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Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene. M F Chersich MBBCh PhD*† and H V Rees MBBCh MA* ...
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Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene M F Chersich

MBBCh PhD*†

and H V Rees

MBBCh MA*‡

*Reproductive Health and HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa; †Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium; ‡London School of Hygiene and Tropical Medicine, London, UK

Summary: South Africa has a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. Much evidence indicates that alcohol independently influences decisions around sex, and undermines skills for condom negotiation and correct use. Thus, not surprisingly, people with problem drinking in Africa have twofold higher risk for HIV than non-drinkers. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising and provision of Brief Interventions. Alcohol counselling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. Within positive-prevention services, alcohol reduction interventions could diminish HIV transmission. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence. However, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable disease, including unsafe sex, sexual violence, unintended pregnancy and, likely, HIV transmission. Keywords: alcohol, South Africa, HIV, drinking patterns, prevention, sexual behaviour, heavy episodic drinking, unsafe sex, risk behaviour

INTRODUCTION Alcohol accounts for 4% of the global burden of disease, similar to that caused by tobacco (4.1%) and high blood pressure (4.4%).1 In South Africa, alcohol’s burden is even greater, an estimated 7.9% of disease.2 HIV and other sexually transmitted infections (STIs) account for about a third of ill health in South Africa3 and globally for 6.3%. Many parts of sub-Saharan Africa, most especially southern Africa, thus have a dual massive burden of HIV and alcohol disease. These two conditions, however, share many common determinants and in tandem exacerbate the striking socioeconomic inequalities in this region. Moreover, as discussed in this article, alcohol and HIV have an especially intimate link – unsafe alcohol use is an important cause of HIV transmission in this setting; albeit indirectly through effects of alcohol on sexual behaviours. Annual costs of direct alcohol harm in South Africa amount to an estimated nine billion rand, around 1% of the gross domestic product (these figures exclude social burdens of alcohol, its effects on social behaviours and an individual’s interaction with their sexual partner(s) and family).4 Levels of fetal alcohol syndrome in South Africa are among the highest worldwide, with nearly 10% of children in some towns in the Western and Northern Cape having clinically apparent physical and cognitive deficits from maternal alcohol use.5,6 Further, about Correspondence to: M F Chersich, PO Box 568, Cramerview 2060, South Africa Email: [email protected]

International Journal of STD & AIDS 2010; 21: 2–7. DOI: 10.1258/ijsa.2009.009432

a quarter of women and men who seek medical attention after having experienced violence, indicate that in their view, alcohol or drugs played a role in the incident.7 Between 17% and 67% of patients in trauma units in South Africa have been drinking prior to the trauma episode8 and 60% of road traffic deaths in South Africa can be attributed to alcohol use.9 Consequences of alcohol use depend on three factors: lifetime cumulative volume consumed; the way alcohol is drunk (drinking patterns); and drinking contexts.10,11 Overall lifetime volume of alcohol is linked with chronic social problems (such as unemployment) and with chronic diseases such as alcoholic liver cirrhosis. By contrast, harmful patterns of drinking (high amount per drinking episode) are a powerful mediator of acute problems such as accidents, interpersonal violence and high-risk sexual behaviour.11,12 Context of alcohol use is especially important in determining its effects on sexual behaviour, as opportunities for sexual encounters and alcohol use often co-exist in social dynamics and physical locations.13 – 16 Thus, the impact of alcohol use on acute social behaviours (including sexual behaviours)17 depends more on the way and where 16 alcohol is drunk, than on the frequency of use or total lifetime volume. As opposed to settings with low-risk drinking patterns (classically southern European patterns of drinking with meals), sub-Saharan Africa is characterized by harmful patterns of drinking.12 This can be defined as the use of high quantities of alcohol per occasion, and generally includes drinking in public spaces, heavy alcohol use during cultural festivals and drinking outside mealtimes.18,19 In South Africa, these patterns

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of intermittent bouts of intoxication predominate, both in rural and urban areas and across social strata.20,21 Alcohol-related morbidity in the country thus mostly manifests as acute problems including road traffic accidents, crime, interpersonal violence and unsafe sex. Hazardous drinking over weekends, as with HIV prevalence, is most common among men aged 35– 44 years (31.4% of male drinkers in this age drink heavily on weekends).22 Among women who drink, 25% do so at high levels during weekends (even higher among adolescent females). Note that peaks in prevalence of alcohol use, disaggregated by age and gender, coincide broadly with the age and gender peaks in HIV prevalence in South Africa. Thus far the potential mediatory role of alcohol in unsafe sex has largely been ignored within HIV prevention strategies.23 This paper describes effects of alcohol on sexual behaviour, lays out the causal pathway between alcohol use and HIV acquisition, and reviews potential policy responses with specific reference to South Africa.

