Download Alcohol use and adherence to ART

The Role of Alcohol Use in the Development of
the HIV/AIDS Epidemic:
The international knowledge base with an
emphasis on Sub-Saharan Africa
NEO K MOROJELE, PHD
CONNIE T KEKWALETSWE, PHD
Alcohol and Drug Abuse Research Unit
SOUTH AFRICAN
MEDICAL RESEARCH COUNCIL
OVERVIEW
• Alcohol use and risk for contraction of HIV
• Alcohol use and progression of HIV disease
• Alcohol use and non-adherence to antiretroviral
therapy (ART)
• Conclusions and Implications
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Alcohol use and contraction of HIV
• There has been much interest in the links between
alcohol use, sexual risk behaviour and HIV in SubSaharan Africa (SSA) in recent years
• Much research shows strong links between alcohol use
and HIV infection
• Mixed results on relationship between alcohol use and
sexual risk behaviour (i.e. unprotected sex and sex with
multiple partners)
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Alcohol use and HIV Infection in Africa
(Fisher, Bang & Kapiga, 2007)
• A systematic review and meta-analysis of studies reporting
links between alcohol use and HIV
• Aim: to determine whether there is a relationship between
alcohol and HIV infection across studies
• 20 studies conducted in Africa:
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Tanzania (N = 6)
Kenya (N = 4)
Zimbabwe (N = 3)
South Africa (N = 3)
Uganda (N = 2)
Botswana (N = 1)
Ethiopia (N = 1)
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Association between alcohol use
and HIV Infection
Study (Number of studies)
Pooled Odds Ratio (95%
Confidence Interval)
All studies (20)
1.70 (1.45-1.99)
Males (10)
1.91 (1.57-2.33)
Females (16)
1.90 (1.68-2.19)
High risk populations (12)
2.01 (1.56-2.58)
Source: Fisher et al. (2007)
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Comment
• Alcohol users have a 70% greater chance than non-users
of being HIV+
• Comparable odds ratios observed across samples
• Odds ratios greater among high-risk drinkers suggestive of
“crude dose-response” relationship with HIV infection
• However, causality not established
• So what are the potential mechanisms in operation?
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Potential mechanism 1
Fisher et al. (2007)
Alcohol
consumption
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Sexual risk
behaviour
HIV
Infection
Potential mechanisms 2
Fisher et al. (2007)
Alcohol
consumption
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Gender-based
violence
HIV
Infection
Potential mechanism 3
Fisher et al. (2007)
Alcohol
consumption
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Immune response
HIV
Infection
Alcohol Consumption and
Sexual Risk Behaviour
• Alcohol consumption and sex with multiple
partners
• Alcohol consumption and engagement in
unprotected sex
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ALCOHOL CONSUMPTION AND
SEX WITH MULTIPLE PARTNERS
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Correlations between number of sexual partners and
alcohol use among adults in a community study (N = 160)
Past month
frequency
Typical
quantity
Problem
drinking
.16
.25*
.25*
Number of
sexual partners
*p < .01
Source: Morojele et al. (2006)
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Source: Nelson Mandela/HSRC HIV/AIDS national
household survey (Shisana et al., 2004)
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ALCOHOL CONSUMPTION
AND CONDOM USE
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Correlations between condom use and alcohol use among
adults in a community study (N = 160)
Past month
frequency
Typical
quantity
Problem
drinking
-.11
-.22
-.15
Consistent
condom use
Note: All correlations not statistically significant
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EVENT LEVEL ANALYSIS
Does drinking before or during a sexual event reduce
condom use during that event?
Leigh (2002): Meta-analysis of event-level studies
examining condom use and alcohol use during sexual
events
13 studies were included in the analyses. The studies
mainly involved:
- North American samples (N=9)
- Adults (N=8)
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Association between alcohol use and condom use
Summary Odds Ratio
95% CI
All
0.90
0.81-0.99
First sex
0.54
0.44-0.66
Recent sex
1.04
0.89-1.21
Recent sex, new partner
1.10
0.92-1.32
Adolescents
0.71
0.61-0.83
Adolescents: Recent sex
0.92
0.75-1.14
Source: Leigh (2002)
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Summary
• Overall, alcohol use was found TO BE
associated with non-condom use:
- At first intercourse
- For adolescents in general (trend)
• Overall, alcohol use was found to NOT be
associated with condom use:
- For adults in general
- For adolescents and adults – recent sexual encounters
- For adults – recent sex with new partner
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Comment
• No consideration of quantities of alcohol
consumed
• Studies conducted primarily in North America
and Europe
• Generalisability of findings to Sub-Saharan
countries unknown
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Conclusion: Alcohol consumption
and sexual risk behaviour
The link seems to be a function of:
 Consumption patterns: Quantity/intoxication/hazardous drinking related
most strongly to sexual risk behaviours
 Consumption settings/contexts: Drinking venues (opportunities for
meeting partners; environment)
 Consuming in presence of whom: casual partners/prospective
partners/sex workers
 Consumer characteristics: younger, inexperienced, male, alcohol
expectancies
 Type of sexual risk behavior – alcohol use is more strongly linked to sex
with multiple partners than with unprotected sex
 Type of sexual partner – alcohol use at last sex more likely with casual
partners, but condom use more likely with casual partners
THE LINKS BETWEEN ALCOHOL CONSUMPTION AND SEXUAL
RISK BEHAVIOUR ARE INDEED COMPLEX
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Role of alcohol use in the
progression of HIV disease
Does alcohol consumption affect the progression
of the HIV disease?
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Alcohol use and disease progression
• Alcohol use has been shown to hasten HIV disease
progression (e.g. Conigliaro et al., 2003; Hao rah et al.,
2004; Samet et al. 2003; Wang et al., 2002).
• Some evidence that the effect is particularly compelling
for those on ART (Samet et al., 2003; Miguez et al.,
2003).
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Mechanisms/hypotheses
• Alcohol (ethanol) leads to hepatotoxicity, which in turn
reduces the liver’s efficiency, hence reducing availability of
ART to curtail replication of HIV (e.g. Conigliaro et al.,
2003).
• Disease progresses faster among alcohol-using ART
patients than non-drinking ART patients, as drinker’s
adherence levels are lower (Samet et al., 2003).
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Comment
• Research findings on the links between alcohol
consumption and disease progression are mixed
• Effects of alcohol on disease progression worst among
those on ART and for hazardous drinkers
• More research is needed on the issue
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Alcohol use and
adherence to ART
Adherence: “extent to which patients carry out the behaviours and
treatments as recommended by their practitioners/doctors”
(Sarafino, 2005)
Most research suggests that to attain optimal therapeutic outcomes of
antiretroviral therapy (ART) requires at least 95% adherence level
(Palella et al., 1998; Paterson et al., 2000).
Despite early scepticism, adherence rates in Africa compare to
developed world & in some cases > than developed world (Attaran,
2007; Mills et al., 2006; Orrell et al., 2003).
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Reasons for non-adherence to ART
Predominant reasons for non-adherence in developing world relative to
developed world:
– Disrupted access to medication
– Medications out of stock
– Financial difficulties
– Transport problems
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Studies on alcohol use and adherence to ART
• Numerous studies indicate that heavy alcohol use is
associated with sub-optimal adherence to ART (Arnsten
et al., 2002; Braithwaite et al., 2005; Cook et al., 2001;
Halkitis et al., 2004; Wolitski & Remien, 2003; Spire et al.,
2002)
• Strong dose-response relationship found between alcohol
consumption and poor ART adherence (Braithwaite et al.,
2005)
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African studies on adherence and alcohol use
Few studies have been conducted on hazardous alcohol use as barrier
to adherence to ART in Africa, despite increasing discussion of this
issue (e.g. Alcohol & Infectious Diseases Technical meeting, July,
2008; PEPFAR meeting in Dar es Salaam, 2006)
African studies on alcohol and ART adherence have mixed results:
One study: a history of alcohol abuse was associated with increased
odds of poor adherence (Selin et al., 2007).
However, other studies fail to observe such a relationship (e.g. crosssectional study conducted in Kampala, Uganda among 304 HIV+
individuals on ART, found that the use of alcohol was not associated
with ART adherence (Byakika-Tusiime et al., 2005).
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Mechanisms to explain the relationship
Potential mediators of relationship between alcohol use and suboptimal ART adherence:
A) cognition/judgment/short-term memory impairment (forgetting)
B) beliefs about ART-alcohol interactions
C) possible depression (hopelessness and pessimism about the
future/efficacy of ART)
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Conclusions
• Despite need for more research, important to consider potential role
of alcohol consumption in non-adherence to ART
• Of concern is denial of ART to alcohol users who are assumed to
be likely to be non-adherent
• Possible effects of alcohol use on adherence need to be assessed
on a case-by-case basis, from initial enrolment onto ART
programmes, and throughout individual’s treatment
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IMPLICATIONS
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Alcohol, sexual risk behaviour and HIV/AIDS
• Policy and programmatic intervention programmes that
reduce both alcohol consumption and risky sexual
behaviours are needed
• Interventions should take into account the complexity of
the relationship between alcohol use and sexual risk
behaviour
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Implications for intervention programmes
Consideration should be given to:

