The Role of Alcohol Use in the Development of the HIV/AIDS Epidemic:

1. NEO K MOROJELE, PHDCONNIE T KEKWALETSWE, PHDAlcohol and Drug Abuse Research UnitSOUTH AFRICANMEDICAL RESEARCH COUNCIL The Role of Alcohol Use in the Development of the HIV/AIDS Epidemic: The international knowledge base with an emphasis on Sub-Saharan Africa

2. OVERVIEW • Alcohol use and risk for contraction of HIV • Alcohol use and progression of HIV disease • Alcohol use and non-adherence to antiretroviral therapy (ART) • Conclusions and Implications

3. Alcohol use and contraction of HIV • There has been much interest in the links between alcohol use, sexual risk behaviour and HIV in Sub-Saharan Africa (SSA) in recent years • Much research shows strong links between alcohol use and HIV infection • Mixed results on relationship between alcohol use and sexual risk behaviour (i.e. unprotected sex and sex with multiple partners)

4. Alcohol use and HIV Infection in Africa(Fisher, Bang & Kapiga, 2007) • A systematic review and meta-analysis of studies reporting links between alcohol use and HIV • Aim: to determine whether there is a relationship between alcohol and HIV infection across studies • 20 studies conducted in Africa: • Tanzania (N = 6) • Kenya (N = 4) • Zimbabwe (N = 3) • South Africa (N = 3) • Uganda (N = 2) • Botswana (N = 1) • Ethiopia (N = 1)

5. Association between alcohol use and HIV Infection Source: Fisher et al. (2007)

6. Comment • Alcohol users have a 70% greater chance than non-users of being HIV+ • Comparable odds ratios observed across samples • Odds ratios greater among high-risk drinkers suggestive of “crude dose-response” relationship with HIV infection • However, causality not established • So what are the potential mechanisms in operation?

7. Potential mechanism 1 Fisher et al. (2007) Alcohol consumption Sexual risk behaviour HIV Infection

8. Potential mechanisms 2 Fisher et al. (2007) Alcohol consumption Gender-based violence HIV Infection

9. Potential mechanism 3 Fisher et al. (2007) Alcohol consumption Immune response HIV Infection

10. Alcohol Consumption and Sexual Risk Behaviour • Alcohol consumption and sex with multiple partners • Alcohol consumption and engagement in unprotected sex

11. ALCOHOL CONSUMPTION AND SEX WITH MULTIPLE PARTNERS

12. Correlations between number of sexual partners and alcohol use among adults in a community study (N = 160)

13. Source: Nelson Mandela/HSRC HIV/AIDS national household survey (Shisana et al., 2004)

14. ALCOHOL CONSUMPTION AND CONDOM USE

15. Correlations between condom use and alcohol use among adults in a community study (N = 160)

16. EVENT LEVEL ANALYSIS Does drinking before or during a sexual event reduce condom use during that event? Leigh (2002): Meta-analysis of event-level studies examining condom use and alcohol use during sexual events 13 studies were included in the analyses. The studies mainly involved: • North American samples (N=9) • Adults (N=8)

17. Association between alcohol use and condom use Source: Leigh (2002)

18. Summary • Overall, alcohol use was found TO BE associated with non-condom use: • At first intercourse • For adolescents in general (trend) • Overall, alcohol use was found to NOT be associated with condom use: • For adults in general • For adolescents and adults – recent sexual encounters • For adults – recent sex with new partner

19. Comment • No consideration of quantities of alcohol consumed • Studies conducted primarily in North America and Europe • Generalisability of findings to Sub-Saharan countries unknown

20. Conclusion: Alcohol consumption and sexual risk behaviour The link seems to be a function of: • Consumption patterns: Quantity/intoxication/hazardous drinking related most strongly to sexual risk behaviours • Consumption settings/contexts: Drinking venues (opportunities for meeting partners; environment) • Consuming in presence of whom: casual partners/prospective partners/sex workers • Consumer characteristics: younger, inexperienced, male, alcohol expectancies • Type of sexual risk behavior – alcohol use is more strongly linked to sex with multiple partners than with unprotected sex • Type of sexual partner – alcohol use at last sex more likely with casual partners, but condom use more likely with casual partners THE LINKS BETWEEN ALCOHOL CONSUMPTION AND SEXUAL RISK BEHAVIOUR ARE INDEED COMPLEX

21. Role of alcohol use in the progression of HIV disease Does alcohol consumption affect the progression of the HIV disease?

22. Alcohol use and disease progression • Alcohol use has been shown to hasten HIV disease progression (e.g. Conigliaro et al., 2003; Hao rah et al., 2004; Samet et al. 2003; Wang et al., 2002).   • Some evidence that the effect is particularly compelling for those on ART (Samet et al., 2003; Miguez et al., 2003).

