Search

In Sub-Saharan Africa, efficacy trials of brief interventions to reduce unhealthy drinking among persons living with HIV (PLWH) have yielded mixed results. A better understanding of the perceptions of drinking, especially by PLWH, and how drinking is talked about at HIV treatment clinics in this setting, may guide more optimal designs for future trials. We conducted a qualitative study at an HIV treatment clinic in South Western Uganda to better understand perceptions of drinking, how drinking is talked about, and perceptions of interventions, especially a protocolled screening and brief intervention (SBI) for unhealthy drinking among PLWH. We conducted in-depth interviews with 17 PLWH who engaged in unhealthy drinking and 6 health workers, and one focus group discussion with 3 community advisory-board members. We performed manual preliminary data analysis and computer-assisted detailed thematic analysis to identify emergent themes. Four themes emerged: perceptions of alcohol use in the general population; perceptions of alcohol use in PLWH; interaction between PLWH and health workers about alcohol use; perceptions of interventions for unhealthy drinking including SBI. Unhealthy drinking was seen as a problem in the general population and among those with HIV, where it was negatively perceived. Communication about drinking was done by counselors, but doctors participated in screening for unhealthy alcohol use. Messages about drinking covered reduction and abstinence. Participants expressed positive attitudes towards SBI and preference for person-delivered SBI over technological alternatives. A protocolled SBI for unhealthy alcohol use among PLWH would be well-received but successful implementation may depend on mode of delivery. [ABSTRACT FROM AUTHOR]

Background: Social desirability can negatively affect the validity of self-reported measures, including underreporting of stigmatized behaviors like alcohol consumption. The Marlowe-Crowne Social Desirability Scale (SDS) is widely implemented and comprised of Denial and Attribution Domains (i.e., tendencies to deny undesirable traits or attribute socially desirable traits to oneself, respectively). Yet, limited psychometric research has been conducted in sub-Saharan Africa, where the prevalence of unhealthy alcohol consumption is high as well as religiosity and hierarchical social norms. To address this gap, we (a) conducted an exploratory study assessing certain psychometric properties of the 28-item SDS (Runyankole-translated) among persons with HIV (PWH) in Uganda, and (b) examined the relationship between social desirability and self-reported alcohol use. Methods: We pooled baseline data (N = 1153) from three studies of PWH engaged in alcohol use from 2017 to 2021. We assessed the translated scale's construct validity (via confirmatory factor analysis), internal consistency, item performance, differential item functioning by gender, concurrent validity with the DUREL religiosity index domains, and the association between social desirability and self-reported alcohol use. Results: Participants had a mean age of 40.42 years, 63% were men, and 91% had an undetectable HIV viral load. The 28-item SDS had satisfactory construct validity (Model fit indices: RMSEA = 0.07, CFI = 0.84, TLI = 0.82) and internal consistency (Denial Domain ΩTotal = 0.82, Attribution Domain ΩTotal = 0.69). We excluded Item 14 ("I never hesitate to help someone in trouble") from the Attribution Domain, which mitigated differential measurement error by gender and slightly improved the construct validity (Model fit indices: RMSEA = 0.06, CFI = 0.86, TLI = 0.85) and reliability (Attribution Domain ΩTotal = 0.72) of the 27-item modified SDS. Using the 27-item SDS, we found that social desirability was weakly correlated with religiosity and inversely associated with self-reported alcohol use after adjusting for biomarker-measured alcohol use and other confounders (β = -0.05, 95% confidence interval: -0.09 to -0.01, p-value = 0.03). Conclusions: We detected and mitigated measurement error in the 28-item Runyankole-translated SDS, and found that the modified 27-item scale had satisfactory construct validity and internal consistency in our sample. Future studies should continue to evaluate the psychometric properties of the Runyankole-translated SDS, including retranslating Item 14 and reevaluating its performance. [ABSTRACT FROM AUTHOR]

