Kalichman SC, Leickness CS, Vermaak R, Cain D, Jooste S, Peltzer K. HIV/AIDS risk reduction counseling for alcohol using sexually transmitted infections clinic patients in Cape Town, South Africa. J Acquir Immune Defic Syndr 2007;44(5):594-600.
To examine the effect of a brief, behavioral risk-reduction counseling intervention on self-reported sexual behavior, alcohol use, and theoretic constructs among men and women using alcohol and receiving treatment at a sexually transmitted infection (STI) clinic in South Africa
Randomized intervention trial
The largest STI clinic in Cape Town, South Africa (approximately 1800 patients per month)
Patients receiving services at an urban STI clinic were referred by a nurse-clinician in the clinic to participate between March 2005 and March 2006. Eligibility criteria included the use of STI diagnostic or treatment services at the clinic and current use of alcohol. Enrollment was capped at 5 individuals per day to ensure that a range of participants were recruited over time and to work within the resource constraints of the study. Of the 465 people approached, 294 were interested in being scheduled for screening; of those, 221 were able to attend and were screened for alcohol use;143 were current drinkers and consented to participate in the study. Of these 143 participants, 122 were men and 21 were women.
Participants were randomly assigned either to the intervention condition, a 60-minute, behavioral skills-building, HIV and alcohol risk-reduction counseling session (n=69) or the control condition, a 20-minute HIV information/educational intervention (n=74). All participants completed a baseline assessment prior to the intervention and an immediate post-intervention assessment and received 100 South African rand as compensation. Participants were followed-up at 3 months and 6 months after the intervention and received an additional 110 South African rand for completing these assessments.
The intervention was adapted from a risk-reduction model previously used by Simbayi et al.(1) The 60-minute intervention was composed of three parts: (1) information/education; (2) motivation; and (3) behavioral self-management and sexual communication skills. Alcohol use was integrated into all segments of counseling. The brief, alcohol counseling model of the WHO was used as the basis for the alcohol risk-reduction component.(2) Participants were given their Alcohol Use Disorders Identification Test (AUDIT) score and were shown how their score represents the potential hazards of drinking. Alcohol risk-reduction was tailored to the level of drinking indicated by the AUDIT score using the algorithm suggested by the WHO. Decision balance techniques were used to elicit self-motivating statements for alcohol reduction. Alcohol use in sexual contexts was discussed specifically in relation to the participant's self-identified risk situations.
The control condition was the same 20-minute HIV risk information and counseling session that constituted the first third of the intervention condition. It was a didactic educational experience similar to that used frequently in STI clinic services.
Primary outcomes included number of sex partners and frequency of sexual behaviors in the previous month-specifically, vaginal and anal intercourse with and without condoms. Participants also were asked about quantity and frequency of alcohol consumption and the number of times they drank alcohol before sex in the previous month. Secondary outcomes included HIV risk and prevention knowledge, AIDS-related stigma, risk-reduction behavioral intentions, risk-reduction self-efficacy, and alcohol outcome expectancies.
Mean age and years of education did not differ between intervention and control groups at baseline. Mean age was 29.3 (SD 5.7) and 28.2 (SD 5.5), and mean years of education was 11.5 (SD 2.3) and 11.4 (SD 2.0), respectively. Among the 41 (28%) participants lost to follow-up at 3 months and the 45 (31%) lost to follow-up at 6 months, however, those lost in the intervention group were older and had less education. Participant age and education, therefore, were included as covariates in all analyses. Eighty percent and 84% of the respective groups were HIV negative by self-report.
Analyses comparing groups and controlling for baseline behaviors and gender, age, and education did not indicate differences between conditions for numbers of sex partners at either follow-up assessment. Less unprotected vaginal sex was reported in the experimental condition at 3- and 6-month follow-ups (mean 0.8, SD 2.1 and mean 1.3, SD 4.5, respectively) than in the control condition (mean 2.1, SD 5.8 and mean 2.1, SD 5.8, respectively) (both p<0.05). Condom use was significantly greater among participants in the experimental condition at both 3- and 6-month follow-ups (90.5%, SD 22.8% and 87.8%, SD 24.9%, respectively) than in the control condition (mean 78.4%, SD 31.9% and 76.4%, SD 38.6%, respectively) (both p<0.05). Participants in the experimental condition were significantly more likely to have used a condom the last time they had sex compared with those in the control condition at the 3-month follow-up (98% vs. 84%; odds ratio [OR]=10.5; p<0.01). Participants in the experimental condition reduced their drinking in sexual contexts in the 3-month follow-up (mean 1.5, SD 2.8 in the experimental condition vs. mean 3.4, SD 6.9 in the control condition; p<0.01), but not at the 6-month follow-up.
