 115 women under 25 years old, Township street survey, South Africa

Lifetime alcohol use

No use of condoms, numbers of partners, exchanging sex, STIs

Lifetime alcohol use was the most commonly used substance but it was not associated with aggregate HIV risk factors.

Wechsberg, 2005

183 women sex workers South Africa

Number of drinks on typical drinking day; alcohol use with sex clients during last 30 days

Condom use

60% alcohol use with sex clients in past month; 62% used alcohol before sex in past month; 48% of violent sex clients were drunk half the time or more.

Kalichman, Simbayi, Jooste, Cain, Cherry, in press

292 men, 219 women STI clinic patients, South Africa

AUDIT scores, drinking before sex, alcohol outcome expectancies

Engaging in unprotected sex, number of partners, sex exchange, STI & genital ulcer history

Alcohol use and alcohol outcome expectancies were associated with sexual risk behaviors. Drinking before sex was most closely associated with HIV risk behaviors.

Kalichman et al., in press

948 men, 1224 women, 3 urban communities, South Africa

Lifetime alcohol use

No use of condoms, numbers of partners, exchanging sex, STIs

History of alcohol use was associated with perceived severity of social problems related to poverty and alcohol use was related to HIV risks. Alcohol did not mediate the association between perceived severity of social problems and HIV risk.

Tanzania

    

Tengia-Kessy, Msamanga, Moshiro, 1998

591 women, 513 men, youth from community samples, Tanzania

Any alcohol use, attending drinking establishments

HIV testing

Alcohol use was prevalent but not associated with risk of HIV infection.

Mnyika et al., 1997

508 men and 1043 women in 1993 population based survey, Tanzania

Frequency of alcohol use on a 4-point scale, use of alcohol before sex

Number of sex partners in past month, 6 months, year, & 5 years; HIV testing

Alcohol use associated with multiple sex partners in men, but not women; for both men and women having sex after drinking was associated with multiple sex partners. Drinking before sex was related to testing HIV+ among women.

Clift et al., 2003

207 mineworkers, 2002 comparison men, 206 women working near mines, 205 comparison women, Tanzania

Dichotomous response whether or not consumes 15 drinks per week

STI symptoms and HIV testing

Testing HIV+ was independently associated with greater alcohol use.

Kapiga, Lyamuya, Lwihula, Hunter, 1998

2471 women family planning clinic patients, Tanzania

Any alcohol use

Number of sex partners; condom use; STI and HIV testing

Women who drank were more likely to report 3 or more partners at follow-up. Women who reported drinking increased risk of HIV.

Kapiga et al., 2002

312 women, Tanzania

Alcohol use once a week or at least twice a week

Number of sex partners; condom use; STI testing

Sexual risk was associated with increasing frequency of alcohol use, with greater risk for drinking twice or more a week than once a week

Kapiga et al., 2003

309 Women, 206 men, bar and hotel workers, Tanzania

Alcohol use once a week, twice a week, or more than twice a week

Number of sex partners; condom use; STI testing

Alcohol use by men once a week was associated with increased risk of STIs compared to non-drinkers, particularly risks for contracting HSV.

Uganda

    

Bailey et al., 1999

188 circumcised, 177 uncircumcised men, Uganda

Regular drinking, drinking at last extramarital sex

Sexual risk practices, STI history, HIV testing

Circumcised men engaged in more sexual risk practices including drinking at last extramarital sex. Drinking co-occurred with sexual risks and clustered in circumcised men.

Mbulaiteye, 2000

1286 women 1083 men from 15 rural neighboring villages, Uganda

Having ever drank, days visiting bars, alcohol use in past week, selling alcohol in house

Lifetime use of condoms, number of sex partners in past 12 month, HIV test

HIV prevalence in households where alcohol was sold was 15% compared to 8% among those living in households where alcohol was not sold; HIV+ persons reported greater lifetime use of alcohol

Koenig et al., 2004

5109 women, rural population based, Uganda

Alcohol consumption before sex by woman and their male partners

Age at first intercourse, partner having sex with others, sexually coercive experiences

One in three women and nearly 60% of male partners drank prior to sex; women who drank and women who reported their partner drank prior to sex were more likely to domestic violence.

Zambia

    

Morrison, Sunkutu, Musaba, Glover, 1997

41 women, 58 men, married couples Zambia

Alcohol use before sex

Number of sex partners; sexual exchange; STI and HIV testing

Own use but not husband use of alcohol before sex was strongly associated with STIs in women.