Background: Smoking and alcohol use frequently co-occur and are the leading causes of preventable death in sub-Saharan Africa (SSA) and are common among people living with HIV (PLWH). While alcohol use has been shown to be associated with reduced adherence to antiretroviral treatment (ART), which may affect HIV viral suppression, the independent effect of smoking on HIV outcomes in SSA is unknown. We aimed to 1) describe the prevalence of current smoking and correlates of smoking; 2) assess the association of smoking with viral suppression, adjusting for level of alcohol use; 3) explore the relationship between smoking and CD4 cell count <350 cells/mm3, among participants who are virally suppressed. Methods: We analyzed data from the Drinkers Intervention to Prevent Tuberculosis (DIPT) and the Alcohol Drinkers' Exposure to Preventive Therapy for TB (ADEPTT) studies conducted in Southwest Uganda. The studies enrolled PLWH who were on ART for at least 6 months and co-infected with latent tuberculosis and dominated with participants who had unhealthy alcohol use. Current smoking (prior 3 months) was assessed by self-report. Alcohol use was assessed using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C, modified for prior 3 months) and phosphatidylethanol (PEth), an alcohol biomarker. We used logistic regression to estimate the cross-sectional association between smoking and lack of virological suppression (≥40 copies/ml), adjusting for level of alcohol use and other covariates, and to examine the association between smoking and CD4 cell counts among PLWH with viral suppression. Results: Of the 955 participants enrolled from 2017 to 2021 who had viral load (VL) results, 63% were men, median age was 40 years (interquartile range [IQR] 32–47), 63% engaged in high/very high-risk alcohol use (AUDIT-C≥6 or PEth≥200 ng/mL), and 22% reported smoking in the prior 3 months. Among 865 participants (91%) with viral suppression and available CD4 count, 11% had a CD4 cell count <350 cells/mm3. In unadjusted and adjusted analyses, there was no evidence of an association between smoking and lack of virological suppression nor between smoking and CD4 count among those with viral suppression. Conclusions: The prevalence of smoking was high among a study sample of PLWH in HIV care with latent TB in Southwest Uganda in which the majority of persons engaged in alcohol use. Although there was no evidence of an association between smoking and lack of virological suppression, the co-occurrence of smoking among PLWH who use alcohol underscores the need for targeted and integrated approaches to reduce their co-existence and improve health. [ABSTRACT FROM AUTHOR]

To better understand the impact of Uganda's initial COVID-19 lockdown on alcohol use, we conducted a cross-sectional survey (August 2020-September 2021) among persons with HIV (PWH) with unhealthy alcohol use (but not receiving an alcohol intervention), enrolled in a trial of incentives to reduce alcohol use and improve isoniazid preventive therapy. We examined associations between bar-based drinking and decreased alcohol use, and decreased alcohol use and health outcomes (antiretroviral therapy [ART] access, ART adherence, missed clinic visits, psychological stress and intimate partner violence), during lockdown. Of 178 adults surveyed whose data was analyzed, (67% male, median age: 40), 82% reported bar-based drinking at trial enrollment; 76% reported decreased alcohol use during lockdown. In a multivariate analysis, bar-based drinking was not associated with greater decreases in alcohol use during lockdown compared to non-bar-based drinking (OR = 0.81, 95% CI: 0.31–2.11), adjusting for age and sex. There was a significant association between decreased alcohol use and increased stress during lockdown (adjusted β = 2.09, 95% CI: 1.07–3.11, P < 0.010), but not other health outcomes. [ABSTRACT FROM AUTHOR]

