AIDS and Behavior

, Volume 22, Issue 9, pp 2840–2850 | Cite as

Associations with Unprotected Sexual Behavior Among HIV-Infected Drinkers in Western Kenya

  • Rebecca K. PapasEmail author
  • Benson N. Gakinya
  • Michael M. Mwaniki
  • Xiaotian K. Wu
  • Hana Lee
  • Steve Martino
  • Debra A. Klein
  • John E. Sidle
  • Michelle P. Loxley
  • Alfred K. Keter
  • Joyce B. Baliddawa
  • Stephen A. Maisto
Original Paper


Approximately 71% of HIV-infected individuals live in sub-Saharan Africa. Alcohol use increases unprotected sex, which can lead to HIV transmission. Little research examines risky sex among HIV-infected individuals in East Africa who are not sex workers. The study purpose was to examine associations with unprotected sex in a high-risk sample of 507 HIV-infected sexually active drinkers in western Kenya. They were enrolled in a trial to reduce alcohol use. Past-month baseline alcohol use and sexual behavior were assessed using the Timeline Followback. A zero-inflated negative binomial model examined associations with occurrence and frequency of unprotected sex. Results showed heavy drinking days were significantly associated with unprotected sex occurrence across gender, and with unprotected sex frequency among women. Among women, transactional sex, alcohol-related sexual expectations, condom use self-efficacy, drinking-and-protected-sex days and age were associated with unprotected sex occurrence while alcohol-related sexual expectations, depressive symptoms and condom use self-efficacy were associated with unprotected sex frequency. Among men, alcohol-related sexual expectations, condom use self-efficacy, and age were associated with unprotected sex occurrence, while drinking-and-protected-sex days were associated with unprotected sex occurrence and frequency. Findings suggest robust relationships between heavy drinking and unprotected sex. Further research is needed elucidating the temporal relationships between drinking and unprotected sex in this population.


HIV Alcohol Unprotected sex Transactional sex Kenya 



This research was funded by Grant R01AA020805 from the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA). It was also supported in part by a grant to the USAID-AMPATH Partnership from the United States Agency for International Development as part of the President’s Emergency Plan for AIDS Relief. Preparation of this manuscript was supported in part by NIAAA Grant 2K05 16928. We extend our appreciation to Chematics, Inc. of North Webster, Indiana for the generous donation of alcohol saliva tests for this project. We thank the participants for their role in this project.

