AIDS and Behavior

, Volume 13, Issue 6, pp 1021–1036 | Cite as

Alcohol as a Correlate of Unprotected Sexual Behavior Among People Living with HIV/AIDS: Review and Meta-Analysis

  • Paul A. Shuper
  • Narges Joharchi
  • Hyacinth Irving
  • Jürgen Rehm
Original Paper


The present investigation attempted to quantify the relationship between alcohol consumption and unprotected sexual behavior among people living with HIV/AIDS (PLWHA). A comprehensive search of the literature was performed to identify key studies on alcohol and sexual risk behavior among PLWHA, and three separate meta-analyses were conducted to examine associations between unprotected sex and (1) any alcohol consumption, (2) problematic drinking, and (3) alcohol use in sexual contexts. Based on 27 relevant studies, meta-analyses demonstrated that any alcohol consumption (OR = 1.63, CI = 1.39–1.91), problematic drinking (OR = 1.69, CI = 1.45–1.97), and alcohol use in sexual contexts (OR = 1.98, CI = 1.63–2.39) were all found to be significantly associated with unprotected sex among PLWHA. Taken together, these results suggest that there is a significant link between PLWHA’s use of alcohol and their engagement in high-risk sexual behavior. These findings have implications for the development of interventions to reduce HIV transmission risk behavior in this population.


Alcohol Condoms HIV Meta-analysis Sexual behavior 



The research was funded by the South African Medical Research Council (MRC) through a grant received from the US President’s Emergency Fund for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. We would also like to thank Dr. Charles Parry at the MRC for his comments on this manuscript, and we are grateful to delegates of the MRC/CDC Alcohol and Infectious Diseases Technical Meeting (July 2008, Cape Town, South Africa) for their feedback regarding this project.


  1. 1.
    UNAIDS. Joint United Nations Programme on HIV/AIDS. Report on the global AIDS epidemic. UNAIDS 2008.Google Scholar
  2. 2.
    Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological, and medical findings. AIDS. 2002;16(2):135–49.CrossRefPubMedGoogle Scholar
  3. 3.
    Kalichman SC. HIV transmission risk behaviors of men and women living with HIV-AIDS: prevalence, predictors, and emerging clinical interventions. Clin Psychol Sci Pract. 2000;7:32–47.CrossRefGoogle Scholar
  4. 4.
    Halkitis PN, Parsons JT. Intentional unsafe sex (barebacking) among HIV-positive gay men who seek sexual partners on the internet. AIDS Care. 2003;15(3):367–78.CrossRefPubMedGoogle Scholar
  5. 5.
    Cook RL, Sereika SM, Hunt SC, Woodward WC, Erlen JA, Conigliaro J. Problem drinking and medication adherence among persons with HIV infection. J Gen Intern Med. 2001;16(2):83–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Galvan FH, Bing EG, Fleishman JA, et al. The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV cost and services utilization study. J Stud Alcohol. 2002;63(2):179–86.PubMedGoogle Scholar
  7. 7.
    Marston C, King E. Factors that shape young people’s sexual behaviour: a systematic review. Lancet. 2006;368(9547):1581–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Dingle GA, Oei TP. Is alcohol a cofactor of HIV and AIDS? Evidence from immunological and behavioral studies. Psychol Bull. 1997;122(1):56–71.CrossRefPubMedGoogle Scholar
  9. 9.
    Steele CM, Josephs RA. Alcohol myopia its prized and dangerous effects. Am Psychol. 1990;45(8):921–33.CrossRefPubMedGoogle Scholar
  10. 10.
    MacDonald TK, MacDonald G, Zanna MP, Fong GT. Alcohol, sexual arousal, and intentions to use condoms in young men: applying alcohol myopia theory to risky sexual behavior. Health Psychol. 2000;19(3):290–8.CrossRefPubMedGoogle Scholar
  11. 11.