Background: Alcohol consumption is a critical driver of the HIV epidemic worldwide, particularly in sub-Saharan Africa, where unhealthy alcohol use and HIV are prevalent. Brief alcohol interventions are effective in reducing alcohol use; however, they depend on effective screening for unhealthy alcohol use, which is often underreported. Thus, there is a need to develop methods to improve reporting of unhealthy alcohol use as an essential step toward referral to brief alcohol interventions. Self-administered digital health screeners may improve reporting. Objective: This study aimed to develop and test a digital, easy-to-use self-administered health screener. The health screener was designed to be implemented in a busy, underresourced HIV treatment setting and used by patients with varying levels of literacy. Methods: We conducted a qualitative study at the Immune Suppression Syndrome (ISS) Clinic of Mbarara Regional Referral Hospital in Uganda to develop and test a digital self-administered health screener. The health screener included a training module and assessed behaviors regarding general health, HIV care, and mental health as well as sensitive topics such as alcohol use and sexual health. We conducted focus group discussions with clinicians and patients with HIV of the Mbarara ISS Clinic who consumed alcohol to obtain input on the need for and content, format, and feasibility of the proposed screener. We iteratively revised a tablet-based screener with a subset of these participants, piloted the revised screener, and conducted individual semistructured in-depth interviews with 20 participants who had taken part in our previous studies on alcohol and HIV, including those who had previously underreported alcohol use and with low literacy. Results: A total of 45 people (n=5, 11% clinicians and n=40, 89% Mbarara ISS Clinic patients) participated in the study. Of the patient participants, 65% (26/40) were male, 43% (17/40) had low literacy, and all (40/40, 100%) had self-reported alcohol use in previous studies. Clinicians and patients cited benefits such as time savings, easing of staff burden, mitigation of patient-provider tension around sensitive issues, and information communication, but also identified areas of training required, issues of security of the device, and confidentiality concerns. Patients also stated fear of forgetting how to use the tablet, making mistakes, and losing information as barriers to uptake. In pilot tests of the prototype, patients liked the feature of a recorded in the local language and found the screener easy to use although many required additional help and training from the study staff to complete the screener. Conclusions: We found a self-administered digital health screener to be appealing to patients and clinicians and usable in a busy HIV clinic setting albeit with concerns about confidentiality and training. Such a screener may be useful in improving reporting of unhealthy alcohol use for referral to interventions. voice in the local language and found the screener easy to use, although many required additional help and training from the study staff to complete the screener. Conclusions: We found a self-administered digital health screener to be appealing to patients and clinicians and usable in a busy HIV clinic setting, albeit with concerns about confidentiality and training. Such a screener may be useful in improving reporting of unhealthy alcohol use for referral to interventions. [ABSTRACT FROM AUTHOR]

Screening and assessing alcohol use accurately to maximize positive treatment outcomes remain problematic in regions with high rates of alcohol use and HIV and TB infections. In this study, we examined the concordance between self-reported measures of alcohol use and point-of-care (POC) urine ethyl glucuronide (uEtG) test results among persons with HIV (PWH) in Uganda who reported drinking in the prior 3 months. For analyses, we used the screening data of a trial designed to examine the use of incentives to reduce alcohol consumption and increase medication adherence to examine the concordance between POC uEtG (300 ng/mL cutoff) and six measures of self-reported alcohol use. Of the 2136 participants who completed the alcohol screening, 1080 (50.6%) tested positive in the POC uEtG test, and 1756 (82.2%) self-reported using alcohol during the prior 72 h. Seventy-two percent of those who reported drinking during the prior 24 h had a uEtG positive test, with lower proportions testing uEtG positive when drinking occurred 24–48 h (64.7%) or 48–72 h (28.6%) prior to sample collection. In multivariate models, recency of drinking, number of drinks at last alcohol use, and Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) score were associated with uEtG positivity. The highest area under the curve (AUC) for a uEtG positive test was for recency of drinking. Overall, we concluded that several measures of drinking were associated with POC uEtG positivity, with recency of drinking, particularly drinking within the past 24 h, being the strongest predictor of uEtG positivity. [ABSTRACT FROM AUTHOR]

Unhealthy alcohol use fuels difficulties with HIV disease management and potentiates secondary transmission of HIV but less is known about how these alcohol use expectancies may shape alcohol use behaviors, particularly in the presence of depressive symptomatology. In this paper, we utilize data from a prospective study of 208 people living with HIV in Southwest Uganda, to examine the correlates of alcohol use expectancies and their association with unhealthy alcohol use. Affective depressive symptoms were positively associated with alcohol use expectancies. Gender moderation was observed such that depression was more strongly associated with alcohol use expectancies among women. In unadjusted analyses, alcohol use expectancies were marginally associated with unhealthy alcohol use and this association was not significant in adjusted analyses. Findings underscore the need to strengthen screening for depression and alcohol use within HIV care services, particularly among women. [ABSTRACT FROM AUTHOR]

