The Unaddressed Needs of Alcohol-Using Couples on Antiretroviral Therapy in Malawi: Formative Research on Multilevel Interventions


Alcohol use among HIV-positive individuals in sub-Saharan Africa directly impacts adherence to antiretroviral therapy and HIV outcomes. Few studies have examined approaches to reduce alcohol use among HIV-affected couples, despite evidence that alcohol use is a couple-level concern. We conducted a qualitative study with 23 alcohol-using couples to identify multilevel barriers and facilitators of alcohol use, and potential intervention options with couples. Data were analyzed at individual and dyadic levels using framework analysis. All couples were married and had at least one partner on ART. Men were the primary alcohol drinkers with few women reporting alcohol use. Most women tried to persuade their partners to reduce their alcohol intake and when unsuccessful, enlisted help from relatives and HIV care providers. Effective couple negotiation around men’s alcohol use was constrained by negative peer influence and men’s desire for friendship to cope with life stressors. Women were primarily concerned about the expense of alcohol and described how alcohol prevented the family from meeting basic needs and investing in the future. Alcohol use was described as a major barrier to ART adherence, but was also viewed as the cause of couple and family violence, extramarital partnerships, food insecurity, and poverty. We conclude that multilevel interventions based on couples’ needs and preferences are urgently needed. Couple-based intervention approaches could include provider-led alcohol counseling with couples, alcohol reduction support groups for couples, couples’ counseling to bolster couple communication and problem-solving around alcohol, and economic-strengthening interventions for couples.

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    Scott-Sheldon LA, Walstrom P, Carey KB, et al. Alcohol use and sexual risk behaviors among individuals infected with HIV: a systematic review and meta-analysis 2012 to early 2013. Curr HIV/AIDS Rep. 2013;10(4):314–23.

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    UNAIDS. The gap report: beginning of the end of AIDS. Geneva, Switzerland: UNAIDS; 2014.

  3. 3.

    World Health Organization. Global status report on alcohol and health. Geneva: World Health Organization; 2014.

    Google Scholar 

  4. 4.

    World Health Organization. Global status report on alcohol and health (Country Profiles: Malawi). Accessed 19 April 2019. Geneva, Switzerland 2014.

  5. 5.

    Hahn JA, Samet JH. Alcohol and HIV disease progression: weighing the evidence. Curr HIV/AIDS Rep. 2010;7(4):226–33.

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Braithwaite RS, Bryant KJ. Influence of alcohol consumption on adherence to and toxicity of antiretroviral therapy and survival. Alcohol Res Health. 2010;33(3):280.

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Barve S, Kapoor R, Moghe A, et al. Focus on the liver: alcohol use, highly active antiretroviral therapy, and liver disease in HIV-infected patients. Alcohol Res Health. 2010;33(3):229.

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Hendershot CS, Stoner SA, Pantalone DW, Simoni JM. Alcohol use and antiretroviral adherence: review and meta-analysis. J Acquir Immune Defic Syndr. 2009;52(2):180–202.

    PubMed  PubMed Central  Google Scholar 

  9. 9.

    Shuper PA, Neuman M, Kanteres F, et al. Causal considerations on alcohol and HIV/AIDS—a systematic review. Alcohol Alcohol. 2010;45(2):159–66.

    PubMed  Google Scholar 

  10. 10.

    Samet JH, Cheng DM, Libman H, et al. Alcohol consumption and HIV disease progression. J Acquir Immune Defic Syndr. (1999). 2007;46(2):194.

    Google Scholar 

  11. 11.

    Wu ES, Metzger DS, Lynch KG, Douglas SD. Association between alcohol use and HIV viral load. J Acquir Immune Defic Syndr. (1999). 2011;56(5):e129.

    Google Scholar 

  12. 12.

    Baliunas D, Rehm J, Irving H, Shuper P. Alcohol consumption and risk of incident human immunodeficiency virus infection: a meta-analysis. Int J Public Health. 2010;55(3):159–66.

    PubMed  Google Scholar 

  13. 13.

    Rusbult C, Arriaga X. Interdependence theory. In: Duck S, editor. Handbook of personal relationships. 2nd ed. London: Wiley; 1997.

    Google Scholar 

  14. 14.

    Rodriguez LM, Neighbors C, Knee CR. Problematic alcohol use and marital distress: an interdependence theory perspective. Addict Res Theory. 2014;22(4):294–312.

    Google Scholar 

  15. 15.

