Neo K. Morojele

Substance Use, Sexual Risk, and Violence: HIV Prevention Intervention with Sex Workers in Pretoria

This paper describes an HIV prevention intervention designed in the US that was adapted and implemented in South Africa. Using an experimental design, 93 women who reported recent substance use and sex trading were randomly assigned to a modified Standard HIV intervention or to a Woman-Focused HIV prevention intervention. Eighty women completed the one-month follow-up interview. Participants reported high rates of sexual risk and violence at baseline. At follow-up, findings showed decreases in the proportion of women reporting unprotected sex and the daily use of alcohol and cocaine. Daily alcohol and cocaine use decreased more for women receiving the Woman-Focused intervention. Although violence continued to be a problem, at follow-up Woman-Focused participants reported being victimized less often than women receiving the Standard intervention. This study demonstrates the feasibility of implementing cross-cultural behavioral HIV prevention interventions, and supports the need for future studies of womens contextual issues and the effectiveness of targeted interventions.

Alcohol: the forgotten drug in HIV/AIDS

Alcohol has long been recognized as a significant contributor to illness and injury, accounting for 4% of the global burden of disease.1 Yet alcohol remains conspicuously absent from the larger field of HIV and substance use research and programming. Perhaps because of its very ubiquity, alcohol use remains an easily overlooked backdrop of HIV epidemics around the world. Patterns of hazardous alcohol consumption prevail in countries experiencing the most severe HIV epidemics, most notably in eastern and southern Africa (Figure 1). In South Africa, for example, where nearly one out of five sexually active adults is HIV positive, the yearly per capita consumption of alcohol is among the highest in the world.3 Strikingly, hazardous drinking patterns also dominate in the concentrated epidemics of Eastern Europe and Asia, where alcohol use among IDU and other marginalized groups may be an additional barrier to effective HIV prevention efforts. Figure 1 Global Distribution of Hazardous Alcohol Use. Based on data from the Comparative Risk Assessment for Alcohol, Global Burden of Disease 2000 study. Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, Sempos C, Frick U, Jernigan D. Alcohol use. In: M. ... Numerous studies conducted in southern and eastern Africa have shown that alcohol use is associated with prevalent and incident HIV infection as well as the behaviours that lead to infection, including unprotected sex, multiple partnering and commercial sex.4 Drinking venues themselves are, not surprisingly, associated with HIV risk.5,6 The pharmacological properties of alcohol help explain a portion of the widely observed association between alcohol use and sexual risk behaviour.7 A nexus of psychological and social influences also appears to be at play. 8,9 A substantial body of research implicating alcohol consumption in sexual risk behaviour provides a compelling call to action. Lessons learned from the small amount of intervention research that has taken place on alcohol-related HIV risk closely mirrors many of the key messages put forth in the paper by Strathdee et al (this issue). We echo the importance of intervening on the structural and environmental influences that shape risk practices and vulnerability to HIV. Because alcohol is a legal commodity in most countries and is typically consumed in public social environments, alcohol-serving venues (both formal and informal) create dynamic opportunities for structural HIV prevention interventions. The most widely tested venue-based interventions have used bar patrons themselves as agents of change to shift community norms and behaviour.10 Implemented in US gay bars, these interventions were shown effective throughout the 1990s but unfortunately have not been replicable in other countries. More successful interventions have infused HIV prevention services into high-risk drinking venues using multilevel models that attempt to simultaneously change individual behaviour, shift social norms, and change HIV prevention policies. One example of a multilevel venue-based intervention was tested in the Philippines with sex workers in bars, discos, and night clubs.11 Peer counselling, focused on condom use and sexual negotiation skills, formed the basis for individual and social norm change. Changes to the bar environment were achieved through working with bar managers to implement HIV prevention practices. The combination of individual, social and environmental intervention elements demonstrated a significant impact on condom use and reductions in subsequent STI. While interventions aimed at social and physical structures within drinking environments appear promising, they have not thus far addressed broader social factors underlying alcohol-associated HIV risks, such as disproportionate gender power-imbalances. Hazardous alcohol use is often assumed primarily to affect men, but it is clear that women are harmed in large numbers by alcohol use—either their own or that of their partner. Women are at risk of alcohol-related sexual risk behaviour in multiple ways. Women who sell and serve alcohol in bars, hotels and other venues, are at increased risk of drinking alcohol themselves, engaging in unprotected sex with their clients, and HIV infection.12 Women’s risk of gender-based and sexual violence is also increased by their partner’s alcohol consumption. Without addressing gender, efforts to reduce alcohol-related sexual risk behaviour may only be partially successful. Programs combining alcohol reduction and gender transformative approaches are needed to reduce sexual risk behaviour and HIV incidence, particularly in resource constrained settings characterized by episodic binge drinking, gender inequalities and high rates of HIV infection. More research, conducted by gender and alcohol researchers jointly, is needed to determine methods of integrating gender into programs focused on reducing alcohol-related sexual risk behaviour and may offer valuable lessons for the wider field of HIV and substance use research.