Background: We aimed to describe the prevalence of PTSD symptoms and its associated factors in persons living with HIV (PLWH) in Uganda who engage in heavy alcohol use. Methods: We analyzed baseline data from the Drinkers Intervention to Prevent Tuberculosis study which enrolls PLWH with latent tuberculosis who engage in heavy alcohol consumption. Using the primary care Post Traumatic Stress Disorder (PTSD) screening scale from the DSM-5 (PC-PTSD-5), probable PTSD was defined as reporting ≥3 of 5 assessed symptoms. We conducted the Alcohol Use Disorders Identification Test-Consumption and assessed demographics, smoking, symptoms of depression, and spirituality/religiosity. Results: Of 421 participants enrolled from 2018 through 2020, the majority (68.2%) were male, median age was 40 years (interquartile range [IQR]: 32–47), and median AUDIT-C score was 6 [IQR: 4–8]. Half (50.1%) of the participants reported ever experiencing a traumatic event, and 20.7% reported ≥3 symptoms of PTSD. The most commonly reported PTSD symptoms in the past 1 month in the entire sample were avoidance (28.3%), nightmares (27.3%), and being constantly on guard (21.6%). In multivariable logistic regression analyses, level of alcohol use was not associated with probable PTSD (adjusted odds ratio [AOR] for each AUDIT-C point: (1.02; 95% CI: 0.92–1.14; p = 0.69); however, lifetime smoking (AOR 1.89; 95% CI: 1.10–3.24) and reporting symptoms of depression (AOR 1.89; 95% CI: 1.04–3.44) were independently associated with probable PTSD. Conclusions and recommendations: A history of traumatic events and probable PTSD were frequently reported among persons who engage in heavy drinking, living with HIV in Uganda. Level of alcohol use was not associated with probable PTSD in this sample of PLWH with heavy alcohol use, however other behavioral and mental health factors were associated with probable PTSD. These data highlight the high prevalence of PTSD in this group, and the need for screening and interventions for PTSD and mental health problems. [ABSTRACT FROM AUTHOR]

We assessed associations between hazardous alcohol use and latent tuberculosis infection (LTBI) among adults living with human immunodeficiency virus (HIV) in Uganda. We compared tuberculin skin test positivity across medium, high, and very-high alcohol use levels, classified by AUDIT-C scores. In multivariable analysis, very high use was associated with LTBI (adjusted odds ratio 1.61, 95% confidence interval: 1.03–2.50). [ABSTRACT FROM AUTHOR]

Although there is evidence of individual associations between depressive symptoms and hazardous alcohol use with suboptimal antiretroviral therapy (ART) adherence among people living with HIV (PLWH), few studies have established how the two risk factors may interact to predict viral suppression. We conducted secondary data analyses with two cohorts of Ugandan PLWH (N = 657) to investigate the hypothesized interaction between depressive symptoms (Center for Epidemiological Studies Depression Scale) and hazardous alcohol use (Alcohol Use Disorder Identification Test -Consumption and/or Phosphatidylethanol biomarker) prior to ART initiation with viral suppression (<550 copies/ml). We were unable to detect an interaction between depressive symptoms and hazardous alcohol use prior to ART initiation with viral suppression in the first two years (M = 19.9 months) after ART initiation (p = 0.75). There was also no evidence of a main effect association for depressive symptoms (Adjusted Odds Ratio [AOR] = 0.88, 95% Confidence Interval [CI]: 0.50, 1.55) or hazardous alcohol use (AOR = 1.37, 95% CI: 0.80, 2.33). PLWH with depressive symptoms and/or hazardous alcohol use appear to exhibit similar levels of viral suppression as others in care; further work is needed to determine effects on HIV testing and treatment engagement. [ABSTRACT FROM AUTHOR]

Background: Self‐report is widely used to assess alcohol use in research and clinical practice, but may be subject to social desirability bias. We aimed to determine if social desirability impacts self‐reported alcohol use. Methods: Among 751 human immunodeficiency virus (HIV)‐infected patients from a clinic in southwestern Uganda, we measured social desirability using the Marlowe–Crowne Social Desirability Scale (SDS) Short Form C, self‐reported alcohol use (prior 3 months) Alcohol Use Disorders Identification Test—Consumption (AUDIT‐C), and phosphatidylethanol (PEth), a biomarker of prior 3 weeks' drinking. We conducted multiple regression analyses to assess the relationship between SDS score (low, medium, and high levels) and (i) any self‐reported recent alcohol use, among those who were PEth‐positive (≥8 ng/ml), and (ii) continuous AUDIT‐C score, among those reporting any recent alcohol use. We controlled for PEth level, age, gender, education, economic assets, marital status, religion, spirituality/religiosity, social support, and study cohort. Results: Of 751 participants, 59% were women; the median age was 31 years (interquartile range [IQR]: 26 to 39). Median SDS score was 9 (IQR: 4 to 10). Two‐thirds (62%) self‐reported any recent alcohol use; median AUDIT‐C was 1 (IQR: 0 to 4). Among those who were PEth‐positive (57%), 13% reported no recent alcohol use. Those with the highest SDS tertile had decreased odds of reporting any recent alcohol use compared to the lowest tertile, but the association did not reach statistical significance in multivariable analyses (adjusted odds ratio 0.55 [95% confidence interval (CI): 0.25, 1.23]). Among participants self‐reporting recent alcohol use, SDS level was negatively associated with AUDIT‐C scores (adjusted β: −0.70 [95% CI: −1.19, −0.21] for medium vs. low SDS and −1.42 [95% CI: −2.05, −0.78] for high vs. low SDS). Conclusions: While use of objective measures (e.g., alcohol biomarkers) is desirable for measuring alcohol use, SDS scores may be used to adjust self‐reported drinking levels by participants' level of social desirability in HIV research studies. [ABSTRACT FROM AUTHOR]