    Marshal MP. For better or for worse? The effects of alcohol use on marital functioning. Clin Psychol Rev. 2003;23(7):959–97.

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Levitt A, Cooper ML. Daily alcohol use and romantic relationship functioning: evidence of bidirectional, gender-, and context-specific effects. Personal Soc Psychol Bull. 2010;36(12):1706–22.

    Google Scholar 

  17. 17.

    Leonard KE, Rothbard JC. Alcohol and the marriage effect. J Stud Alcohol Suppl. 1999;13:139–46.

    CAS  PubMed  Google Scholar 

  18. 18.

    Leddy A, Chakravarty D, Dladla S, Bruyn GD, Darbes L. Sexual communication self-efficacy, hegemonic masculine norms and condom use among heterosexual couples in South Africa. AIDS Care. 2015;28(2):228–33.

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Rogers AJ, Achiro L, Bukusi EA, et al. Couple interdependence impacts HIV-related health behaviours among pregnant couples in southwestern Kenya: a qualitative analysis. J Int AIDS Soc. 2016;19(1):21224.

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Conroy AA. The influence of relationship power dynamics on HIV testing in rural Malawi. J Sex Res. 2014;52(3):347–59.

    PubMed  PubMed Central  Google Scholar 

  21. 21.

    Conroy AA. ‘It means there is doubt in the house’: perceptions and experiences of HIV testing in rural Malawi. Cult Health Sex. 2014;16(4):397–411.

    PubMed  PubMed Central  Google Scholar 

  22. 22.

    Turan JM, Darbes LA, Musoke PL, et al. Development and piloting of a home-based couples intervention during pregnancy and postpartum in Southwestern Kenya. AIDS Patient Care STDS. 2018;32(3):92–103.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Darbes LA, McGrath NM, Hosegood V, et al. Results of a couples-based randomized controlled trial aimed to increase testing for HIV. JAIDS J Acquir Immune Defic Syndr. 2019;80(4):404–13.

    PubMed  Google Scholar 

  24. 24.

    Conroy AA, Wong LH. How reliable are self-reports of HIV status disclosure? Evidence from couples in Malawi. Soc Sci Med. 2015;144:28–37.

    PubMed  PubMed Central  Google Scholar 

  25. 25.

    Conroy A, Ruark A, Darbes L, et al. Relationship dynamics and dyadic coordination are associated with ART adherence among married couples from Malawi. Paper presented at the Conference on HIV Treatment and Prevention Adherence; 8–10 June 2018. Miami2018.

  26. 26.

    Conroy A, Leddy A, Johnson M, et al. ‘I told her this is your life’: relationship dynamics, partner support and adherence to antiretroviral therapy among South African couples. Cult Health Sex. 2017;19(11):1239–53.

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    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;8:141–51.

    PubMed  Google Scholar 

  28. 28.

    Conroy AA, Mckenna SA, Ruark A. Couple interdependence impacts alcohol use and adherence to antiretroviral therapy in Malawi. AIDS Behav. 2019;23(1):201–10.

    PubMed  Google Scholar 

  29. 29.

    Nkosi S, Rich EP, Kekwaletswe CT, Morojele NK. Experiences of alcohol consumption and taking antiretroviral medication among men living with HIV in Tshwane, South Africa. Afr J AIDS Res. 2016;15(4):367–76.

    PubMed  Google Scholar 

  30. 30.

    Fatch R, Emenyonu NI, Muyindike W, et al. Alcohol interactive toxicity beliefs and ART non-adherence among HIV-infected current drinkers in Mbarara, Uganda. AIDS Behav. 2016:1-13.

  31. 31.

    Conroy AA, McKenna SA, Leddy A, et al. “If she is drunk, I don’t want her to take it”: partner beliefs and influence on use of alcohol and antiretroviral therapy in South African Couples. AIDS Behav. 2017;21(7):1885–91.

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Scott-Sheldon LA, Carey KB, Johnson BT, Carey MP, Team MR. Behavioral interventions targeting alcohol use among people living with HIV/AIDS: a systematic review and meta-analysis. AIDS Behav. 2017;21(2):126–43.

    PubMed  PubMed Central  Google Scholar 

  33. 33.

    Wandera B, Tumwesigye NM, Nankabirwa JI, et al. Efficacy of a single, brief alcohol reduction intervention among men and women living with HIV/AIDS and using alcohol in Kampala, Uganda: a randomized trial. J Int Assoc Provid AIDS Care (JIAPAC). 2017;16(3):276–85.

    PubMed  Google Scholar 

  34. 34.