Jones et al., 2005

180 HIV+ women, 152 men partners Zambia

Alcohol use items taken from coping scale, alcohol use before sex

Frequency of intercourse

Ten percent of women and 19% of their partners reported using alcohol before sex.

Zimbabwe

    

Wilson, Chiroro, Lavelle, Mutero, 1989

100 women sex workers, 100 clients Zimbabwe

 

Women: condom use; Men clients: visits to sex workers, condom use

23% of women always & 27% often drank with client; 50% last client was drank; clients preferred to drink before sex

Gwati, 1995

120 men, Zimbabwe

Drank previous day and / or previous weekend

Treated for an STI

Men who drank were 7 times more likely to have had an STI.

Fritz et al. 2002

324 men attending beer halls, Zimbabwe

Number of drinking days and number of days drank to intoxication

Meeting partners in beer halls; sex while intoxicated; exchanged money for sex

HIV prevalence increased with greater frequency of drinking; 11% of men reporting no alcohol use were HIV+ as were 41% men that drank 15 or more of last 30 days. HIV prevalence and incidence was related to meeting sex partners in beer halls and sex while intoxicated.

Mataure et al., 2002

227 men, 78 women, 15–21 year old youth at nightclubs, bottle stores, Zimbabwe

History of alcohol use, sex after drinking in past 90 days, alcohol use at last sex, condom use

Sexual intercourse and condom use in past 90 days, meeting sex partners at drinking establishments

Sexual exchange is common I alcohol establishments. 60% of young women at drinking establishments usually meet sex partners there, 42% had sex after drinking in past 90 days.

Sebit, 2003

147 women, 47 men, Zimbabwe

AUDIT

Sex partners in last 5 yrs, STDs HIV test

HIV+ persons were somewhat more likely to use and misuse alcohol; AUDIT scores were not associated with HIV status

Lewis, 2005

5149 women, 4331 men, rural household survey, Zimbabwe

Number of beer hall visits in the last month

Frequency of sex; number of sex partners; STI symptoms; HIV testing

Visiting beer halls was related to greater lifetime sex partners; women and men age 17–24 who visited beer halls reported higher levels of risk behavior; Condom use was more frequent for women who went to beer halls; HIV infection was significantly associated with going to beer halls for men and women.

We structured our review in accordance with a conceptual model designed to explain alcohol-sexual risk associations in Africa (Morojele et al., 2006). The model includes factors that are common to biopsychosocial models of alcohol use and has been framed with direct relevance to alcohol use in southern Africa. As shown in Fig. 1, predictors of alcohol use, such as socio-cultural, community, and intrapersonal factors influence alcohol consumption which in turn has direct psychoactive effects. Alcohol therefore influences sexual risk behavior through its effects on cognitive processes (e.g., reasoning ability, judgment, and sense of responsibility). This framework also recognizes an array of factors that can moderate the effects of alcohol on sexual risk behavior, such as drinking environments, economic conditions, and sexual coercion. Morojele et al.'s conceptual model, therefore, provides a comprehensive framework for organizing empirical research on the association between alcohol use and sexual risks for HIV/AIDS. Although this model overlaps with past models of alcohol use, it is important to note that Morojele et al. (2006) constructed this model focusing on factors that are most relevant to African societies. Our review of the research literature therefore follows this framework for understanding the association between alcohol use and sexual risks in southern Africa.

Alcohol use and sexual risks

As many as 50% of people living in areas of southern Africa where HIV is most prevalent report current alcohol use (Shisana et al., 2005). Alcohol use is associated with STI and HIV prevalence. Studies in southern Africa have shown that testing positive for STIs (e.g., Gwati, Guli, & Todd, 1995; Shaffer, Njeri, Justice, Odero, & Tierney, 2004) and HIV (e.g., Ayisi et al., 2000; Shisana et al., 2005) are independently associated with alcohol use. Men are more likely to drink than women, but women are more likely to drink with their sex partners than are men (Morojele et al., 2004). For example, only 1% of HIV positive women themselves reported drinking before sex in their current relationship, but 19% reported that their current sex partner usually drinks before sex (Mataure et al., 2002). Although men are more likely to drink frequently than women, women drink in greater quantities. These gender differences in alcohol use illustrate one of several ways in which women's risks for HIV are attributable to men's behavior.