CAUSAL LINKS BETWEEN ALCOHOL INTOXICATION AND HIV TRANSMISSION If we can say that drinking before driving causes unsafe driving and car accidents . . . then we can say that drinking before sex causes unsafe sex and HIV acquisition. Substantiating a causal link between alcohol, and acute or social problems is ridden with epidemiological nuance.11,24 There are difficulties with disentangling the social determinants of alcohol use from alcohol’s social consequences and this complicates analysis of the social effects of alcohol. For example, though clearly alcohol misuse can break down social and economic structures, poverty itself increases its use. In the recent past, causal linkages between alcohol, and acute or social outcomes were disputed as data were predominately from cross-sectional studies and accuracy of self-reported drinking was questioned. Some studies suggested that personality factors such as impulsivity or sensation seeking, as well as contextual factors may confound the alcohol and sex relationship.25 – 27 However, in recent years, the causal pathway between alcohol intoxication, unsafe sex and HIV acquisition has been more clearly delineated and broadly accepted (Figure 1).15

Figure 1 Model of alcohol use and sexual risk behaviour, adapted from Morojele et al.15

Arguments used to substantiate causal links between alcohol and road traffic accidents form a useful basis for defining the causal pathway between acute intoxication, unsafe sex and HIV. Firstly, there is a biological explanation for the relationship: alcohol affects serotonin and gamma-aminobutyric acid brain receptors in a similar way to benzodiazepine drugs such as valium.28,29 The subjective experience of this can be reduced anxiety about the consequences of one’s actions, resulting in deceased cognitive restraint and increased risk-taking, be it while driving or during sex.28,29 Alcohol disinhibition impairs decision-making, decreasing awareness of social norms or perceptions of acceptable behaviour.30 Additionally, there appears to be a dose –response relationship. Heavy-drinking episodes with intoxication are associated with higher sexual risks than lighter or non-binge drinking.31 In a Zimbabwe study, the number of days a week that men drink correlated with the number of episodes of unprotected sex and HIV prevalence.32 Causality is also supported by results of event-level condom use (reduction in condom use coinciding with heavy-drinking events). Data suggest that adoption of safer drinking behaviour may reduce unsafe sex, providing evidence for the important reversibility criteria of causality.33 – 35 Overall, based on available evidence, a strong argument can be made that alcohol has independent effects on decision-making and verbal skills. Not surprisingly, this also applies to decisions about sexual behaviour, and skills for condom negotiation and their correct use. Poly-drug use markedly affects sexual behaviour. In particular, evidence is gathering of the important contribution of methamphetamine to high-risk sexual behaviour.36,37

EVIDENCE OF THE EFFECTS OF HARMFUL ALCOHOL USE ON SEXUAL BEHAVIOUR AND HIV TRANSMISSION IN AFRICA Globally, drinking alcohol has been linked with an increased number of sexual partners, regretted sexual relations, inconsistent condom use, condom accidents and an increased incidence of STIs.12,30,38 – 40 Studies in sub-Saharan Africa, in particular,14 have found strong associations between alcohol consumption and unprotected sex, multiple sex partners and having an STI.12,14,17,41,42 A 2008 household survey in South Africa found that 26% of high-risk drinkers reported having multiple sex partners, while this figure was only around 10% in the general population.43 Effects of alcohol on sexual behaviour are generally similar in women and men.16,31,44,45 However for a woman, drinking problems in a male partner increases her likelihood of exposure to risky sexual behaviour.17 In South Africa, as elsewhere, alcohol use is associated with risky sex within first-time sexual encounters.46,47 Alcohol use among men who have sex with men has also been associated with increased HIV infection in South Africa.48 HIV and alcohol share common ground with sexual violence for victims and perpetrators.49 A person’s risk of rape is higher during heavy drinking episodes, possibly because alcohol intoxication makes the drinker an easier target for potential perpetrators.45,50 – 52 Further, for perpetrators, during episodes of alcohol use it is possible that there is a heightening of the underlying common belief among men that they can dominate women and exert control over them.53,54