Controlling for baseline values, gender, age, and education, there were no differences between the two conditions at either follow-up in HIV-related knowledge, AIDS stigma, intentions to change risk behaviors, risk-reduction self-efficacy, and expectancies that alcohol use would lead to loss of control. The expectancy that alcohol use would lead to sexual enhancement was significantly greater (p<0.05) among control participants (mean score 2.3, SD 0.9) than intervention participants (mean score 1.9, SD 0.8) at the 3-month follow-up, but this difference was not observed at 6 months.
The 60-minute skills-building HIV prevention counseling intervention with a focus on alcohol consumption reduced self-reported HIV transmission risks for up to 6 months in this STI clinic population in Cape Town, South Africa. Overall, the HIV risk-reduction skills counseling intervention was associated with more than a 25% increase in condom use and a 65% reduction in unprotected sex over the 6-month follow-up period. Numbers of sex partners were unchanged, and reductions in drinking alcohol were not sustained at the 6-month follow-up.
Although participants were randomized to the two conditions, neither the researchers nor the participants were blinded to the treatment condition. The 20-minute information/education session that the control group received was not an appropriate comparison condition for the 60-minute HIV prevention counseling session given to the intervention group-the longer time allotted to the intervention may alone account for the observed differences. Additionally, the intervention's efficacy relied on self-reported measures of sexual risk and alcohol use. The sample also was limited by the small number of women enrolled in the trial. The authors recommend that future studies oversample women to increase their numbers for outcome analyses. Furthermore, the validity of the findings is questionable given the relatively high rates of refusal to participate and the number of participants lost to follow-up. The age and education differences among participants lost to follow-up may have introduced bias not adequately controlled by adjusting for those variables in analysis. Finally, because the current intervention was carried out in a dedicated STI clinic, the generalizability of the current study to other clinic settings is unknown.
People living with HIV/AIDS in southern Africa are more than twice as likely as uninfected individuals to report a history of alcohol use.(3) Additionally, Africans living with HIV/AIDS are more likely to consume alcohol daily compared with Africans who are not HIV positive.(4,5) In Cape Town, 42% of men and 12% of women receiving STI clinic services report drinking before sex, and the rate of alcohol use before sex jumps to 61% among STI clinic patients who are problem drinkers.(6) Thus, interventions that incorporate messages regarding alcohol use, especially drinking in sexual contacts, may result in significant HIV risk reduction.
The brief, behavioral risk-reduction counseling intervention presented in this study is particularly useful for several reasons: (1) it can be delivered by nonprofessional counselors who have minimal training; (2) it is relatively inexpensive to implement; and (3) it can be combined with other interventions, such as biomedical strategies, to enhance the effects of these strategies. The current intervention demonstrated a reduction in HIV transmission risks up to 6 months. The reductions in alcohol use seen with this intervention, however, were short-lived, as were the accompanying reductions in the expectations that alcohol use is a sexual experience enhancement. More substantial and more sustained interventions may be required to achieve significant, longer-term risk reduction. For sustained risk reduction and behavior change, the authors propose that this intervention be combined with structural interventions to reduce alcohol use in sexual contexts. They report that the lack of sustained effects on the alcohol outcomes "suggests that the sexual risk reduction behaviour changes may also deteriorate over time and indicates the need for more intensive alcohol risk reduction intervention components and maintenance intervention strategies." Finally, the authors stress that "changing sexual risk behaviours in the long term among persons at greatest risk for HIV infection requires multilevel intervention strategies that address individual behaviour change and also change the behavioural context and social milieu."
- Simbayi LC, Kalichman SC, Skinner D, et al. Theory-based HIV risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa. Sex Transm Dis 2004;31:727-33.
- Babor TF, de la Fuente JR, Saunders J, et al. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva: World Health Care Organization; 1992. Abstract unavailable.
- Mbulaiteye SM, Ruberantwari A, Nakiyingi JS, et al. Alcohol and HIV: a study among sexually active adults in rural southwest Uganda. Int J Epidemiol 2000;29:911-15.
- Hargreaves JR, Morison LA, Chege J, et al. Socioeconomic status and risk of HIV infection in an urban population in Kenya. Trop Med Int Health 2002;7:793-802.
- Zuma K, Gouws E, Willaims B, et al. Risk factors for HIV infection among women in Carletonville, South Africa: migration, demography and sexually transmitted diseases. Int J STD AIDS 2003;14:814-17.
- Simbayi LC, Kalichman SC, Jooste S, et al. Alcohol use and sexual risks for HIV infection among men and women receiving sexually transmitted infection clinic services in Cape Town, South Africa. J Alcohol Studies 2004;65:434-42.