Trends in alcohol prevalence, age of initiation and association with alcohol-related harm among South African youth: Implications for policy

OBJECTIVES To understand alcohol use trends and alcohol-related harm among youth in South Africa (SA) between 1998 and 2008, and discuss implications for the current alcohol policy process. METHODS A review was conducted of 4 national prevalence and 2 sentinel surveillance studies. Data were extracted to Epi Info (version 7) and chi-square analyses undertaken. RESULTS. Lifetime alcohol use remained stable but high at 20 - 25% and 49.1 - 49.6% according to South African Demographic and Health Survey (SADHS) and Youth Risk Behaviour Survey (YRBS) data, respectively. Age of initiation remained stable; 12% of adolescents initiated alcohol use prior to age 13 years. Significant gender differences existed with more males having ever consumed alcohol, engaged in binge drinking, and driven or walked under the influence of alcohol (DUI and WUI, respectively). Binge drinking among females increased significantly from 27% to 36% (SADHS) and 18% to 27% (YRBS). DUI and WUI increased. Homicide/violence, suicide and unintentional deaths were significantly associated with blood alcohol concentration (BAC). CONCLUSIONS Although SA has made significant strides in alcohol control and prevention of alcohol-related harm over the past decade, early alcohol initiation remains a concern and binge drinking is increasing, especially among females. Significant associations exist between BAC and alcohol-related fatalities. Findings imply that regulatory policies are inadequate; additional efforts are required to ensure that control strategies translate into a reduction in harmful alcohol use by SA youth.

Clinical presentations and diagnostic issues in dual diagnosis disorders

Purpose of review The co-occurrence of mental disorders and substance use disorders (SUDs) is very common, and associated with substantial psychiatric morbidity, functional and quality of life impairments, and societal costs. However, dual disorders are often underdetected, misdiagnosed and inadequately treated in both substance abuse and mental health settings. Recent findings Individuals with dual or multiple disorders generally have worse clinical features and long-term outcomes than those with single disorders. However, findings can vary depending on factors such as type(s) of psychiatric disorder(s) and substance(s) involved, and whether the mental disorder is primary or secondary, or substance-induced or independent. Underdiagnosis or misdiagnosis of dual disorders may occur due, in part, to the use of measurement instruments and diagnostic approaches that have uncertain clinical utility. Summary Routine, thorough, and integrated screening and diagnosis of dual disorders are needed to facilitate implementation of appropriate treatment. Results suggest that forthcoming revisions to the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases should categorize and define mental and SUDs such that clinicians can more readily detect and diagnose all types of substance use and mental health comorbid conditions. Adoption and widespread use of appropriate screening, assessment and diagnostic instruments, and more thorough diagnostic (clinimetric) approaches are recommended.