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Table 1 Summary of effective strategies to reduce alcoholrelated harm Strategies

Policy and programme elements

Raising awareness and political commitment

Activities aim to build strong public awareness and support. These include alcohol education, policies, targets and action plans at country level. Annual or bi-annual country-level reports of the prevalence of harmful alcohol use may be effective. Studies in southern Africa suggest schooland community-based education reduces alcohol use in adolescents.53,63,64 Community actions can increase recognition of alcohol-related harm at the community level, reduce the acceptability of public drinking, enhance partnerships of community agencies and non-governmental organizations, provide care and support for affected individuals and their families, and mobilize the community against the selling and consumption of illicit and potentially contaminated alcohol. Engagement is particularly important where unrecorded alcohol consumption is high or social consequences like public drunkenness, violence against intimate partners and sexual violence are prevalent. Screening and Brief Interventions reduce alcohol consumption and alcohol-related harm. Early identification is needed and effective treatment in health-care settings. Alcohol dependence treatment is most effective when supported by sound policies and health systems. Introducing lower limits for blood alcohol concentration reduces alcohol harm. Many countries have successfully lowered alcohol limits for new and young drivers. Success of legislation depends largely on its enforcement and on the severity of penalties imposed. Regulating production and distribution of alcoholic beverages is effective, in particular in protecting young people and other vulnerable groups. Government issued licenses can be suspended or withdrawn if required. Industry restrictions are more cost-effective for governments than enforcement at retail and consumer level. Nevertheless, it is also effective to restrict the age of consumers, the type of retail establishments that can sell alcohol, with limits on hours and days of sale, and regulations on vendors and the density of outlets. Informal markets in South Africa are a major source of alcohol, hindering formal controls on sale. Lowering density of retail outlets reduces underage drinking.65 Controls or partial bans on the amount, placement and content of alcohol advertising are important, in particular to protect adolescents and young people from pressure to start drinking. Full bans on alcohol advertising should be considered. Alcohol marketing is a public health issue. Industry “self-regulation” of marketing, by itself, is poorly effective. Price is an important determinant of alcohol consumption and of the extent of alcohol-related problems, especially in young. Tax influences price and consumer demand, by increasing cost of alcohol relative to alternative spending choices.

Community action to reduce harmful use of alcohol

Health-sector response

Drink-driving policies and countermeasures

Reducing the availability of alcohol

Addressing marketing of alcoholic beverages

Pricing policies

(Continued)

Table 1

Continued

Strategies

Policy and programme elements

Regulating the drinking context

Modifying the drinking context can reduce alcohol social harms. Interventions focusing on changing drinking settings can reduce the harmful consequences of drinking in and around these settings, without necessarily altering overall consumption levels. Provision of condoms in drinking venues and safer sex work settings would improve the safety of drinking contexts in South Africa.

Adapted from report of WHO Expert Committee on Problems Related to Alcohol Consumption66 and WHO Report on Strategies to Reduce the Harmful Use of Alcohol67

Given associations between alcohol and the above factors that increase risk for HIV acquisition, more than 20 studies in Africa have found higher levels of HIV infection among people with problem drinking.14,17,31,42,55 A meta-analysis of these studies found that compared with non-drinkers, problem drinkers had a twofold higher prevalence, with non-problem drinkers at intermediate risk (1.6-fold).31 Effect measures are strongly consistent across studies and similar effects were seen in women and men. Importantly, studies among adolescents also implicate alcohol use in the spread of HIV.47,56 Sex workers, migrant labourers and those who work in the transport industry are particularly vulnerable to the effects of alcohol on sexual behaviour, mostly as their drinking contexts are often unsafe.