    Bachanas P, Kidder D, Medley A, et al. Delivering prevention interventions to people living with HIV in clinical care settings: results of a cluster randomized trial in Kenya, Namibia, and Tanzania. AIDS Behav. 2016;20(9):2110–8.

    PubMed  PubMed Central  Google Scholar 

  35. 35.

    Senyonyi RM, Underwood LA, Suarez E, Musisi S, Grande TL. Cognitive behavioral therapy group intervention for HIV transmission risk behavior in perinatally infected adolescents. Health (N Y). 2012;4(12):1334.

    Google Scholar 

  36. 36.

    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.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    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.

    PubMed  PubMed Central  Google Scholar 

  38. 38.

    Remien RH, Stirratt MJ, Dolezal C, et al. Couple-focused support to improve HIV medication adherence: a randomized controlled trial. AIDS. 2005;19:807–14.

    PubMed  Google Scholar 

  39. 39.

    Speizer IS, Zule WA, Carney T, et al. Changing sex risk behaviors, gender norms, and relationship dynamics among couples in Cape Town, South Africa: efficacy of an intervention on the dyad. Soc Sci Med. 2018;209:95–103.

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Weiser SD, Palar K, Frongillo EA, et al. Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda. AIDS. 2014;28:115–20.

    CAS  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Kagee A, Remien RH, Berkman A, et al. Structural barriers to ART adherence in Southern Africa: challenges and potential ways forward. Global Public Health. 2011;6(1):83–97.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. 42.

    O’farrell TJ, Murphy CM. Marital violence before and after alcoholism treatment. J Consult Clin Psychol. 1995;63(2):256.

    PubMed  Google Scholar 

  43. 43.

    Fals-Stewart W, Birchler GR, Kelley ML. Learning sobriety together: a randomized clinical trial examining behavioral couples therapy with alcoholic female patients. J Consult Clin Psychol. 2006;74(3):579.

    PubMed  Google Scholar 

  44. 44.

    Wechsberg WM, Zule WA, El-Bassel N, et al. The male factor: outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township. Drug Alcohol Depend. 2016;161:307–15.

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Wechsberg WM, El-Bassel N, Carney T, et al. Adapting an evidence-based HIV behavioral intervention for South African couples. Subst Abuse Treat Prev Policy. 2015;10(1):6.

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Brofenbrenner U. The ecology of human development. Cambridge: Harvard University Press; 1979.

    Google Scholar 

  47. 47.

    Karney BR, Hops H, Redding CA, et al. A framework for incorporating dyads in models of HIV-prevention. AIDS Behav. 2010;14(2):189–203.

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Bush K, Kivlahan D, McDonell M, Fihn S, Bradley K. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789–95.

    CAS  Google Scholar 

  49. 49.

    Conroy AA, McKenna SA, Comfort ML, et al. Marital infidelity, food insecurity, and couple instability: a web of challenges for dyadic coordination around antiretroviral therapy. Soc Sci Med. 2018;214:110–7.

    PubMed  PubMed Central  Google Scholar 

  50. 50.

    Eisikovits Z, Koren C. Approaches to and outcomes of dyadic interview analysis. Qual Health Res. 2010;20(12):1642–55.

    PubMed  Google Scholar 

  51. 51.

    Spencer L, Ritchie J. Qualitative data analysis for applied policy research. Analyzing qualitative data: Routledge; 2002. p. 187–208.

    Google Scholar 

  52. 52.

    Sundararajan R, Wyatt MA, Woolf-King S, et al. Qualitative study of changes in alcohol use among HIV-infected adults entering care and treatment for HIV/AIDS in rural southwest Uganda. AIDS Behav. 2015;19(4):732–41.

    PubMed  Google Scholar 

  53. 53.

    Woolf-King SE, Maisto SA. Alcohol use and high-risk sexual behavior in Sub-Saharan Africa: a narrative review. Arch Sex Behav. 2011;40(1):17–42.

    PubMed  Google Scholar 

  54. 54.

    Kalichman SC, Simbayi L, Jooste S, Vermaak R, Cain D. Sensation seeking and alcohol use predict HIV transmission risks: prospective study of sexually transmitted infection clinic patients, Cape Town South Africa. Addict Behav. 2008;33(12):1630–3.

    PubMed  PubMed Central  Google Scholar 

  55. 55.

    Lewis MA, Butterfield RM. Social control in marital relationships: effect of one’s partner on health behaviors 1. J Appl Soc Psychol. 2007;37(2):298–319.

