Pilot Trial Results of Mlambe: An Economic and Relationship-Strengthening Intervention to Address Heavy Drinking and Adherence to Antiretroviral Therapy in Malawi

Abstract

We evaluated the feasibility, acceptability, and preliminary efficacy of an economic and relationship-strengthening intervention to reduce heavy alcohol use among couples living with HIV in Malawi (Mlambe). Mlambe consisted of training on financial literacy and relationship skills, combined with 1:1 matched savings accounts to invest in an income-generating activity. In a randomized controlled trial, we compared Mlambe to enhanced usual care (EUC). We enrolled 78 married couples having a partner on antiretroviral therapy (ART) who reported heavy alcohol use based on the AUDIT-C. Using targets of 75%, primary outcomes included retention rates at 10 and 15-months, session attendance rates, and satisfaction with Mlambe. Exploratory outcomes were heavy alcohol use (AUDIT-C and/or PEth positive), number of drinking days in the past month, AUDIT-C score, optimal adherence to ART (95% or higher), and viral suppression. We exceeded our targets for feasibility and acceptability metrics. Retention rates were 96% at 15-months. Session attendance and satisfaction levels were both 100%. From baseline to 15-months, Mlambe participants reported decreases in mean number of drinking days (from 6.8 to 2.1) and AUDIT-C scores (from 7.5 to 3.1); while ART adherence rates improved across the same period (from 63.2 to 73.9%). Participants in Mlambe, as compared to those in EUC, had lower rates of heavy alcohol use (89.5% vs. 97.2%) and higher rates of viral suppression (100% vs. 91.9%) at 10-months. Differences between arms were not statistically significant in this small pilot study. Mlambe was highly feasible and acceptable, and shows promise for reducing heavy alcohol use and viral non-suppression among couples with HIV in a larger efficacy study.

Keywords: Antiretroviral therapy; Couples; Economic intervention; HIV/AIDS; Heavy alcohol use; Sub-Saharan Africa.

Fig. 1

CONSORT diagram for randomized controlled trial of the Mlambe intervention versus an enhanced usual care (EUC) control arm

Fig. 2

Self-reported alcohol use and adherence to ART over the study period. (A) Mean self-reported number of drinking days in the past 30 with 95% confidence intervals (index patients, N = 78). (B) Percentage reporting optimal ART adherence (all participants on ART, N = 141) with 95% confidence intervals