Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa

Abstract

Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked. Physiological and behavioural research indicates that alcohol independently affects decision-making concerning sex, and skills for negotiating condoms and their correct use. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care), must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.

Figure 1

Do personality types confound associations between alcohol and unsafe sex or is alcohol an intermediate factor on the causal pathway between personality and unsafe sex?. In the confounding theory, the association between heavy drinking episodes and unsafe sex (arrow B) is explained by the confounding factor of personality types (arrows A). In this model, a reduction in heavy drinking would have no effect on unsafe sex as personality types are independently associated with unsafe sex (Arrow C). In the causal pathway theory, heavy drinking is an intermediary factor in the causal pathway between personality types and unsafe sex (arrow D plus E). Prevention of heavy episodic drinking would reduce the portion of unsafe sex attributable to arrow E, though will have no effect on the contribution of arrow F.