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					The Role of Alcohol Use in the Development of
           the HIV/AIDS Epidemic:
  The international knowledge base with an
      emphasis on Sub-Saharan Africa

                       NEO K MOROJELE, PHD
                 CONNIE T KEKWALETSWE, PHD


          Alcohol and Drug Abuse Research Unit
                            SOUTH AFRICAN
             MEDICAL RESEARCH COUNCIL
                                              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


 building a healthy nation through research
            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)

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                 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)
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               Association between alcohol use
                      and HIV Infection

Study (Number of studies)                               Pooled Odds Ratio (95%
                                                          Confidence Interval)
All studies (20)                                             1.70 (1.45-1.99)
Males (10)                                                   1.91 (1.57-2.33)
Females (16)                                                 1.90 (1.68-2.19)
High risk populations (12)                                   2.01 (1.56-2.58)




                                     Source: Fisher et al. (2007)
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                                              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?

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                          Potential mechanism 1
                                     Fisher et al. (2007)




           Alcohol                           Sexual risk      HIV
         consumption                          behaviour     Infection




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                         Potential mechanisms 2
                                         Fisher et al. (2007)




           Alcohol                             Gender-based       HIV
         consumption                             violence       Infection




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                          Potential mechanism 3
                                         Fisher et al. (2007)




           Alcohol                                                HIV
                                              Immune response
         consumption                                            Infection




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                             Alcohol Consumption and
                              Sexual Risk Behaviour


• Alcohol consumption and sex with multiple
  partners

• Alcohol consumption and engagement in
  unprotected sex




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                       ALCOHOL CONSUMPTION AND
                      SEX WITH MULTIPLE PARTNERS




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


                                   Past month           Typical     Problem
                                   frequency            quantity    drinking
Number of                              .16                .25*         .25*
sexual partners
*p < .01

                                   Source: Morojele et al. (2006)




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                  Source: Nelson Mandela/HSRC HIV/AIDS national
                      household survey (Shisana et al., 2004)
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                    ALCOHOL CONSUMPTION
                       AND CONDOM USE




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


                                   Past month    Typical    Problem
                                   frequency     quantity   drinking
Consistent                            -.11         -.22       -.15
condom use
Note: All correlations not statistically significant




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                              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)


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      Association between alcohol use and condom use

                                         Summary Odds Ratio    95% CI
All                                              0.90          0.81-0.99
First sex                                        0.54          0.44-0.66
Recent sex                                       1.04          0.89-1.21
Recent sex, new partner                          1.10          0.92-1.32
Adolescents                                      0.71          0.61-0.83
Adolescents: Recent sex                          0.92          0.75-1.14



                                        Source: Leigh (2002)




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                                             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



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                                              Comment

• No consideration of quantities of alcohol
  consumed

• Studies conducted primarily in North America
  and Europe

• Generalisability of findings to Sub-Saharan
  countries unknown


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                     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

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                         Role of alcohol use in the
                        progression of HIV disease


Does alcohol consumption affect the progression
 of the HIV disease?




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                  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).




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                         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).




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                                              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




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                                        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).




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                    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




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         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)



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          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).

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               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)




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                                         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




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                                     IMPLICATIONS




building a healthy nation through research
 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




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                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


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                       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




 building a healthy nation through research
                          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




 building a healthy nation through research
                                       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




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                            ACKNOWLEDGEMENTS

• Centers for Disease Control and Prevention (CDC)

• National Institutes of Health (NIH)

• South African Medical Research Council (MRC)

• World Health Organization (WHO)




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