    MacDonald TK, Fong GT, Zanna MP, Martineau AM. Alcohol myopia and condom use: can alcohol intoxication be associated with more prudent behavior? J Pers Soc Psychol. 2000;78(4):605–19.CrossRefPubMedGoogle Scholar
  12. 12.
    Bryan A, Ray LA, Cooper ML. Alcohol use and protective sexual behaviors among high-risk adolescents. J Stud Alcohol Drugs. 2007;68(3):327–35.PubMedGoogle Scholar
  13. 13.
    Crowe LC, George WH. Alcohol and human sexuality: review and integration. Psychol Bull. 1989;105(3):374–86.CrossRefPubMedGoogle Scholar
  14. 14.
    George WH, Stoner SA. Understanding acute alcohol effects on sexual behavior. Annu Rev Sex Res. 2000;11:92–124.PubMedGoogle Scholar
  15. 15.
    Gordon CM, Carey MP, Carey KB. Effects of a drinking event on behavioral skills and condom attitudes in men: implications for HIV risk from a controlled experiment. Health Psychol. 1997;16(5):490–5.CrossRefPubMedGoogle Scholar
  16. 16.
    LaBrie J, Earleywine M, Schiffman J, Pedersen E, Marriot C. Effects of alcohol, expectancies, and partner type on condom use in college males: event-level analyses. J Sex Res. 2005;42(3):259–66.PubMedCrossRefGoogle Scholar
  17. 17.
    Maisto SA, Carey MP, Carey KB, Gordon CM. The effects of alcohol and expectancies on risk perception and behavioral skills relevant to safer sex among heterosexual young adult women. J Stud Alcohol. 2002;63(4):476–85.PubMedGoogle Scholar
  18. 18.
    Murphy ST, Monahan J, Miller LC. Inference under the influence: the impact of alcohol and inhibition conflict on women’s sexual decision making. Pers Soc Psychol Bull. 1998;24(5):517–28.CrossRefGoogle Scholar
  19. 19.
    Fisher JC, Bang H, Kapiga SH. The association between HIV infection and alcohol use: a systematic review and meta-analysis of African studies. Sex Transm Dis. 2007;34(11):856–63.CrossRefPubMedGoogle Scholar
  20. 20.
    Stall R, Leigh B. Understanding the relationship between drug or alcohol use and high risk sexual activity for HIV transmission: where do we go from here? Addiction. 1994;89(2):131–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Woolf SE, Maisto SA. Alcohol use and risk of HIV infection among men who have sex with men. AIDS Behav. [Epub ahead of print]. doi: 10.1007/s10461-007-9354-0.
  22. 22.
    Kalichman SC, Heckman T, Kelly JA. Sensation seeking as an explanation for the association between substance use and HIV-related risky sexual behavior. Arch Sex Behav. 1996;25(2):141–54.CrossRefPubMedGoogle Scholar
  23. 23.
    Kalichman SC, Weinhardt L, DiFonzo K, Austin J, Luke W. Sensation seeking and alcohol use as markers of sexual transmission risk behavior in HIV-positive men. Ann Behav Med. 2002;24(3):229–35.CrossRefPubMedGoogle Scholar
  24. 24.
    Zuckerman M. Behavioral expressions and biosocial bases of sensation seeking. New York, NY: Cambridge University Press; 1994.Google Scholar
  25. 25.
    Kalichman SC, Johnson JR, Adair V, Rompa D, Multhauf K, Kelly JA. Sexual sensation seeking: scale development and predicting AIDS-risk behavior among homosexually active men. J Pers Assess. 1994;62(3):385–97.CrossRefPubMedGoogle Scholar
  26. 26.
    Benotsch EG, Kalichman SC, Kelly JA. Sexual compulsivity and substance use in HIV-seropositive men who have sex with men: prevalence and predictors of high-risk behaviors. Addict Behav. 1999;24(6):857–68.CrossRefPubMedGoogle Scholar
  27. 27.