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    UNAIDS. The joint United Nations programme on HIV/AIDS. The gap report. (2014). Accessed 8 Sept 2017.
  2. 2.
    Othieno CJ, Kathuku DM, Ndetei DM. Substance abuse in outpatients attending rural and urban health centres in Kenya. East Afr Med J. 2000;77(11):592–5.PubMedGoogle Scholar
  3. 3.
    Saunders JB, Aasland OG, Amundsen A, Grant M. Alcohol consumption and related problems among primary health care patients: WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-I. Addiction. 1993;88:349–62.PubMedCrossRefGoogle Scholar
  4. 4.
    Papas RK, Sidle JE, Wamalwa ES, et al. Estimating alcohol content of traditional brew in Western Kenya using culturally relevant methods: the case for cost over volume. AIDS Behav. 2010;14(4):836–44.PubMedCrossRefGoogle Scholar
  5. 5.
    Shaffer DN, Njeri R, Justice AC, Odero WW, Tierney WM. Alcohol abuse among patients with and without HIV infection attending public clinics in western Kenya. East Afr Med J. 2004;81(11):594–8.PubMedGoogle Scholar
  6. 6.
    Ayisi JG, van Eijk AM, ter Kuil OF, et al. Risk factors for HIV infection among asymptomatic pregnant women attending an antenatal clinic in western Kenya. Int J STD & AIDS. 2000;11:393–401.CrossRefGoogle Scholar
  7. 7.
    Hargreves JR. Socioeconomic status and risk of HIV infection in an urban population in Kenya. Trop Med Int Health. 2002;7:793–802.CrossRefGoogle Scholar
  8. 8.
    Feldblum PJ, Kuyoh M, Omari M, Ryan KA, Bwayo JJ, Welsh M. Baseline STD prevalence in a community intervention trial of the female condom in Kenya. Sex Transm Infect. 2000;76:454–6.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Steele CM, Josephs RA. Alcohol myopia: its prized and dangerous effects. Am Psychol. 1990;45(8):921.PubMedCrossRefGoogle Scholar
  10. 10.
    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.PubMedCrossRefGoogle Scholar
  11. 11.
    Morojele NK, Kachieng’a MA, Nkoko MA, et al. Perceived effects of alcohol use on sexual encounters among adults in South Africa. Afr J Drug Alcohol Stud. 2004;3(1):1–20.Google Scholar
  12. 12.
    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 Synd. 2008;49(2):219–26.CrossRefGoogle Scholar
  13. 13.
    Medley A, Seth P, Pathak S, et al. Alcohol use and its association with HIV risk behaviors among a cohort of patients attending HIV clinical care in Tanzania, Kenya, and Namibia. AIDS Care. 2014;26(10):1288–97.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Leigh BC. Alcohol expectancies. Psychol Addict Behav. 1990;4:91–6.CrossRefGoogle Scholar
  15. 15.
    Leigh BC. The relationship of sex-related alcohol expectancies to alcohol consumption and sexual behavior. Br J Addict. 1990;85(7):919–28.PubMedCrossRefGoogle Scholar
  16. 16.
    Kalichman SC, Simbayi LC, Cain D, Jooste S. Alcohol expectancies and risky drinking among men and women at high-risk for HIV infection in Cape Town South Africa. Addict Behav. 2007;32(10):2304–10.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Brien TM, Thombs DL, Mahoney CA, Wallnau L. Dimensions of self-efficacy among three distinct groups of condom users. J Am Coll Health. 1994;42(4):167–74.PubMedCrossRefGoogle Scholar
  18. 18.
    Wagner GJ, Holloway I, Ghosh-Dastidar B, Ryan G, Kityo C, Mugyenyi P. Factors associated with condom use among HIV clients in stable relationships with partners at varying risk for HIV in Uganda. AIDS Behav. 2010;14(5):1055–65.PubMedCrossRefGoogle Scholar
  19. 19.
    Jama Shai N, Jewkes R, Levin J, Dunkle K, Nduna M. Factors associated with consistent condom use among rural young women in South Africa. AIDS Care. 2010;22(11):1379–85.PubMedCrossRefGoogle Scholar
  20. 20.
    Onoya D, Reddy PS, Ruiter RA, Sifunda S, Wingood G, van den Borne B. Psychosocial correlates of condom use consistency among Isixhosa-speaking women living with HIV in the Western Cape Province of South Africa. J Health Psychol. 2011;16(8):1208–20.PubMedCrossRefGoogle Scholar