Interactive toxicity beliefs regarding mixing alcohol and antiretroviral therapy (ART) may influence ART adherence. HIV-infected patients in Uganda completed quarterly visits for 1 year, or one visit at 6 months, depending on study randomization. Past month ART non-adherence was less than daily or <100 % on a visual analog scale. Participants were asked if people who take alcohol should stop taking their medications (belief) and whether they occasionally stopped taking their medications in anticipation of drinking (behavior). Visits with self-reported alcohol use and ART use for ≥30 days were included. We used logistic regression to examine correlates of the interactive toxicity belief and behavior, and to determine associations with ART non-adherence. 134 participants contributed 258 study visits. The toxicity belief was endorsed at 24 %, the behavior at 15 %, and any non-adherence at 35 % of visits. In multivariable analysis, the odds of non-adherence were higher for those endorsing the toxicity behavior [adjusted odds ratio (AOR) 2.06; 95 % confidence interval (CI) 0.97-4.36] but not the toxicity belief (AOR 0.63; 95 % CI 0.32-1.26). Clear messaging about maintaining adherence, even if drinking, could benefit patients. [ABSTRACT FROM AUTHOR]

Background In Sub-Saharan Africa ( SSA), HIV-infected patients may underreport alcohol consumption. We compared self-reports of drinking to phosphatidylethanol ( PEth), an alcohol biomarker. In particular, we assessed beverage-type-adjusted fractional graduated frequency ( FGF) and quantity frequency ( QF) measures of grams of alcohol, novel nonvolume measures, and the Alcohol Use Disorders Identification Test-Consumption ( AUDIT-C). Methods We analyzed cohort entry data from the Biomarker Research of Ethanol Among Those with HIV cohort study (2011 to 2013). Participants were HIV-infected past-year drinkers, newly enrolled into care. Self-report measures included FGF and QF grams of alcohol, the AUDIT-C, number of drinking days, and novel adaptations of FGF and QF methods to expenditures on alcohol, time spent drinking, and symptoms of intoxication. PEth levels were measured from dried blood spots. We calculated Spearman's rank correlation coefficients of self-reports with PEth and bias-corrected bootstrap 95% confidence intervals ( CIs) for pairwise differences between coefficients. Results A total of 209 subjects (57% men) were included. Median age was 30; interquartile range ( IQR) 25 to 38. FGF grams of alcohol over the past 90 days (median 592, IQR 43 to 2,137) were higher than QF grams (375, IQR 33 to 1,776), p < 0.001. However, both measures were moderately correlated with PEth: ρ = 0.58, 95% CI 0.47 to 0.66 for FGF grams and 0.54, 95% CI 0.43 to 0.63 for QF grams (95% CI for difference −0.017 to 0.099, not statistically significant). AUDIT-C, time drinking, and a scale of symptoms of intoxication were similarly correlated with PEth ( ρ = 0.35 to 0.57). Conclusions HIV-infected drinkers in SSA likely underreport both any alcohol consumption and amounts consumed, suggesting the need to use more objective measures like biomarkers when measuring drinking in this population. Although the FGF method may more accurately estimate drinking than QF methods, the AUDIT-C and other nonvolume measures may provide simpler alternatives. [ABSTRACT FROM AUTHOR]