    Benotsch EG, Kalichman SC, Pinkerton SD. Sexual compulsivity in HIV-positive men and women: prevalence, predictors, and consequences of high-risk behaviors. Sex Addict Compuls. 2001;8(2):83–99.CrossRefGoogle Scholar
  28. 28.
    Kalichman SC, Rompa D. Sexual sensation seeking and sexual compulsivity scales: reliability, validity, and predicting HIV risk behavior. J Pers Assess. 1995;65(3):586–601.CrossRefPubMedGoogle Scholar
  29. 29.
    Kalichman SC, Cain D. The relationship between indicators of sexual compulsivity and high risk sexual practices among men and women receiving services from a sexually transmitted infection clinic. J Sex Res. 2004;41(3):235–41.PubMedGoogle Scholar
  30. 30.
    Leigh BC, Stall R. Substance use, risky sexual behavior for exposure to HIV. Issues in methodology, interpretation, and prevention. Am Psychol. 1993;48(10):1035–45.CrossRefPubMedGoogle Scholar
  31. 31.
    Halpern-Felsher BL, Millstein SG, Ellen JM. Relationship of alcohol use and risky sexual behavior: a review and analysis of findings. J Adolesc Health. 1996;19(5):331–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S. Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings. Prev Sci. 2007;8(2):141–51.CrossRefPubMedGoogle Scholar
  33. 33.
    Leigh BC, Morrison DM, Hoppe MJ, Beadnell B, Gillmore MR. Retrospective assessment of the association between drinking and condom use. J Stud Alcohol Drugs. 2008;69(5):773–6.PubMedGoogle Scholar
  34. 34.
    Leigh BC. Alcohol and condom use: a meta-analysis of event-level studies. Sex Transm Dis. 2002;29(8):476–82.CrossRefPubMedGoogle Scholar
  35. 35.
    Weinhardt LS, Carey MP. Does alcohol lead to sexual risk behavior? Findings from event-level research. Annu Rev Sex Res. 2000;11:125–57.PubMedGoogle Scholar
  36. 36.
    Cooper ML. Alcohol use and risky sexual behavior among college students and youth: evaluating the evidence. J Stud Alcohol. 2002;(Suppl 14):101–17.Google Scholar
  37. 37.
    Babor TF, Higgins-Biddle J, Saunders J, Monteiro M. AUDIT: the alcohol use disorders identification test: guidelines for use in primary health care. Geneva: World Health Organization; 2001.Google Scholar
  38. 38.
    McLellan A, Kushner H, Metzger D, et al. The fifth edition of the addiction severity index. J Subst Abuse Treat. 1992;9:199–213.CrossRefPubMedGoogle Scholar
  39. 39.
    National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Updated 2005. Accessed 8 Feb 2009.
  40. 40.
    Kiene SM, Simbayi LC, Abrams A, Cloete A, Tennen H, Fisher JD. High rates of unprotected sex occurring among HIV-positive individuals in a daily diary study in South Africa: the role of alcohol use. J Acquir Immune Defic Syndr. 2008;49(2):219–26.CrossRefPubMedGoogle Scholar
  41. 41.
    Kalichman SC, Rompa D, Cage M. Sexually transmitted infections among HIV seropositive men and women. Sex Transm Infect. 2000;76(5):350–4.CrossRefPubMedGoogle Scholar
  42. 42.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.CrossRefPubMedGoogle Scholar
  43. 43.
    Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.CrossRefPubMedGoogle Scholar
  44. 44.
    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.CrossRefPubMedGoogle Scholar
  45. 45.
    Egger M, Davey-Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.PubMedGoogle Scholar
  46. 46.
    Stata for Windows [computer program]. Version 10.1. College Station, TX: Stata Corporation; 2008.Google Scholar
  47. 47.
    Stein M, Herman DS, Trisvan E, Pirraglia P, Engler P, Anderson BJ. Alcohol use and sexual risk behavior among human immunodeficiency virus-positive persons. Alcohol Clin Exp Res. 2005;29(5):837–43.CrossRefPubMedGoogle Scholar
  48. 48.