Consumption patterns - interventions should focus on hazardous
alcohol use (which is common pattern of consumption in SSA)

Consumption settings/contexts - interventions may be conducted
in drinking venues

Type of sexual risk behavior - focus should be on reducing sex
with multiple partners as well as unprotected sex

Type of sexual partner – focus should be on sex with casual
partners (where condom use is greater), as well as with regular
partner/spouse
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Alcohol consumption and
disease progression
• Need for alcohol counselling and treatment for
individuals with HIV disease who use ART
• Efforts should be made to reduce alcohol consumption
among HIV+ people
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Alcohol consumption and
non-adherence to ART
• Research is urgently needed on the role of alcohol in
non-adherence to ART
• Need for integrated HIV and alcohol treatment services
• Training of service providers (e.g. adherence
counsellors) required to enhance their ability to
appropriately serve HIV+ patients who consume alcohol
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CONCLUSION
• Alcohol consumption plays varying roles in HIV disease
transmission, progression and non-adherence to ART
• Alcohol use interventions should be incorporated into
HIV prevention and treatment intervention efforts as a
matter of urgency
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ACKNOWLEDGEMENTS
• Centers for Disease Control and Prevention (CDC)
• National Institutes of Health (NIH)
• South African Medical Research Council (MRC)
• World Health Organization (WHO)
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