Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers

Matthew F Chersich,Marleen Temmerman,Nzioki King’Ola,Wilkister Bosire,Stanley Luchters

doi:10.1186/1744-8603-10-22

Abstract

AimsTo investigate putative links between alcohol use, and unsafe sex and incident HIV infection in sub-Saharan Africa.MethodsA cohort of 400 HIV-negative female sex workers was established in Mombasa, Kenya. Associations between categories of the Alcohol Use Disorders Identification Test (AUDIT) and the incidence at one year of unsafe sex, HIV and pregnancy were assessed using Cox proportional hazards models. Violence or STIs other than HIV measured at one year was compared across AUDIT categories using multivariate logistic regression.ResultsParticipants had high levels of hazardous (17.3%, 69/399) and harmful drinking (9.5%, 38/399), while 36.1% abstained from alcohol. Hazardous and harmful drinkers had more unprotected sex and higher partner numbers than abstainers. Sex while feeling drunk was frequent and associated with lower condom use. Occurrence of condom accidents rose step-wise with each increase in AUDIT category. Compared with non-drinkers, women with harmful drinking had 4.1-fold higher sexual violence (95% CI adjusted odds ratio [AOR] = 1.9-8.9) and 8.4 higher odds of physical violence (95% CI AOR = 3.9-18.0), while hazardous drinkers had 3.1-fold higher physical violence (95% CI AOR = 1.7-5.6). No association was detected between AUDIT category and pregnancy, or infection with Syphilis or Trichomonas vaginalis. The adjusted hazard ratio of HIV incidence was 9.6 comparing women with hazardous drinking to non-drinkers (95% CI = 1.1-87.9).ConclusionsUnsafe sex, partner violence and HIV incidence were higher in women with alcohol use disorders. This prospective study, using validated alcohol measures, indicates that harmful or hazardous alcohol can influence sexual behaviour. Possible mechanisms include increased unprotected sex, condom accidents and exposure to sexual violence. Experimental evidence is required demonstrating that interventions to reduce alcohol use can avert unsafe sex.

Highlights

When considered separately, harmful alcohol use and unsafe sex account for a considerable portion of disease in eastern and southern Africa [1,2,3]
This setting was selected as the research team had strong links with the community leaders and sex workers in these divisions, as well as the high incidence of alcohol use, unsafe sex and HIV in the area [37]
We examined associations between Alcohol Use Disorders Identification Test (AUDIT) group and the proximal study outcomes: unsafe sex, physical and sexual violence, as well as the distal outcomes

Summary

Introduction

Harmful alcohol use and unsafe sex account for a considerable portion of disease in eastern and southern Africa [1,2,3]. Opportunities for alcohol use and sex often co-exist within physical locations, [15,16,17] and social contexts. Links between alcohol and unsafe sex may be mediated by alcohol’s pharmacological effects [22]; the nature of drinking venues in Africa [23,24]; intersections between alcohol and other drugs [25]; and likely by a set of psychological and social influences [26,27,28]. Meta-analyses in two systematic reviews showed that those who drink alcohol have approximately 70% higher risk for HIV [29,31]. These studies used an array of alcohol exposure measures, and few had longitudinal study designs [31,32]

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Discussion

Conclusion