Objective: Unhealthy alcohol use is a crucial driver of HIV in sub-Saharan Africa, and interventions are needed. The goal of this study was to assess whether assessment itself (assessment reactivity) causes declines in alcohol use in a research study in persons with HIV in Uganda.Method: Study participants were adult patients of the Immune Suppression Syndrome (ISS) Clinic in Mbarara, Uganda, who were new to HIV care and reported any alcohol consumption in the prior year. Participants were randomized to (a) a study cohort, with structured interviews, breath alcohol analysis tests, and blood draws conducted quarterly, or (b) a minimally assessed arm that engaged in these procedures only once, at 6 months after baseline. The main outcome was unhealthy drinking at 6 months, defined as Alcohol Use Disorders Identification Test-Consumption [AUDIT-C] positive (≥3 for women, ≥4 for men) or phosphatidylethanol (PEth; an alcohol biomarker) level ≥ 50 ng/ml. We also examined this outcome stratified by gender.Results: We examined 175 and 139 persons in the quarterly assessed versus minimally assessed arms, respectively. Overall, 54.8% were male, the median age was 30 (interquartile range: 25-36), and 58.0% initiated anti-retroviral therapy at 6 months. Nearly equal proportions (53.7% and 51.1% in the study quarterly assessed vs. minimally assessed arm, respectively) engaged in unhealthy drinking in the 3 months before the 6-month study visit (p = .64), and we found no evidence of interaction by gender (p = .36).Conclusions: We found no evidence of assessment reactivity in a study that included quarterly study visits. Assessment is not sufficient to act as an intervention itself in this population with high levels of unhealthy drinking. Interventions are needed to decrease alcohol consumption in this population. [ABSTRACT FROM AUTHOR]