Populations that are at greatest risk for HIV/AIDS in southern Africa also have the greatest history of alcohol use. For example, among drug using commercial sex workers, 26% report that alcohol was the first drug they ever used, 51% had started drinking by age 17, and 18% drank daily (Wechsberg, 2005). Sexually transmitted infection (STI) clinic patients who are also at high risk for HIV commonly report drinking before sex (Simbayi et al., 2004a). Alcohol use is also associated with testing positive for an STI among women employed in Kenyan plantations (Feldblum et al., 2000), and daily alcohol use predicts incident STI diagnoses among Kenyan commercial sex workers (Yadav et al., 2005).

Although frequency of drinking is related to increased sexual risks, the number of times individuals drink appears less important in predicting sexual risks than does the quantity of alcohol consumed. Campbell et al. (2002) and Campbell (2003), for example, found that men and women who drink are significantly more likely to be HIV positive, but frequency of drinking was unrelated to HIV status. Morojele et al. (2004) also found that frequency of alcohol use was not associated with sexual risk behaviors, but quantity of alcohol consumed was related to having greater numbers of recent sex partners. People who drink more heavily and report being intoxicated in sexual situations also report less condom use and more concurrent sex partners, clearly demonstrating higher risk for HIV (Dunkle et al., 2004; Mataure et al., 2002; Mnyika, Klepp, Kvale, & Ole-King'ori, 1997; Zachariah et al., 2003).

In summary, people who drink alcohol in southern Africa are at higher risk for HIV than individuals who do not drink. The association between drinking and sexual risks is also observed across a wide array of populations. Any alcohol use at all and drinking greater quantities of alcohol are closely associated with HIV transmission risks in southern Africa.

Predictors of alcohol use

Following our conceptual framework presented in Fig. 1, several factors likely predict alcohol use in sexual contexts, including community norms, and intrapersonal characteristics. Unfortunately, relatively few studies have examined factors that predict alcohol use and sexual risks in Africa. Although people who drink often recognize the potential for alcohol to impair their judgment and therefore increase their risks for STI/HIV, this awareness does not necessarily translate to increased perceptions of personal risks for STI and HIV among drinkers (Lewis et al., 2005). Studies in southern Africa suggest that cognitive and personality factors are associated with alcohol-related sexual risks. Consistent with the gender differences in alcohol use discussed above, men are significantly more likely to expect that alcohol will increase their sexual desires, whereas women expect the opposite effects of alcohol on sexual desires. In addition, sexual enhancement expectations are related to greater numbers of sex partners and the number of times people regret having had sex (Morojele et al., 2004).

The most widely studied personality disposition related to both alcohol use and sexual risk behavior is sensation seeking (Hoyle, Fejfar, & Miller, 2000). Sensation seeking is defined as the propensity to seek optimal sensations through novel and arousing experiencing. The sensation seeking personality disposition reliably predicts engaging in an array of risk behaviors including sexual behaviors and alcohol use across cultures (Zuckerman, 1994). Kalichman et al. (2006) reported that sensation seeking predicts both alcohol use in sexual contexts and a cumulative index of HIV transmission risk factors among STI clinic patients in South Africa. The potential importance of underlying personality characteristics in predicting alcohol use and risk behavior is further supported by research that shows alcohol use is only one of several behaviors that cluster together to increase risk for HIV transmission (Bailey, Neema, & Othieno, 1999). Drinking alcohol as a means of coping with stress is also related to engaging in higher risk behaviors for HIV transmission (Jones, Ross, Weiss, Bhat, & Chitalu, 2005; Wechsberg, Luseno, & Lam, 2005). Lifestyles that are characterized by alcohol use, especially heavy drinking, can therefore compound HIV risk through multiple channels (Morojele et al., 2004).

Psychoactive effects of alcohol

Few studies have examined alcohol's direct effects on thoughts and behaviors in relation to sexual risks in Africa. One qualitative study conducted with STI clinic patients found that alcohol use to the point of intoxication was believed to lower sexual inhibitions and created barriers to using condoms among both men and women (Simbayi, Mwaba, & Kalichman, 2006). This finding is consistent with studies that report that greater quantities of alcohol consumption are associated with engaging in unprotected sex as well as other risk behaviors in southern Africa (Wechsberg et al., 2005). Unfortunately, no research conducted in Africa has yet investigated the actual psychoactive effects of alcohol and related mechanisms on subsequent risks for HIV transmission.

