Couple Interdependence Impacts Alcohol Use and Adherence to Antiretroviral Therapy in Malawi
In sub-Saharan Africa, harmful alcohol use among male drinkers is high and has deleterious consequences on adherence to antiretroviral therapy (ART), HIV clinical outcomes, and couple relationship dynamics. We conducted in-depth qualitative interviews with 25 Malawian couples on ART to understand how relationships influence adherence to ART, in which alcohol use emerged as a major theme. Almost half of men (40%) reported current or past alcohol use. Although alcohol use was linked to men’s non-adherence, women buffered this harm by encouraging husbands to reduce alcohol use and by offering adherence support when men were drinking. Men’s drinking interfered with being an effective treatment guardian for wives on ART and also weakened couple support systems needed for adherence. Relationship challenges including food insecurity, intimate partner violence, and extramarital relationships appeared to exacerbate the negative consequences of alcohol use on ART adherence. In this setting, alcohol may be best understood as a couple-level issue. Alcohol interventions for people living with HIV should consider approaches that jointly engage both partners.
KeywordsCouples Alcohol Antiretroviral therapy Adherence Sub-Saharan Africa HIV/AIDS
The authors would like to thank the tireless efforts of the research staff at Invest in Knowledge in Malawi for data collection.
This study was funded by the National Institutes of Health under Grants K01MH107331 and T32DA13911.
Compliance with Ethical Standards
Conflict of interest
There are no conflicts of interest for any of the study authors.
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 was obtained from all individual participants included in the study.
- 18.Gotlib IH, McCabe SB. Marriage and psychopathology. In: Fincham F, Bradbury T, editors. The psychology of marriage. New York: Guilford; 1990. p. 226–57.Google Scholar
- 20.O’Farrell T, Rotunda R. Couples interventions and alcohol abuse. In: Halford W, Markman H, editors. Clinical handbook of marriage and couples interventions. Chichester: Wiley; 1997. p. 555–88.Google Scholar
- 22.World Health Organization. Global status report on alcohol and health. Geneva, Switzerland: World Health Organization; 2014.Google Scholar
- 27.Woolf-King S, Conroy A, Fritz K, et al. Alcohol use and relationship quality among South African couples: implications for couples-based HIV interventions. In: International AIDS conference, 18–22 July 2016, Durban, South Africa; 2016.Google Scholar
- 28.Kelley HH, Thibalt JW. Interpersonal relations: a theory of interdependence. New York: Wiley; 1978.Google Scholar
- 30.Rusbult C, Arriaga X. Interdependence theory. In: Duck S, editor. Handbook of personal relationships. 2nd ed. London: Wiley; 1997.Google Scholar
- 33.Singer M. A dose of drugs, a touch of violence, a case of AIDS, part 2: further conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 2006;34(1):39–53.Google Scholar
- 34.Singer M. A dose of durgs, a touch of violence, a case of AIDS: conceptualizing the SAVA epidemic. Free Inq Creat Sociol. 1996;24(2):99–110.Google Scholar
- 48.National Statistical Office (NSO) [Malawi] and ICF. Malawi Demographic and Health Survey 2015–2016. Zomba: NSO and ICF; 2017.Google Scholar
- 49.UNAIDS. UNAIDS Country Report on Malawi. http://www.unaids.org/en/regionscountries/countries/malawi. 2018.
- 50.Ministry of Health Malawi. 3rd Edition of the Malawi Guidelines for Clinical Management of HIV in Children and Adults. Malawi: Lilongwe; 2016.Google Scholar
- 52.Ritchie J, Lewis J, Nicholls CM, et al. Qualitative research practice: A guide for social science students and researchers. London: Sage; 2013.Google Scholar
- 54.Mugweni E, Pearson S, Omar M. Concurrent sexual partnerships among married Zimbabweans—implications for HIV prevention. Int J Women’s Health. 2015;7:819.Google Scholar