  21. 21.
    Council National Aids Control. UNGASS 2008 country report for Kenya. Nairobi: NACC; 2008.Google Scholar
  22. 22.
    Simbayi LC, Kalichman SC, Strebel A, Cloete A, Henda N, Mqeketo A. Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa. Sex Transm Infect. 2007;83(1):29–34.PubMedCrossRefGoogle Scholar
  23. 23.
  24. 24.
    Weiser SD, Leiter K, Bangsberg DR, et al. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland. PLoS Med. 2007;4(10):e260.PubMedCentralCrossRefGoogle Scholar
  25. 25.
    Robinson J, Yeh E. Transactional sex as a response to risk in western Kenya. Am Econ J Appl Econ. 2011;3(1):35–64.CrossRefGoogle Scholar
  26. 26.
    Muchomba FM, Wang JS, Agosta LM. Women’s land ownership and risk of HIV infection in Kenya. Soc Sci Med. 2014;114:97–102.PubMedCrossRefGoogle Scholar
  27. 27.
    Berhan A, Berhan Y. Is the sexual behaviour of HIV patients on antiretroviral therapy safe or risky in sub-Saharan Africa? Meta-analysis and meta-regression. AIDS Res Ther. 2012;9(1):14.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Ostrow DE, Fox KJ, Chmiel JS, et al. Attitudes towards highly active antiretroviral therapy are associated with sexual risk taking among HIV-infected and uninfected homosexual men. AIDS. 2002;16(5):775–80.PubMedCrossRefGoogle Scholar
  29. 29.
    Stolte IG, Dukers NH, Geskus RB, Coutinho RA, de Wit JB. Homosexual men change to risky sex when perceiving less threat of HIV/AIDS since availability of highly active antiretroviral therapy: a longitudinal study. AIDS. 2004;18(2):303–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Mujugira A, Celum C, Ngure K, Thomas KK, Katabira E, Baeten JM. Antiretroviral therapy initiation is not associated with risky sexual behavior among heterosexual human immunodeficiency virus-infected persons in serodiscordant partnerships. Sex Transm Dis. 2017;44(1):57–61.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Kiene SM, Lule H, Sileo KM, Silmi KP, Wanyenze RK. Depression, alcohol use, and intimate partner violence among outpatients in rural Uganda: vulnerabilities for HIV, STIs and high risk sexual behavior. BMC Infect Dis. 2017;17(1):88.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Sikkema KJ, Watt MH, Meade CS, et al. Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa. J Acquir Immune Defic Syndr. 2011;57(3):230–7.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Einterz RM, Kimaiyo S, Mengech HNK, et al. Responding to the HIV pandemic: the power of an academic medical partnership. Acad Med. 2007;82(812):818.Google Scholar
  34. 34.
    Mamlin J, Kimaiyo S, Nyandiko W, Tierney W, Einterz R. Academic institutions linking access to treatment and prevention: case study. Geneva: World Health Organization; 2004.Google Scholar
  35. 35.
    Gordon AJ, Maisto SA, McNeil M, et al. Three questions can detect hazardous drinkers. J Fam Pract. 2001;50(4):313–20.PubMedGoogle Scholar
  36. 36.
    Saunders JB, Aasland OG, Babor TF, DeLaFuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88:791–804.PubMedCrossRefGoogle Scholar
  37. 37.
    World Health Organization. WHO—Process of translation and adaptation of instruments. (2009). Accessed 11 Aug 2016.
  38. 38.
    Papas RK, Sidle JE, Martino S, et al. Systematic cultural adaptation of cognitive-behavioral therapy to reduce alcohol use among HIV-infected outpatients in western Kenya. AIDS Behav. 2010;14(3):669–78.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Maisto SA, Sobell LC, Sobell MB. Comparison of alcoholics’ self-reports of drinking behavior with reports of collateral informants. J Consult Clin Psychol. 1979;47(1):106–12.PubMedCrossRefGoogle Scholar
  40. 40.
    Sobell LC, Maisto SA, Sobell MB, Cooper AM. Reliability of alcohol abusers’ self-reports of drinking behavior. Behav Res Ther. 1979;17(2):157–60.PubMedCrossRefGoogle Scholar
  41. 41.