Moderating factors

In our conceptual model, moderating factors are the forces that influence the use of alcohol and its relationship to HIV risks, including environmental factors, economics, and sexual coercion (Morojele et al., 2006).

Drinking environments

Businesses and venues that serve alcohol are often the very places that link alcohol use with risk for HIV infection. Informal alcohol serving establishments, such as private homes where alcoholic beverages are sold and served, are also often the same places where sex partners meet (Morojele et al., 2004). Research conducted in South Africa has demonstrated the close association between patronizing shebeens and HIV risks. Weir et al. (2003) mapped the linkages among places where people meet new sex partners and places where people drink alcohol. The study demonstrated a remarkable overlap among these venues; over 85% of the locations where people meet sex partners are alcohol serving establishments. The overlap was observed in both urban and rural areas. Across three cities, between 78% and 87% of new sex partners were met at shebeens. As many as 57% of men and 46% of women who drink at shebeens report having two or more sex partners in the past two weeks. Unfortunately, shebeens and other alcohol serving establishments, such as taverns and bottle stores, rarely have condoms available for their customers (Weir et al., 2003).

In Ugandan villages, 4% of people live in homes that sell alcohol but 15% of people living in these homes are HIV positive, nearly double HIV prevalence in the surrounding community (Mbulaiteye et al., 2000). HIV risks are notably higher for people who go to nightclubs, bottle stores, and taverns (Lewis et al., 2005; Mataure et al., 2002). The most studied drinking places in relation to HIV risks in Africa are beer halls; large social venues that primarily serve beer. HIV prevalence is as much as two times higher among men in Zimbabwe who attend beer halls than among men in the general Zimbabwe population (Bassett et al., 1996). Sixty percent of men and 41% of women who report having multiple current sex partners drink at beer halls (Lewis et al., 2005). Fritz et al. (2002) demonstrated that HIV prevalence increases with greater use of alcohol in beer halls. The number of days of the week that men drink correlates with their frequency of engaging in unprotected sex with casual partners.

In addition to their patrons, employees of alcohol serving establishments demonstrate considerable risks for HIV infection. Kapiga et al. (2003) reported that men who work in Tanzanian bars and hotels and drink at least once a week were significantly more likely to have Herpes Simplex Virus, a known marker for HIV transmission, than their male co-workers who did not drink. Similarly, women who work in food and recreational businesses near gold mines and drink are significantly more likely to have HIV and other STI than other women who drink in the communities that surround the mines but do not work in food and recreation businesses (Clift et al., 2003).

The connection between alcohol serving establishments and sexual risks for HIV is at least in part a function of drinking in sexual networking contexts. Drinking before sex is more common with non-regular than with regular sex partners (Myer, Matthews, & Little, 2002). Drinking establishments may amplify HIV transmission risks by providing a place where high-risk sex encounters can easily unfold (Fritz et al., 2002). Alcohol establishments are often themselves sex venues, where back rooms, back corners, and adjacent buildings or shacks offer locations for sex (Morojele et al., 2006). Places that serve alcohol therefore appear uniquely linked to HIV transmission risks in southern Africa.

Economic conditions

Both HIV infection and alcohol use are most concentrated in areas of poverty. Although poverty may well be the foundation for the association between alcohol use and HIV risks in southern Africa, there is surprisingly little research on the connection between poverty, alcohol use, and HIV infection in this region. One factor that connects poverty to alcohol and HIV risk is transactional sex (e.g., exchanging sex for money or to meet survival needs). Poverty and unemployment foster both substance use and commercial sex work. In fact, transactional sex in Africa is directly related to alcohol use (Dunkle et al., 2004). For example, among women who meet sex partners in shebeens and taverns, nearly half say that their sex partners buy them drinks for sex. The exchange of alcohol or gifts for sex is most common between older men and younger women (Mataure et al., 2002). Women who are involved in sexual exchange are at greatest risk when they work in bars or nightclubs as compared to women who exchange sex in homes (Yadav et al., 2005).

