Prevention of Alcohol-Related HIV Risk Behaviors

"In developing countries battling severe HIV epidemics, addressing harmful drinking in conjunction with interventions to reduce sexual risk behavior may reduce HIV transmission more quickly than conventional HIV prevention interventions alone."

This technical brief from the Case Study Series from the United States Agency for International Development (USAID)'s AIDSTAR-One (AIDS Support and Technical Assistance Resources, Sector 1, Task Order 1) catalogues what is known about the relationship between harmful alcohol use and HIV sexual risk behaviour and offers a critical analysis of interventions to address the issue. It has been informed by a review of the published literature on alcohol and HIV, the AIDSTAR-One database of good and promising programmatic practices, and interviews with experts in the field of alcohol and HIV prevention.

As detailed here, research shows that in developing countries, alcohol use and HIV risk behaviour are strongly associated. More specifically, multiple studies have shown that drinking alcohol before sex or being intoxicated during sex is directly linked with HIV. Drinking venues themselves have also been associated with HIV risk, as they bring together the opportunity to drink alcohol and meet casual sex partners. Social science research has also elucidated the association between sexual risk-taking and alcohol use from a gendered perspective; for example, research has shown that for men, the capacity to drink heavily and engage in sex with multiple casual partners symbolised masculinity. Implications of this research for programme design:

• Conduct formative research to understand how people perceive the benefits of excessive alcohol use, including expectations that alcohol may increase the opportunity to attract a sexual partner or enhance the enjoyment of sex.
• Create messages that challenge the idea that alcohol use imparts physical strength or is associated with wealth, health, and masculinity.
• Increase awareness and understanding of what constitutes excessive alcohol use and the range of physical and social harms that are associated with it.
• Harness the force of peer influence to support risk reduction. Create messages that challenge the ways in which peers and social networks encourage risky behaviour.
• Ensure that condoms are available and heavily promoted at all venues where alcohol is consumed, especially where most-at-risk populations (e.g., sex workers and their clients) drink and socialise.
• When conducting HIV prevention activities at drinking venues, tailor messages and activities to the gender-specific needs of patrons.
• Provide alternative recreation opportunities for adults and youth so that bars are not the only places to go for socialising and entertainment.

Programmes specifically designed to address the link between alcohol and HIV are "extremely rare anywhere in the world." However, a small number of alcohol and HIV prevention interventions have been developed and implemented in sub-Saharan Africa and India. The characteristics, strengths, and limitations of each approach are described on pages 3-6 of the technical brief. In summary:

1. The HIV and Alcohol Prevention in Schools (HAPS) Project in KwaZulu-Natal Province, South Africa, uses a curriculum called "Our Times, Our Choices", designed for 9th graders to increase their knowledge about alcohol and HIV and to develop their skills in recognising and avoiding risks associated with alcohol use and sex. Core programme elements included: audio monologues delivered by 4 fictional characters describing their lives, as well as dilemmas about whether to use alcohol and/or have sex; peer leaders, elected by students, who receive two days of training to lead class discussions based on the monologues; exercises in which students explore positive alternatives to drinking alcohol and having sex; and role plays to give students the opportunity to practice strategies for resisting peer pressure to drink and/or have sex.

   A randomised controlled field trial showed that the programme significantly reduced the frequency of alcohol use before or during sex among those who became sexually active during the intervention (p < 0.05). Additionally, girls in the intervention group reported feeling more confident to refuse sex (p < 0.05). Among students who were sexually active before the intervention, intention to use a condom was higher among those in the intervention group than in the control.

1. As part of a brief alcohol and HIV risk reduction counselling programme in Cape Town, South Africa, a 60-minute HIV and alcohol risk reduction counselling session is delivered by trained counsellors to sexually transmitted infection (STI) clinic patients. The programme is based on the Information-Motivation-Behavioral Skills model of behaviour change, motivational interviewing techniques, and the World Health Organization brief alcohol counselling model.

   A randomised controlled intervention trial showed that alcohol use before or during sex and expectancies that alcohol use enhances sexual experiences were both lower among participants receiving the counselling session. Intervention participants also had a 25% increase in condom use and a 65% reduction in unprotected sex in the six months after the session.

1. An peer opinion leader (POL)-led HIV and alcohol prevention programme in wine bars in Chennai, India included: behavioural surveillance of wine bar patrons' alcohol use patterns and sexual risk behaviour; identification of a cadre of POLs among wine bar patrons; training of POLs using a standardised curriculum, culturally adapted for the Chennai wine bar context, delivered during 5 weekly sessions; and POL engagement in conversations with members of their social networks at the wine shops. According to programme organisers, "a cadre of POLs was successfully recruited and trained, with high acceptability of the program among bar patrons."

Challenges and barriers to prevention of alcohol-related HIV risk, and they are outlined within the technical brief. Some of the communication-related take-home messages include:

• "Successful programs will be based on an understanding of the social values attached to drinking and will need to provide alternative activities through which the same or similar social bonding can take place."
• "Alcohol production and retail sale are vibrant industries in the developing world, contributing significantly to national tax revenue as well as to household livelihoods....In order for programs to effectively address the intersection of alcohol use and HIV risk, producers, retailers, and consumers of alcohol need to be included in the process of program development."
• "The proliferation of informal, home-based alcohol selling in poor communities poses a structural barrier that is not easily overcome by individual or even community-level responses. Policies to assist impoverished communities in gaining access to other livelihoods are a crucial component of any approach to reducing alcohol-related HIV risk."
• Strategies need to be developed to ensure that families, communities, and national governments provide a supportive social and policy environment for sustainably reducing the wide range of negative effects of hazardous drinking, including HIV risk."
• "Those who drink most heavily may be in need of alcohol dependency treatment before they can be receptive to HIV prevention messages. Awareness-raising combined with simple risk reduction messaging may be sufficiently effective for light drinkers, while moderate drinkers are likely to need awareness-raising and intensive skills-building in how to avert risks associated with drinking."
• "The broad range of existing HIV prevention programming provides excellent opportunities to integrate content about alcohol use. For example...[i]n mass media approaches to HIV prevention, such as serial radio or television dramas, barbased or alcohol-related scenarios can be easily incorporated to help viewers learn about how alcohol may exacerbate risk and how those risks can be averted. Existing community-based prevention programs can plan outreach activities to drinking venues in order to provide activities tailored to alcohol drinkers."