    Sobell LC, Sobell MB. Timeline followback: a technique for assessing self-reported alcohol consumption. In: Litten RZ, editors. Measuring alcohol consumption, vol. 1st. Totowa: Humana Press; 1992. p. 41–72.CrossRefGoogle Scholar
  42. 42.
    Sobell LC, Sobell MB, Leo GI, Cancilla A. Reliability of a timeline method: assessing normal drinkers’ reports of recent drinking and a comparative evaluation across several populations. Br J Addict. 1988;83(4):393–402.PubMedCrossRefGoogle Scholar
  43. 43.
    Papas RK, Sidle JE, Gakinya BN, et al. Treatment outcomes of a stage 1 cognitive-behavioral trial to reduce alcohol use among human immunodeficiency virus-infected out-patients in western Kenya. Addiction. 2011;106(12):2156–66.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    NIAAA. Helping patients who drink too much: a clinician’s guide. (2005). Accessed 1 Sept 2016.
  45. 45.
    Reece M, Shacham E, Monahan P, et al. Psychological distress symptoms of individuals seeking HIV-related psychosocial support in western Kenya. AIDS Care. 2007;19(10):1194–200.PubMedCrossRefGoogle Scholar
  46. 46.
    Kingori C, Reece M, Obeng S, et al. Psychometric evaluation of a cross-culturally adapted felt stigma questionnaire among people living with HIV in Kenya. AIDS Patient Care STDS. 2013;27(8):481–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Monahan PO, Shacham E, Reece M, et al. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya. J Gen Intern Med. 2009;24(2):189–97.PubMedCrossRefGoogle Scholar
  49. 49.
    Asante KO, Doku PN. Cultural adaptation of the Condom Use Self Efficacy Scale (CUSES) in Ghana. BMC Public Health. 2010;10(1):227.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Vuong QH. Likelihood ratio tests for model selection and non-nested hypotheses. Econometrica. 1989;57:307–33.CrossRefGoogle Scholar
  51. 51.
    Shuper PA, Joharchi N, Irving H, Rehm J. Alcohol as a correlate of unprotected sexual behavior among people living with HIV/AIDS: review and meta-analysis. AIDS Behav. 2009;13(6):1021–36.PubMedCrossRefGoogle Scholar
  52. 52.
    Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Soc Sci Med. 2004;59(8):1581–92.PubMedCrossRefGoogle Scholar
  53. 53.
    Amuyunzu-Nyamongo M, Okeng’O L, Wagura A, Mwenzwa E. Putting on a brave face: the experiences of women living with HIV and AIDS in informal settlements of Nairobi, Kenya. AIDS Care. 2007;19(sup1):25–34.CrossRefGoogle Scholar
  54. 54.
    Weinhardt LS, Carey MP. Does alcohol lead to sexual risk behavior? Findings from event-level research. Annu Rev Sex Res. 2000;11:125–57.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Odek WO, Busza J, Morris CN, Cleland J, Ngugi EN, Ferguson AG. Effects of micro-enterprise services on HIV risk behaviour among female sex workers in Kenya’s urban slums. AIDS Behav. 2009;13(3):449.PubMedCrossRefGoogle Scholar
  56. 56.
    Kim J, Ferrari G, Abramsky T, et al. Assessing the incremental effects of combining economic and health interventions: the IMAGE study in South Africa. Bull World Health Org. 2009;87(11):824–32.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Rebecca K. Papas
    • 1
    Email author
  • Benson N. Gakinya
    • 2
  • Michael M. Mwaniki
    • 3
  • Xiaotian K. Wu
    • 4
  • Hana Lee
    • 4
  • Steve Martino
    • 5
  • Debra A. Klein
    • 6
  • John E. Sidle
    • 7
  • Michelle P. Loxley
    • 4
  • Alfred K. Keter
    • 3
  • Joyce B. Baliddawa
    • 2
  • Stephen A. Maisto
    • 8
  1. 1.Department of Psychiatry and Human BehaviorAlpert Medical School of Brown UniversityProvidenceUSA
  2. 2.School of MedicineMoi University College of Health SciencesEldoretKenya
  3. 3.Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
  4. 4.Brown University School of Public HealthProvidenceUSA
  5. 5.Yale University School of MedicineNew HavenUSA
  6. 6.Right Response LLCMinneapolisUSA
  7. 7.Indiana University School of MedicineIndianapolisUSA
  8. 8.Syracuse UniversitySyracuseUSA

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