Measurement of Risk and Protective Factors for Drug Use and Anti-Social Behavior among High School Students in South Africa

The study sought to examine, for South African adolescents: 1) the reliability of sub-scales of the Communities that Care Youth Survey (CTC Youth Survey) of risk and protective factors for drug use and anti-social behavior; and 2) the extent to which tobacco, alcohol and marijuana use can be predicted from community, family, school, and peer-individual factors based on sub-scales of the CTC Youth Survey. On two occasions, 92 male and 31 female, Grade 8 and 11 students completed measures concerning: 1) their past month tobacco, alcohol and marijuana use; and 2) various community, family, school, and peer-individual factors. Cronbach alpha coefficients of sub-scales of the questionnaire ranged between .60 and .94. Kappa values were at least moderate (above .40) on 19 sub-scales, and on the remaining sub-scales observed agreement levels ranged between .49 and .94. Each domain predicted tobacco, alcohol, and marijuana use. Multiple logistic regression analyses revealed that alcohol use was most strongly accounted for by the peer domain, tobacco use by the school domain, and marijuana use by the peer and community domains. The findings support use of the CTC Youth Survey, with slight revisions, among South African high school students.

Alcohol use antiretroviral therapy adherence and preferences regarding an alcohol-focused adherence intervention in patients with human immunodeficiency virus.

Background The primary objectives of this study were to determine the association between alcohol and antiretroviral therapy (ART) adherence and the perceived appropriateness and acceptability of elements of an adherence counseling program with a focus on alcohol-related ART nonadherence among a sample of ART recipients in human immunodeficiency virus (HIV) clinics in Tshwane, South Africa. Methods We conducted a cross-sectional study with purposive sampling. The sample comprised 304 male and female ART recipients at two President’s Emergency Plan For AIDS Relief-supported HIV clinics. Using an interview schedule, we assessed patients’ alcohol use (Alcohol Use Disorders Identification Test), other drug use, level of adherence to ART, and reasons for missing ART doses (AIDS Clinical Trials Group adherence instrument). Additionally, patients’ views were solicited on: the likely effectiveness of potential facilitators; the preferred quantity, duration, format, and setting of the sessions; the usefulness of having family members/friends attend sessions along with the patient; and potential skill sets to be imparted. Results About half of the male drinkers’ and three quarters of the female drinkers’ Alcohol Use Disorders Identification Test scores were suggestive of hazardous or harmful drinking. Average self-reported ART adherence was 89.7%. There was a significant association between level of alcohol use and degree of ART adherence. Overall, participants perceived two clinic-based sessions, each of one hour’s duration, in a group format, and facilitated by a peer or adherence counselor, as most appropriate and acceptable. Participants also had a favorable attitude towards family and friends accompanying them to the sessions. They also favored an alcohol-focused adherence counseling program that employs motivational interviewing and cognitive behavioral therapy-type approaches. Conclusion The association between alcohol use and ART nonadherence points to a need for alcohol-focused ART adherence interventions. Patients’ perceptions suggest their amenability to clinic-based brief motivational interviewing and cognitive behavioral therapy-type adherence interventions delivered by lay persons in group settings. Further research should investigate how best to implement such interventions in the existing health system.

The association between substance use and common mental disorders in young adults: results from the South African Stress and Health (SASH) Survey

Introduction Although substance use is commonly associated with mental disorders, limited data on this association are available from low and middle income countries such as South Africa. The aims of the study were i) to determine patterns of substance use in young adults, ii) to identify trends of common psychiatric disorders in relation to use of specific substances, and iii) to determine whether specific psychiatric disorders were associated with use of specific substances in the South African population. Methods Data were drawn from the South African Stress and Health (SASH) study, a nationally-representative, cross-sectional survey of South African households that forms part of a World Health Organisation (WHO) World Mental Health (WMH) initiative to standardise information on the global burden of mental illness and its correlates. Data from a subset (n = 1766; aged 18 to 30 years) of the SASH sample of 4351 individuals were analysed. The Composite International Diagnostic Interview Version 3 (CIDI 3.0) was used to elicit basic demographic details and information regarding mental illness and substance use. Multiple regression analyses, adjusted for age and gender, were used to identify associations between mental disorders and substance use. Results Significant associations were found between substance use and mood and anxiety disorders, with a particularly strong relationship between cannabis use and mental disorder. Conclusion The results are consistent with those from previous studies, and reinforce the argument that comorbid substance use and mental disorders constitute a major public health burden.