    Purcell DW, Parsons JT, Halkitis PN, Mizuno Y, Woods WJ. Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men. J Subst Abuse. 2001;13(1–2):185–200.CrossRefPubMedGoogle Scholar
  49. 49.
    Purcell DW, Moss S, Remien RH, Woods WJ, Parsons JT. Illicit substance use, sexual risk, and HIV-positive gay and bisexual men: differences by serostatus of casual partners. AIDS. 2005;19(Suppl 1):S37–47.CrossRefPubMedGoogle Scholar
  50. 50.
    Morin SF, Steward WT, Charlebois ED, et al. Predicting HIV transmission risk among HIV-infected men who have sex with men: findings from the healthy living project. J Acquir Immune Defic Syndr. 2005;40(2):226–35.CrossRefPubMedGoogle Scholar
  51. 51.
    Kalichman SC. Psychological and social correlates of high-risk sexual behaviour among men and women living with HIV/AIDS. AIDS Care. 1999;11(4):415–27.CrossRefPubMedGoogle Scholar
  52. 52.
    Ehrenstein V, Horton NJ, Samet JH. Inconsistent condom use among HIV-infected patients with alcohol problems. Drug Alcohol Depend. 2004;73(2):159–66.CrossRefPubMedGoogle Scholar
  53. 53.
    Chuang CH, Liebschutz JM, Horton NJ, Samet JH. Association of violence victimization with inconsistent condom use in HIV-infected persons. AIDS Behav. 2006;10(2):201–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Bouhnik AD, Preau M, Lert F, et al. Unsafe sex in regular partnerships among heterosexual persons living with HIV: evidence from a large representative sample of individuals attending outpatients services in France. AIDS. 2007;21(Suppl 1):S57–62.CrossRefPubMedGoogle Scholar
  55. 55.
    Bouhnik AD, Preau M, Schiltz MA, et al. Unprotected sex in regular partnerships among homosexual men living with HIV: a comparison between sero-nonconcordant and seroconcordant couples. AIDS. 2007;21(Suppl 1):S43–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Brewer TH, Zhao W, Metsch LR, Coltes A, Zenilman J. High-risk behaviors in women who use crack: knowledge of HIV serostatus and risk behavior. Ann Epidemiol. 2007;17(7):533–9.CrossRefPubMedGoogle Scholar
  57. 57.
    Cook RL, McGinnis KA, Kraemer KL, et al. Intoxication before intercourse and risky sexual behavior in male veterans with and without human immunodeficiency virus infection. Med Care. 2006;44(8 Suppl 2):S31–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Darrow WW, Webster RD, Kurtz SP, Buckley AK, Patel KI, Stempel RR. Impact of HIV counseling and testing on HIV-infected men who have sex with men: the south beach health survey. AIDS Behav. 1998;2(2):115–26.CrossRefGoogle Scholar
  59. 59.
    Krupitsky EM, Horton NJ, Williams EC, et al. Alcohol use and HIV risk behaviors among HIV-infected hospitalized patients in St. Petersburg, Russia. Drug Alcohol Depend. 2005;79(2):251–6.CrossRefPubMedGoogle Scholar
  60. 60.
    Milam J, Richardson JL, Espinoza L, Stoyanoff S. Correlates of unprotected sex among adult heterosexual men living with HIV. J Urban Health. 2006;83(4):669–81.CrossRefPubMedGoogle Scholar
  61. 61.
    Moatti JP, Prudhomme J, Traore DC, et al. Access to antiretroviral treatment and sexual behaviours of HIV-infected patients aware of their serostatus in Cote d’Ivoire. AIDS. 2003;17(Suppl 3):S69–77.PubMedCrossRefGoogle Scholar
  62. 62.