The pressures of living in poverty are related to drinking and risks for HIV infection beyond the risks associated with transactional sex. Research conducted in three urban communities in Cape Town, for example, found that sexual risk behaviors were related to perceived stress of poverty (Kalichman et al., 2006). Individuals who perceived greater stress resulting from violence, crime, and discrimination reported greater risks for HIV infection. In this study, alcohol use was related to both perceived stress and HIV risk behavior. Importantly, alcohol use did not account for the association between perceptions of poverty-related social problems and HIV risk behaviors. Perceptions of poverty and alcohol use are therefore related to each other and both are associated with HIV risk behaviors.

Sexual coercion

Sexual assault is prevalent in southern Africa and sexual violence is related to alcohol use and HIV transmission risks (Dunkle et al., 2004; Jewkes, Levin, & Penn-Kekana, 2002). Men who have a history of sexual violence are more likely to drink than men who have not been sexually assaultive (Abrahams, Jewkes, Hoffman, & Laubsher, 2004). Likewise, alcohol use is associated with having been sexually assaulted among women (King et al., 2004). In Uganda, for example, half of women who had been abused reported that their partner drank and one in four reported that their partner drank frequently (Koenig et al., 2003). The association between relationship violence and HIV risk is at least partly accounted for by alcohol use (Phorano, Nthomang, & Ntseane, 2005). Although it is clear that alcohol consumption and sexual violence are related, their temporal association is less clear. That is alcohol use may precede or follow sexual violence. The power dynamics between men and women are known to foster HIV risk behaviors in southern Africa and alcohol can be used as an instrument for leveraging power in these relationships.

Methodological considerations

Table 1 describes the measures and samples reported in studies of alcohol use in relation to sexual risk behavior in southern Africa. This literature is composed mostly of cross-sectional studies that have relied on self-reported alcohol use and sexual behavior. Findings are therefore constrained in terms of their ability to draw causal conclusions and all reports of behavior in this literature must be interpreted with caution. What the literature is most seriously missing are longitudinally designed studies between alcohol use and sexual risks. Only with prospective research can the temporal associations between alcohol use and sexual risk behaviors be disentangled. For example, ecological momentary assessments can record drinking and sexual behavior on a daily basis, as well as mediating factors such as mood, stress, and relationship events. Timeline follow-back assessment procedures can similarly determine the temporal sequence and causal links of alcohol use and sexual risk behaviors.

The research in this area is also limited by sampling constraints. Although some studies have used large samples drawn from general populations, most studies have relied on small convenience samples, particularly of individuals recruited from alcohol serving establishments. In some cases, survey venues were selected explicitly because they serve alcohol and are known as locations where sexual partners meet, such as taverns, beer halls, and informal drinking establishments. Studies have typically included questions about drinking within a more comprehensive behavioral survey that also included questions about sexual risk behavior.

Studies of alcohol use and sexual risk behavior have also varied in their strategies for measuring drinking and its relationship to sexual risk. Measures of alcohol use have included global retrospective accounts without attention to frequency or quantity of alcohol use; i.e., any use of alcohol in the past or any current use of alcohol. In contrast to measures of global alcohol use, event level analyses afford a greater degree of precision in estimating alcohol use in relation to sexual behavior (Weinhardt & Carey, 2001). Unfortunately, few studies have assessed alcohol at the event level and have therefore been unable to examine drinking in proximity to sexual risk behaviors. In one exceptional study that could be considered a model for event level analysis, Myer et al. (2002) investigated over 3,200 sexual events reported by 384 individuals, allowing for a direct examination of condom use during sexual episodes which did and did not involve alcohol over the course of a two-week period. This study therefore directly tested the hypothesis as to whether sexual risks co-occur with alcohol use.

Some studies we reviewed asked participants to report whether they had drank at all in a specified time period. Studies also examined substance use by collapsing alcohol use with the use of any other drugs (Dunkle et al., 2004). Studies have also defined drinking as a lifestyle characteristic (e.g., Hargreave et al., 2002). It is often not possible to differentiate alcohol use from alcohol abuse and dependence although the distinction is important in understanding HIV risks. Similar problems are common in measuring of sexual risk behavior in this literature. Some studies in our review defined sexual behavior in equally vague terms, such as ``having ever had a relationship'' (e.g., Mugisha & Zulu, 2004). More recent research has included measures of alcohol use in sexual contexts and there are increasing numbers of studies that include brief, standardized tests of alcohol use and misuse, such as the Alcohol Use Disorders Identification Test (AUDIT, Saunders, Aasland, Babor, DeLaFuente, & Gran,t, 1993). These studies offer greater precision in describing alcohol use as well as its association to sexual risks.