STRATEGIES TO REDUCE THE CUMULATIVE ALCOHOL-HIV BURDEN Multilevel interventions are required to control excessive alcohol use and consequent unsafe sex (Table 1).57 In South Africa, to date, alcohol interventions have been fragmented across different government departments and are poorly implemented.58,59 An historical experience provides perhaps the starkest illustration of the potential effects of alcohol control. In Russia, between 1984 and 1987 a 25% drop in estimated per capita consumption of alcohol (due to vodka shortages) was accompanied by a 40% reduction in male homicide deaths.60 South Africans have similar binge drinking patterns to those of Russians and it is possible that a comparable reduction in intentional injuries, crime and HIV in South Africa could occur with more robust alcohol control. Like the tobacco industry, the alcohol industry prefers the onus of alcohol control to fall on individuals who are encouraged to adopt ‘responsible behaviour’.61,62 To inform development of the WHO global strategy to reduce harmful use of alcohol, representatives of alcohol industry, trade and agriculture submitted an almost 300-page document, which makes no mention of the role that alcohol plays in HIV transmission and focuses almost exclusively on the importance of individual responsibility.61 Raising tax on alcohol is able to influence even the behaviour of heavy drinkers, but importantly is particularly effective with younger drinkers who are more price sensitive. Practical experience to date with implementation of alcohol laws in South Africa suggests that actions such as increased taxation may be more effective than enhancing restrictions on public drinking,

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for example. Levels of alcohol tax in South Africa are below global standards and those in the neighbouring country Botswana, which has raised taxes and increased limits on alcohol sales.58 Alcohol tax also recoups some costs of alcohol’s harm and an argument could be made for ring-fencing such revenues for use in programmes to reduce the effects of alcohol on HIV transmission. Policies and interventions targeting establishments that serve alcohol are especially important because of the overlap between drinking and sexual networks in these contexts.17 Integrating HIV prevention activities within drinking venues, such as bars, beer halls and taverns, could reach large numbers of persons at greatest risk for HIV infection.32 In US cities, intensive interventions among gay and bisexual men attending bars have demonstrated positive effects.68 People working in drinking venues have especially high HIV risks and need heightened protection.69

interventions are needed to change the way alcohol is drank. Overall, promotion of safer drinking patterns and contexts are more effective than promoting total abstinence from alcohol. Several studies in South Africa and elsewhere have indicated that selective alcohol interventions can alter high-risk sexual behaviour.33,34,74 The effectiveness of a three-hour interactive small-group session on alcohol and HIV was assessed in a trial among men in Cape Town.33 Two communities were randomly allocated to receive either the intervention or a gender-based violence intervention. In follow-up, men in the alcohol-intervention arm reported less unprotected sex and that they had begun to separate their drinking from their sexual behaviours. Another trial in Cape Town among men and women recruited from informal drinking venues showed that a three-hour HIV–alcohol risk-reduction intervention was effective in reducing unprotected sex and partner number.34 The intervention was most effective among lighter drinkers and in the short term.

Universal community-wide interventions

ALCOHOL SCREENING AND BRIEF INTERVENTIONS IN CLINICAL SETTINGS

Evidence-based strategies for changing community norms, attitudes and practices of alcohol use should be utilized.70,71 Interventions with highest effectiveness include regulating the physical availability of alcohol and restricting alcohol advertising. Banning alcohol adverts on billboards, or allowing TV alcohol adverts only after 21:00 have been suggested.71 Although general public education and warning labels on drinks, for example, are generally uncontested by alcohol industry, they are poorly effective in their current form.72 Evidence from use of warning labels in tobacco control suggest that use of more graphic and larger warnings, with rotating messages can influence behaviour. Being explicit about the links between alcohol use, unsafe sex and HIV transmission might be useful. Studies in Namibia and Gauteng Province, South Africa have shown that educational interventions in schools can reduce drinking and alcohol use concurrent with sex.63,64 Also, in the Eastern Cape, a trial evaluated an HIV prevention programme consisting of a total of 50 hours of participatory learning for groups of 15 –26 year olds (the Stepping Stones programme). A year after the intervention, men who had been exposed to the programme were less likely to be hazardous or harmful drinkers.53 Overall, evidence supports the effectiveness of combining alcohol and sex topics within educational initiatives in schools.63,64 The knowledge, attitudes and skills necessary to avoid risk behaviours such as binge drinking are closely related to those necessary to avoid risky sex. Universal (community-wide) interventions targeting the general population often have little or no effect on incipient or established problem drinkers as their behaviour is generally too entrenched to be changed by messaging alone. Universal measures may, however, increase willingness of this group to participate in more intense alcohol-reduction activities and prevent problem drinking among future generations.

