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Randomized Controlled Trial
. 2025 Jul;29(7):2312-2323.
doi: 10.1007/s10461-025-04694-y. Epub 2025 Apr 5.

Alcohol Use and the Pre-exposure Prophylaxis Continuum of Care Among Men in Rural South Africa: Results from a Longitudinal Study

Alison C Castle  1   2   3 , Jacob Busang  4 , Jaco Dreyer  4 , Carina Herbst  4 , Nonhlanhla Okesola  4 , Natsayi Chimbindi  4   5   6 , Thembelihle Zuma  4   5   6 , Jana Jarolimova  7   8 , Judith A Hahn  9 , Christina Psaros  8   10 , Sheela V Shenoi  11 , Maryam Shahmanesh #  4   5 , Mark J Siedner #  4   7   8   6
Affiliations
Randomized Controlled Trial

Alcohol Use and the Pre-exposure Prophylaxis Continuum of Care Among Men in Rural South Africa: Results from a Longitudinal Study

Alison C Castle et al. AIDS Behav. 2025 Jul.

Abstract

Despite freely available oral HIV pre-exposure prophylaxis (PrEP), HIV incidence among young men in South Africa remains high. This study explores the impact of alcohol use on PrEP initiation and continuation among South African men. We performed a secondary data analysis from a trial involving men aged 16-29, randomly selected in KwaZulu-Natal. Participants were referred to sexual health services, and those who were HIV negative and sexually active were offered oral PrEP. Alcohol consumption was categorized using AUDIT-C criteria as no/low risk (0-3) and hazardous alcohol use (4-12). Primary outcomes were PrEP initiation and continuation, defined as refilling prescriptions for ≥ 4 months. Logistic regression models adjusted for clinical and demographic confounders estimated relationships between PrEP initiation/continuation and alcohol use. Among 325 men analyzed, average age was 22.9 years (SD 3.6), with 146 (45%) reporting hazardous alcohol consumption. PrEP initiation was greatest among the hazardous/very-high risk group (40%), with the lowest uptake among men who do not use alcohol (17%). In multivariate analyses, those with hazardous alcohol use remained more likely to initiate PrEP compared to those with no/low risk alcohol use (aOR 1.96, 95%CI 1.13-3.40; p-value = 0.017). Only 27% (24/88) remained on PrEP at 4 months, with continuation similar between alcohol use groups (aOR 1.56, 95%CI: 0.47-5.12, p = 0.47). Hazardous alcohol use is prevalent among men in rural South Africa and associated with increased PrEP initiation. However, overall PrEP continuation was low and consistent across alcohol use levels. Hazardous alcohol use should not deter PrEP implementation efforts to engage young men.

Keywords: Alcohol; HIV prevention; Men; Pre-exposure prophylaxis; Retention; South Africa.

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Conflict of interest statement

Declarations. Conflict of interest: Dr. Hahn served as a consultant for Pear Therapeutics in 2022. All other authors declare no competing interests that are relevant to the content of this article. Ethical approval: The institutional review boards approved the Isisekelo Sempilo study at the University of KwaZulu-Natal Biomedical Research Ethics Committee (BREC/00000473/2019) and University College London Research Ethics Committee (5672/003). Consent to participate: Written informed consent was obtained from participants aged 18–29 years; written assent was obtained from participants aged 16–17 years, with written consent from their parents or guardian.

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