Implications for future research

Most of the research available in the current literature included measures of alcohol and sexual risk behavior as part of studies that were not focused on their association. Thus, most study findings are based on a few imprecise measures of alcohol and sexual risks. There is a great need for research that uses well defined and standard measures of alcohol and sexual risk behavior to confirm and refine the observed associations. At minimum, alcohol measures must distinguish between alcohol use, alcohol abuse, and alcohol dependence and sexual behavior, all assessed within the same time frame. Research is also needed to examine alcohol use in relation to sexual behavior using prospective study designs as well as research conducted at the event level, the two types of studies that are most effective at disentangling confounding factors from the alcohol and sexual behavior association.

The mechanisms that account for the associations between alcohol and risks have not been widely studied in southern Africa. Factors such as personality dispositions, alcohol expectancies, sexual coercion and the connection between drinking and poverty warrant further study. Future research is most urgently needed to test the efficacy of interventions designed to reduce HIV risks, particularly risk-related alcohol use among populations at greatest risk for HIV infection. There is a particular need for interventions that target alcohol use as a risk factor for HIV transmission. Interventions should also be tested that target men and women who drink, especially those who frequent alcohol serving establishments.

Implications for HIV prevention interventions

The direct and indirect effects of alcohol on sexual risk behavior offer multiple opportunities for HIV prevention. Interventions can be designed to reduce alcohol use in relation to sexual behavior as well as target predictors and moderators of the association between alcohol use and sexual risks.

At the individual level, HIV prevention and alcohol reduction interventions can be integrated into existing counseling services, such as counseling for HIV risk reduction in clinic settings, HIV counseling and testing services, and substance abuse treatment. Brief prevention counseling models for HIV risk reduction have demonstrated positive effects in southern Africa and could be adapted to integrate brief education and counseling for reducing risks associated with alcohol use (Allen et al., 1992; Simbayi et al., 2004b). One approach to brief alcohol treatment that can feasibly be integrated with brief HIV risk reduction counseling is the World Health Organization's brief alcohol counseling model (Babor et al., 1992). This model uses the AUDIT to define levels of alcohol risk and tailors alcohol reduction counseling to these levels. Brief integrated HIV risk reduction and alcohol treatment counseling may be a viable strategy for targeting particularly high risk populations, such as persons undergoing HIV counseling and testing, women in antenatal clinics, and STI clinic patients.

Social level interventions can target families, schools, churches and other social and cultural institutions. Families have become a common target for both substance abuse prevention and HIV prevention interventions and these approaches have started to be adapted for use in southern Africa. For example, the Collaborative HIV/AIDS and Adolescent Mental Health Program (CHAMP) has been adapted for use in South Africa (Bhana et al., 2003). In this model, youth, their families, schools and other elements of the community are targeted for reducing sexual risks by increasing knowledge, enhancing motivations, and building risk reduction skills. This model is already being tested in South Africa and provides an opportunity for addressing alcohol-related HIV risks (Bhana et al., 2003).

At the structural level, HIV prevention interventions can be implemented in alcohol serving establishments. By integrating HIV prevention into well-established and frequently attended social institutions, such as beer halls, shebeens, and taverns HIV prevention activities have the potential to reach large numbers of persons at greatest risk for HIV infection. Fritz et al. (2002) reported that beer hall owners express interest in the possibility of implementing HIV prevention interventions in their businesses, suggesting that there is an opportunity for HIV prevention interventions to be delivered in alcohol serving businesses. Condoms can be made accessible in drinking establishments with minimal disruption to the environment and can be promoted with simple messages displayed in small media such as posters or brochures. More intensive intervention models, such as Kelly et al.'s (1991, 1992) Popular Opinion Leader (POL) intervention demonstrated positive effects when delivered to gay and bisexual men attending bars in US cities. These models are particularly compelling for alcohol serving establishments because of the overlap between social and sexual networks that develop in these settings. Culturally adapted multi-level alcohol – HIV risk reduction interventions for use in southern Africa should remain a top public health priority.

Footnotes
1

We collectively include Uganda, Kenya and Tanzania, which are East African countries, along with southern African countries as southern Africa throughout.

 

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© Society of Prevention Research 2007