Selective alcohol interventions, targeting individuals to break the alcohol – unsafe sex– HIV nexus The health sector could play a critical role in mitigating alcoholrelated harm. The World Health Assembly has given control of alcohol, including alcohol–sex linkages, high priority.73 For individuals with hazardous or harmful drinking, evidence-based

One important practical solution is for health services to screen people for hazardous or harmful alcohol use, especially in HIV services. Conceptually, routine provider-initiated screening for alcohol use is analogous to provider-initiated HIV testing. The AUDIT screening interview and similar tools can identify whether a person has hazardous drinking (patterns of drinking that increase the risk of harmful consequences for the user and others), harmful use (alcohol consumption resulting in consequences to social, physical or mental health) or alcohol dependence (a cluster of behavioural, cognitive and physiological phenomena, including increased alcohol tolerance and withdrawal).75 Alcohol treatment services are indicated for people who are alcohol dependant. However, access to public-sector services for substance abuse treatment is low in resource-constrained settings and underfunded by government. Disparities in access occur along racial lines in South Africa, with few black people entering substance abuse treatment in the public sector, due to cultural, linguistic and logistical barriers.76 Individuals identified as having hazardous or harmful drinking require targeted services such as Brief Interventions.57 Brief Interventions are time-limited, patient-centred counselling, which focuses on changing behaviour and empowering people to control their alcohol use and its effects on sexual behaviour.77 Research in Kenya has shown that targeted alcohol–HIV counselling can be incorporated within HIV voluntary counselling and testing.78 Brief Interventions consist of several steps, where people are: informed of the results of screening; assisted to identify risks and discuss consequences of their drinking; given medical advice; asked to make a commitment to change their alcohol behaviours; and helped to identify their own goal (such as abstaining from drinking or reducing alcohol use on weekends). These discussions should include the effects of alcohol on sexual behaviours and plans to change this. Follow-up visits with reinforcement may be beneficial. Brief Interventions are typically delivered in primary healthcare settings for patients who are not seeking help for an alcohol problem, but are identified through screening. Across diverse settings, they have led to substantial benefits for individuals and communities, are cost-effective and recommended by WHO for wide use.79 These interventions fill the gap between community-level prevention efforts and more intensive treatment for alcohol dependant people.

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Selective alcohol interventions for people with HIV infection: an important component of positive prevention Similar to findings in other countries,80,81 a study in Cape Town showed that almost one in five adults with HIV infection met the criteria for alcohol abuse or dependence.44 At initial diagnosis of HIV and later visits for HIV care and treatment, healthcare providers should screen for hazardous or harmful use of alcohol, and specifically discuss the association between alcohol use and unsafe sex. As an HIV diagnosis commonly leads to changes in sexual behaviour, this is a critical opportunity to intervene, especially among HIV-positive men, in whom heavy drinking before sex remains common.44,82 In addition to supporting positive-prevention efforts, safer alcohol use might improve adherence to antiretroviral treatment.83

RESEARCH PRIORITIES Additional research is needed to document the steps necessary for broad implementation of alcohol screening within a range of health services. Prospective studies could document the feasibility of changing drinking patterns and drinking contexts in South Africa, and that this lowers the incidence of sexual violence and HIV. In the interim, evidence-based, simplified, but high-quality services are required. Studies of the effects of alcohol should use standard international indicators, especially when measuring patterns of drinking. To date, varying measures of total alcohol volume, drinking patterns and contexts have been used, hampering interpretation and direct comparisons between studies. Research is also needed to quantify the proportion of unsafe sex and sexual violence in South Africa that is attributable to alcohol use, and thus how much of the burden of HIV, other STIs and unintended pregnancy can be attributed to alcohol.

CONCLUSION Plans to reduce alcohol harm can build on lessons learnt in tobacco control and on increasing regional and international initiatives in this regard. Urgency for prevention interventions is clear, as are the drinking venues where such interventions are most needed. Alcohol-reduction interventions, within multicomponent HIV prevention packages, include addressing the context and patterns of alcohol use, as well as the availability of effective individuallevel interventions within health services.57,79,84 Campaigns against alcohol harm may take time to alter sexual behaviours, but are equally essential as more direct HIV prevention such as condom promotion. Far-reaching structural measures such as alcohol control create the conditions necessary for achieving sustained HIV prevention results. Implementing these measures to reduce the chronic burden of alcohol, and its mediatory effects on unsafe sex, sexual violence and HIV, is long overdue.

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