Alcohol Use and Sexual Risks for HIV/AIDS in Sub-Saharan Africa: Systematic Review of Empirical Findings
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- Kalichman, S.C., Simbayi, L.C., Kaufman, M. et al. Prev Sci (2007) 8: 141. doi:10.1007/s11121-006-0061-2
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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.
KeywordAlchohol and sexul risksHIV/AIDS PreventionSouthern Africa
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
Studies of alcohol use in relation to HIV transmission risks in southern Africa
HIV risk behaviors
related to alcohol
Associations between alcohol and sexual risks
52 women, 83 men, TB patients Botswana
Number of drinks per day, Drinks before sex
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.
Ayisi et al., 2000
2844 women, antenatal clinic patients, Kenya
Current use of alcohol determined from interview
Testing HIV+ was independently associated with current use of alcohol.
Feldblum, et al., 2000
1929 women plantation employees, Kenya
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
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%).
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.
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.
HIV Risk behaviors
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.
183 women sex workers South Africa
Number of drinks on typical drinking day; alcohol use with sex clients during last 30 days
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.
Tengia-Kessy, Msamanga, Moshiro, 1998
591 women, 513 men, youth from community samples, Tanzania
Any alcohol use, attending drinking establishments
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.
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.
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.
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.
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
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.
147 women, 47 men, Zimbabwe
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
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.
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).
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.
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 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.
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.
We collectively include Uganda, Kenya and Tanzania, which are East African countries, along with southern African countries as southern Africa throughout.