    Olley BO, Seedat S, Gxamza F, Reuter H, Stein DJ. Determinants of unprotected sex among HIV-positive patients in South Africa. AIDS Care. 2005;17(1):1–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Palepu A, Raj A, Horton NJ, Tibbetts N, Meli S, Samet JH. Substance abuse treatment and risk behaviors among HIV-infected persons with alcohol problems. J Subst Abuse Treat. 2005;28(1):3–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Theall KP, Clark RA, Powell A, Smith H, Kissinger P. Alcohol consumption, ART usage and high-risk sex among women infected with HIV. AIDS Behav. 2007;11(2):205–15.CrossRefPubMedGoogle Scholar
  65. 65.
    Tucker JS, Kanouse DE, Miu A, Koegel P, Sullivan G. HIV risk behaviors and their correlates among HIV-positive adults with serious mental illness. AIDS Behav. 2003;7(1):29–40.CrossRefPubMedGoogle Scholar
  66. 66.
    Reilly T, Woo G. Predictors of high-risk sexual behavior among people living with HIV/AIDS. AIDS Behav. 2001;5(3):205–17.CrossRefGoogle Scholar
  67. 67.
    Niklowitz M, Eich-Hochli D. Is there a correlation between alcohol drinking and sexual risk taking? A discussion of conceptional aspects exemplified by HIV infected men with homosexual behavior [in German]. Soz Praventivmed. 1997;42(5):286–97.CrossRefPubMedGoogle Scholar
  68. 68.
    Kiene SM, Christie S, Cornman DH, et al. Sexual risk behaviour among HIV-positive individuals in clinical care in urban KwaZulu-Natal, South Africa. AIDS. 2006;20(13):1781–4.CrossRefPubMedGoogle Scholar
  69. 69.
    Godin G, Savard J, Kok G, Fortin C, Boyer R. HIV seropositive gay men: understanding adoption of safe sexual practices. AIDS Educ Prev. 1996;8(6):529–45.PubMedGoogle Scholar
  70. 70.
    Braithwaite RS, Conigliaro J, McGinnis KA, Maisto SA, Bryant K, Justice AC. Adjusting alcohol quantity for mean consumption and intoxication threshold improves prediction of nonadherence in HIV patients and HIV-negative controls. Alcohol Clin Exp Res. 2008;32(9):1645–51.CrossRefPubMedGoogle Scholar
  71. 71.
    Barta WD, Portnoy DB, Kiene SM, Tennen H, Abu-Hasaballah KS, Ferrer R. A daily process investigation of alcohol-involved sexual risk behavior among economically disadvantaged problem drinkers living with HIV/AIDS. AIDS Behav. 2008;12:729–40.CrossRefPubMedGoogle Scholar
  72. 72.
    Parsons JT, Vicioso K, Kutnick A, Punzalan JC, Halkitis PN, Velasquez MM. Alcohol use and stigmatized sexual practices of HIV seropositive gay and bisexual men. Addict Behav. 2004;29(5):1045–51.CrossRefPubMedGoogle Scholar
  73. 73.
    Parsons JT, Vicioso KJ, Punzalan JC, Halkitis PN, Kutnick A, Velasquez MM. The impact of alcohol use on the sexual scripts of HIV-positive men who have sex with men. J Sex Res. 2004;41(2):160–72.PubMedGoogle Scholar
  74. 74.
    Bogart LM, Collins RL, Kanouse DE, et al. Patterns and correlates of deliberate abstinence among men and women with HIV/AIDS. Am J Public Health. 2006;96(6):1078–84.CrossRefPubMedGoogle Scholar
  75. 75.
    Kalichman SC, Simbayi LC, Vermaak R, et al. Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town South Africa. Ann Behav Med. 2008;36(3):270–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Paul A. Shuper
    • 1
    • 2
  • Narges Joharchi
    • 1
  • Hyacinth Irving
    • 1
  • Jürgen Rehm
    • 1
    • 3
    • 4
  1. 1.Centre for Addiction and Mental HealthTorontoCanada
  2. 2.Department of PsychologyUniversity of TorontoTorontoCanada
  3. 3.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  4. 4.Institute for Clinical Psychology and PsychotherapyTU DresdenDresdenGermany

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