    Google Scholar 

  56. 56.

    Umberson D. Gender, marital status, and the social control of health behavior. Soc Sci Med. 1992;34(8):907–17.

    CAS  PubMed  Google Scholar 

  57. 57.

    Lewis MA, Rook KS. Social control in personal relationships: impact on health behaviors and psychological distress. Health Psychol. 1999;18(1):63.

    CAS  PubMed  Google Scholar 

  58. 58.

    Tan JY, Conroy A, Lee I, Pratto F. Leveraging power in intimate partner relationships a power basis perspective. Cambridge: Cambridge University Press; 2017.

    Google Scholar 

  59. 59.

    Fals-Stewart W, Clinton-Sherrod M. Treating intimate partner violence among substance-abusing dyads: the effect of couples therapy. Prof Psychol. 2009;40(3):257.

    Google Scholar 

  60. 60.

    Klostermann KC, Fals-Stewart W. Intimate partner violence and alcohol use: exploring the role of drinking in partner violence and its implications for intervention. Aggress Viol Behav. 2006;11(6):587–97.

    Google Scholar 

  61. 61.

    Dworkin SL, Treves-Kagan S, Lippman SA. Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: a review of the global evidence. AIDS Behav. 2013;17(9):2845–63.

    PubMed  Google Scholar 

  62. 62.

    Minnis AM, Doherty IA, Kline TL, et al. Relationship power, communication, and violence among couples: results of a cluster-randomized HIV prevention study in a South African township. Int J Women’s Health. 2015;7:517.

    Google Scholar 

  63. 63.

    Babor TF, Higgins-Biddle JC, Organization WH. Brief intervention for hazardous and harmful drinking: a manual for use in primary care. 2001.

  64. 64.

    Kaner EF, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: a systematic review. Drug Alcohol Rev. 2009;28(3):301–23.

    PubMed  Google Scholar 

  65. 65.

    Chang G, McNamara TK, Orav EJ, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105(5 Pt 1):991.

    PubMed  PubMed Central  Google Scholar 

  66. 66.

    Karriker-Jaffe KJ, Room R, Giesbrecht N, Greenfield TK. Alcohol’s harm to others: opportunities and challenges in a public health framework. J Stud Alcohol Drugs. 2018;79(2):239–43.

    PubMed  PubMed Central  Google Scholar 

  67. 67.

    Velleman R, Orford J. Young adult offspring of parents with drinking problems: recollections of parents’ drinking and its immediate effects. Br J Clin Psychol. 1990;29(3):297–317.

    CAS  PubMed  Google Scholar 

  68. 68.

    Christoffersen MN, Soothill K. The long-term consequences of parental alcohol abuse: a cohort study of children in Denmark. J Subst Abuse Treat. 2003;25(2):107–16.

    PubMed  Google Scholar 

  69. 69.

    Swann M. Economic strengthening for retention in HIV care and adherence to antiretroviral therapy: a review of the evidence. AIDS Care. 2018;30(sup3):85–98.

    PubMed  Google Scholar 

  70. 70.

    Arrivillaga M, Salcedo JP. A systematic review of microfinance-based interventions for HIV/AIDS prevention. AIDS Educ Prev. 2014;26(1):13–27.

    PubMed  Google Scholar 

  71. 71.

    Wagner G, Rana Y, Linnemayr S, Balya J, Buzaalirwa L. A qualitative exploration of the economic and social effects of microcredit among people living with HIV/AIDS in Uganda. AIDS Res Treat. 2012.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


This research was funded by the National Institute of Mental Health (NIMH) under grant K01MH107331 and the National Institute of Allergy and Infectious Diseases under grant P30AI027763 (awards to AAC). AR was funded by the National Institute of Drug Abuse under grant T32DA13911. JYT was funded by the NIMH under grant K01MH106416. JAH was funded by the National Institute of Alcohol Abuse and Alcoholism under grant K24AA022586. The authors would like to thank the tireless efforts of the research staff at Invest in Knowledge in Malawi for data collection.

Author information



Corresponding author

Correspondence to Amy A. Conroy.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Conroy, A.A., Ruark, A., McKenna, S.A. et al. The Unaddressed Needs of Alcohol-Using Couples on Antiretroviral Therapy in Malawi: Formative Research on Multilevel Interventions. AIDS Behav 24, 1599–1611 (2020).

Download citation


  • Couples
  • Alcohol
  • Antiretroviral Therapy
  • Adherence
  • Sub-Saharan Africa