Factors associated with female high-risk drinking in a rural and urban South African site

OBJECTIVE To assess and compare the extent of high-risk drinking and factors associated with high-risk drinking in the adult female population of a rural and an urban region in South Africa. DESIGN Cross-sectional household survey using multistage sampling methods. Setting. A rural wine farming area of the Western Cape and an urban site in Gauteng. Subjects. Women of reproductive age (18 - 44 years). Outcome measures. The extent of risky alcohol consumption measured using the Alcohol Use Disorders Identification Test (AUDIT) scale which categorises current drinkers into high- and low-risk drinkers. RESULTS Twenty-seven per cent (166/606) and 46% (188/412) of the women interviewed in Gauteng and the Western Cape respectively were current drinkers. In turn, 20% (33/166) of the Gauteng current drinkers and 68% (128/188) of the Western Cape current drinkers were classified as high-risk drinkers. Multivariate analysis indicated that employed people in Gauteng were less likely to be high-risk drinkers (odds ratio (OR) 0.3, 95% confidence interval (CI) 0.1 - 0.8). Living in a household that never/seldom went hungry was inversely associated with risky drinking for both sites (OR 0.3, 95% CI 0.1 - 0.9 for Gauteng and OR 0.2, 95% CI 0.3 - 1.2 for the Western Cape). Current smokers (Western Cape) (OR 7.6, 95% CI 3.1 - 18.9) and respondents with an alcohol problem in one or more family members (both sites) (OR 6.0, 95% CI 2.3 - 15.7 and OR 3.1, 95% CI 1.5 - 6.4) were more likely to be high-risk drinkers. CONCLUSIONS High-risk drinking by women is a major problem, especially in the Western Cape. Targeted interventions are needed for women with alcohol problems in the family setting, lower socio-economic status, and concurrent substance abuse.

Individual latent growth curves in the development of marijuana use from childhood to young adulthood.

The present study was designed to examine the relationship between unconventionality and marijuana use over time. The sample for this paper consisted of 532 male and female participants interviewed during early adolescence, late adolescence, their early twenties, and their late twenties. Latent growth modeling was used. The findings indicated that (1) the influence of initial unconventionality (T2) on initial marijuana use (T2) was stronger for males, (2) unconventionality at T2 was not significantly related to overall rate of growth in marijuana use, and (3) change in unconventionality was related to overall growth rate of marijuana use. The implications of the findings for prevention and treatment are discussed.

Patterns and predictors of antiretroviral therapy use among alcohol drinkers at HIV clinics in Tshwane, South Africa

Alcohol use is associated with compromised antiretroviral therapy (ART) adherence. We aimed to identify patterns and predictors of ART use among alcohol drinkers. Using purposive sampling, we recruited 304 male and female patients from two ART clinics in Tshwane, South Africa. Interviews were conducted using a structured questionnaire comprising measures of demographic factors, psychosocial factors (i.e., ART adherence, self-efficacy beliefs, alcohol and ART interactions beliefs, ART-alcohol outcome expectancy, attitude towards drinking alcohol and taking ART and HIV stigma) and alcohol use (AUDIT). Data were analysed using descriptive statistics and three multivariate linear regressions. Forty percent of the sample reported drinking alcohol. Half of the drinkers endorsed one of three unique patterns of ART use: (1) dosing ART earlier than required (2) taking ART while drinking alcohol and (3) skipping ART doses. The other half endorsed combinations of ART use on drinking days, for example, earlier ART dosing and taking ART while drinking alcohol was the most common combination. High adherence perseverance (a self-efficacy subscale) and a non-favourable attitude towards drinking alcohol and taking ART predicted the unique pattern of taking ART early when planning to drink alcohol. The unique pattern of taking ART despite drinking alcohol was predicted by higher levels of education (marginal significance) and experiencing low HIV stigma. A high score on the AUDIT and experience of high stigma predicted the unique pattern of skipping ART doses when drinking alcohol. Patterns of ART taking in alcohol drinkers in this sample are varied, and not always mutually exclusive. This apparent complexity of medication taking patterns among alcohol drinkers warrants further exploration. Furthermore, the finding that different psychosocial factors predict different ART-taking patterns suggests a need for programmes to improve alcohol-related non-adherence to ART to be multifaceted.