23. Mechanisms/hypotheses • Alcohol (ethanol) leads to hepatotoxicity, which in turn reduces the liver’s efficiency, hence reducing availability of ART to curtail replication of HIV (e.g. Conigliaro et al., 2003). • Disease progresses faster among alcohol-using ART patients than non-drinking ART patients, as drinker’s adherence levels are lower (Samet et al., 2003).

24. Comment • Research findings on the links between alcohol consumption and disease progression are mixed • Effects of alcohol on disease progression worst among those on ART and for hazardous drinkers • More research is needed on the issue

25. Alcohol use and adherence to ART Adherence: “extent to which patients carry out the behaviours and treatments as recommended by their practitioners/doctors” (Sarafino, 2005) Most research suggests that to attain optimal therapeutic outcomes of antiretroviral therapy (ART) requires at least 95% adherence level (Palella et al., 1998; Paterson et al., 2000). Despite early scepticism, adherence rates in Africa compare to developed world & in some cases > than developed world (Attaran, 2007; Mills et al., 2006; Orrell et al., 2003).

26. Reasons for non-adherence to ART Predominant reasons for non-adherence in developing world relative to developed world: • Disrupted access to medication • Medications out of stock • Financial difficulties • Transport problems

27. Studies on alcohol use and adherence to ART • Numerous studies indicate that heavy alcohol use is associated with sub-optimal adherence to ART (Arnsten et al., 2002; Braithwaite et al., 2005; Cook et al., 2001; Halkitis et al., 2004; Wolitski & Remien, 2003; Spire et al., 2002) • Strong dose-response relationship found between alcohol consumption and poor ART adherence (Braithwaite et al., 2005)

28. African studies on adherence and alcohol use Few studies have been conducted on hazardous alcohol use as barrier to adherence to ART in Africa, despite increasing discussion of this issue (e.g. Alcohol & Infectious Diseases Technical meeting, July, 2008; PEPFAR meeting in Dar es Salaam, 2006) African studies on alcohol and ART adherence have mixed results: One study: a history of alcohol abuse was associated with increased odds of poor adherence (Selin et al., 2007). However, other studies fail to observe such a relationship (e.g. cross-sectional study conducted in Kampala, Uganda among 304 HIV+ individuals on ART, found that the use of alcohol was not associated with ART adherence (Byakika-Tusiime et al., 2005).

29. Mechanisms to explain the relationship Potential mediators of relationship between alcohol use and sub-optimal ART adherence: A) cognition/judgment/short-term memory impairment (forgetting) B) beliefs about ART-alcohol interactions C) possible depression (hopelessness and pessimism about the future/efficacy of ART)

30. Conclusions • Despite need for more research, important to consider potential role of alcohol consumption in non-adherence to ART • Of concern is denial of ART to alcohol users who are assumed to be likely to be non-adherent • Possible effects of alcohol use on adherence need to be assessed on a case-by-case basis, from initial enrolment onto ART programmes, and throughout individual’s treatment

31. IMPLICATIONS

32. Alcohol, sexual risk behaviour and HIV/AIDS • Policy and programmatic intervention programmes that reduce both alcohol consumption and risky sexual behaviours are needed • Interventions should take into account the complexity of the relationship between alcohol use and sexual risk behaviour

33. Implications for intervention programmes Consideration should be given to: • Consumption patterns - interventions should focus on hazardous alcohol use (which is common pattern of consumption in SSA) • Consumption settings/contexts - interventions may be conducted in drinking venues • Type of sexual risk behavior - focus should be on reducing sex with multiple partners as well as unprotected sex • Type of sexual partner – focus should be on sex with casual partners (where condom use is greater), as well as with regular partner/spouse

34. Alcohol consumption and disease progression • Need for alcohol counselling and treatment for individuals with HIV disease who use ART • Efforts should be made to reduce alcohol consumption among HIV+ people

35. Alcohol consumption and non-adherence to ART • Research is urgently needed on the role of alcohol in non-adherence to ART • Need for integrated HIV and alcohol treatment services • Training of service providers (e.g. adherence counsellors) required to enhance their ability to appropriately serve HIV+ patients who consume alcohol

36. CONCLUSION • Alcohol consumption plays varying roles in HIV disease transmission, progression and non-adherence to ART • Alcohol use interventions should be incorporated into HIV prevention and treatment intervention efforts as a matter of urgency

37. ACKNOWLEDGEMENTS • Centers for Disease Control and Prevention (CDC) • National Institutes of Health (NIH) • South African Medical Research Council (MRC) • World Health Organization (WHO)