Background: Alcohol use is common among people with HIV and is a risk factor for tuberculosis disease and non-adherence to isoniazid preventive therapy (IPT). Few interventions exist to reduce alcohol use and increase IPT adherence in sub-Saharan Africa. The aim of this study was to test the hypothesis that financial incentives conditional on point-of-care negative urine alcohol biomarker testing and positive urine isoniazid testing would reduce alcohol use and increase isoniazid adherence, respectively, in people with HIV who have latent tuberculosis infection and hazardous alcohol use., Methods: We conducted an open-label, 2×2 factorial randomised controlled trial in Uganda. Eligible for the study were non-pregnant HIV-positive adults (aged ≥18 years) prescribed antiretroviral therapy for at least 6 months, with current heavy alcohol use confirmed by urine ethyl glucuronide (biomarker of recent alcohol use) and a positive Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; ≥3 for women, ≥4 for men) for the past 3 months' drinking, no history of active tuberculosis, tuberculosis treatment, or tuberculosis preventive therapy, and a positive tuberculin skin test. We randomly assigned participants (1:1:1:1) initiating 6 months of IPT to: no incentives (group 1); or incentives for recent alcohol abstinence (group 2), isoniazid adherence (group 3), or both (group 4). Escalating incentives were contingent on monthly point-of-care urine tests negative for ethyl glucuronide (groups 2 and 4), or positive on IsoScreen (biomarker of recent isoniazid use; groups 3 and 4). The primary alcohol outcome was non-hazardous use by self-report (AUDIT-C <3 for women, <4 for men) and phosphatidylethanol (PEth; past-month alcohol biomarker) <35 ng/mL at 3 months and 6 months. The primary isoniazid adherence outcome was more than 90% bottle opening of days prescribed. We performed intention-to-treat analyses. This trial is registered with ClinicalTrials.gov (NCT03492216), and is complete., Findings: From April 16, 2018, to Aug 2, 2021, 5508 people were screened, of whom 680 were randomly assigned: 169 to group 1, 169 to group 2, 170 to group 3, and 172 to group 4. The median age of participants was 39 years (IQR 32-47), 470 (69%) were male, 598 (90%) of 663 had HIV RNA viral loads of less than 40 copies per mL, median AUDIT-C score was 6 (IQR 4-8), and median PEth was 252 ng/mL (IQR 87-579). Among 636 participants who completed the trial with alcohol use endpoint measures (group 1: 152, group 2: 159, group 3: 161, group 4: 164), non-hazardous alcohol use was more likely in the groups with incentives for alcohol abstinence (groups 2 and 4) versus no alcohol incentives (groups 1 and 3): 57 (17·6%) of 323 versus 31 (9·9%) of 313, respectively; adjusted risk difference (aRD) 7·6% (95% CI 2·7 to 12·5, p=0·0025). Among 656 participants who completed the trial with isoniazid adherence endpoint measures (group 1: 158, group 2: 163, group 3: 168, group 4: 167), incentives for isoniazid adherence did not increase adherence: 244 (72·8%) of 335 in the isoniazid incentive groups (groups 3 and 4) versus 234 (72·9%) of 321 in the no isoniazid incentive groups (groups 1 and 2); aRD -0·2% (95% CI -7·0 to 6·5, p=0·94). Overall, 53 (8%) of 680 participants discontinued isoniazid due to grade 3 or higher adverse events. There was no significant association between randomisation group and hepatotoxicity resulting in isoniazid discontinuation, after adjusting for sex and site., Interpretation: Escalating financial incentives contingent on recent alcohol abstinence led to significantly lower biomarker-confirmed alcohol use versus control, but incentives for recent isoniazid adherence did not lead to changes in adherence. The alcohol intervention was efficacious despite less intensive frequency of incentives and clinic visits than traditional programmes for substance use, suggesting that pragmatic modifications of contingency management for resource-limited settings can have efficacy and that further evaluation of implementation is merited., Funding: National Institute on Alcohol Abuse and Alcoholism., Translation: For the Runyankole translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Intimate partner violence (IPV) and alcohol use are interrelated public health issues. Heavy and frequent alcohol use increase the risk of IPV, but the relationship between alcohol use and IPV (including recent and lifetime IPV victimization and perpetration) has not been well described among persons living with HIV (PWH) in sub-Saharan Africa., Methods: We used baseline data from the Drinker's Intervention to Prevent Tuberculosis study. All participants were PWH co-infected with tuberculosis and had an Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) positive score (hazardous drinking) and positive urine ethyl glucuronide test, indicating recent drinking. High-risk drinking was defined as AUDIT-C > 6 and/or alcohol biomarker phosphatidylethanol (PEth) ≥ 200 ng/mL. We measured IPV using the Conflict Tactics Scale. We estimated the association between alcohol use level and recent (prior six months) IPV victimization (recent perpetration was too low to study) using multivariable logistic regression models adjusted for gender, age, assets, education, spouse HIV status, religiosity, depressive symptoms, and social desirability. We additionally estimated the interaction of alcohol use and gender on IPV victimization and the association between alcohol use and lifetime victimization and perpetration., Results: One-third of the 408 participants were women. Recent IPV victimization was reported by 18.9% of women and 9.4% of men; perpetration was reported by 3.1% and 3.6% of women and men. One-fifth (21.6%) of those reporting recent IPV victimization also reported perpetration. In multivariable models, alcohol use level was not significantly associated with recent IPV victimization (p = 0.115), nor was the interaction between alcohol use and gender (p = 0.696). Women had 2.34 times greater odds of recent IPV victimization than men (p = 0.016). Increasing age was significantly associated with decreased odds of recent IPV victimization (p = 0.004)., Conclusion: Prevalence of IPV victimization was comparable to estimates from a recent national survey, while perpetration among men was lower than expected. Alcohol use level was not associated with IPV victimization. It is possible that alcohol use in this sample was too high to detect differences in IPV. Our results suggest that women and younger PWH are priority populations for IPV prevention., (© 2022. The Author(s).)

While alcohol is a known risk factor for HIV infection in sub-Saharan Africa (SSA), studies designed to investigate the temporal relationship between alcohol use and unprotected sex are lacking. The purpose of this study was to determine whether alcohol used at the time of a sexual event is associated with unprotected sex at that same event. Data for this study were collected as part of two longitudinal studies of HIV-infected Ugandan adults. A structured questionnaire was administered at regularly scheduled cohort study visits in order to assess the circumstances (e.g., alcohol use, partner type) of the most recent sexual event (MRSE). Generalized estimating equation logistic regression models were used to examine the association between alcohol use (by the participant, the sexual partner, or both the participant and the partner) and the odds of unprotected sex at the sexual event while controlling for participant gender, age, months since HIV diagnosis, unhealthy alcohol use in the prior 3 months, partner type, and HIV status of partner. A total of 627 sexually active participants (57% women) reported 1817 sexual events. Of these events, 19% involved alcohol use and 53% were unprotected. Alcohol use by one's sexual partner (aOR 1.70; 95% CI 1.14, 2.54) or by both partners (aOR 1.78; 95% CI 1.07, 2.98) during the MRSE significantly increased the odds of unprotected sex at that same event. These results add to the growing event-level literature in SSA and support a temporal association between alcohol used prior to a sexual event and subsequent unprotected sex.