Kalichman SC, Simbayi LC, Vermaak R, Cain D, Smith G, Mthebu J. Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town, South Africa. Ann Behav Med 2008 Oct 4.
To measure the efficacy of a brief, single-session intervention to reduce HIV-alcohol risk among men and women at informal drinking establishments (shebeens) in South Africa.
Four shebeens in a suburban township of Cape Town, South Africa
Randomized community intervention trial
One hundred seventeen men and 236 women aged 18 years and older recruited from local shebeens and who reported use of alcohol in the previous month
Unprotected intercourse, alcohol use before sex, number of sex partners, partners met at shebeens, and increased condom use
Shebeen owners identified two or three patrons who were referred to the researchers. These patrons were asked to refer others they knew from the shebeen for the study. Informational flyers describing the study were also placed in the selected shebeens. Interested patrons self-referred to the study, where they completed a baseline assessment and then were randomly assigned to a single, 3-hour HIV-alcohol and HIV risk-reduction skills intervention or a 1-hour single HIV education control group. Intervention and control activities were conducted in groups of 8 to 10 same-sex participants and facilitated by a male and female counselor.
The risk-reduction intervention, based on a social-cognitive model of health behavior, was an expanded version of a previously successful intervention for sexually transmitted infection (STI) clinic patients.(1) The intervention included an HIV information and education component and skills training that used motivational interviewing techniques for change and for commitment to change that included an adaptation of the WHO's brief alcohol intervention model. Alcohol use in a sexual context was discussed in relation to risk situations. The third component of the intervention focused on behavioral self-management and sexual communication skills-building exercises. Group members discussed risk situation and cues related to sexual risk activities, and facilitators introduced the concept of triggers and environmental and cognitive-affective cues for high-risk situations. Alcohol was discussed specifically as a trigger for risk. Participants were guided through identifying ways to manage triggers and reduce risk. The control group received the HIV information/education component of the intervention without the motivation and behavioral skills building.
Analysis of covariance was used to measure differences in continuous variables between the intervention and control groups at 3- and 6-months of follow-up after controlling for baseline values and potential confounders. Differences in categorical variables were measured using logistic regression models. All participants who completed baseline assessments were enrolled and analyzed.
A total of 598 persons were recruited, of whom 513 attended screening sessions. Of this number, 353 drank alcohol and completed baseline assessments. Retention was 89%. Alcohol use was measured using the Alcohol Use Disorder Identification Test (AUDIT); over 70% of participants had AUDIT scores above 8 and over 50% above 12, indicating high levels of alcohol use. The intervention and control groups were similar with regard to baseline characteristics.
After controlling for sex, education, employment, marriage, and baseline risk, the intervention group had significantly lower rates of unprotected intercourse at 3 months and drinking at time of sex and higher rates of consistent condom use, number of partners, and meeting partners at shebeens. At 6 months, only less alcohol use in the context of sex remained significantly different from controls. There was interaction between degree of alcohol use and outcomes, with the intervention having a greater effect on drinkers who drank less heavily.
The intervention was effective at 3 months, but not at 6, and was most effective for those who drank less heavily.
This study was of fair quality. It was randomized, although many details of the randomization process were not described. Blinding of allocation was not possible although outcomes were consistently measured through self-administered questionnaires. Retention was high and all persons randomized were analyzed.
Alcohol has been associated with high-risk sexual behavior in South Africa.(2) Among the various alcohol-serving establishments where people meet their sex partners, informal drinking sites (i.e., shebeens) are considered to be of the highest risk, with over 50% of men at shebeens reporting 2 or more sex partners in a 2-week period.(2,3)
Although the intervention was effective only at 3 months, repeated interventions, particularly among large groups of individuals, may result in a large proportion of the at-risk population adopting safer behaviors, even in the short term. Over time, these effects may lead to greater social change through changes in social norms as more individuals engage in lower risk activities.(4,5) Thus, there is some possibility for interventions such as this to have a larger effect on overall risk in a community; however, more durable interventions should be pursued and disseminated.
- Kalichman SC, Simbayi LC, 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. JAIDS 2007;44:594-600.
- Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S. Alcohol and HIV/AIDS risk behaviors in Southern Africa: Systematic review of empirical findings. Prev Science 2007;8:141-51.
- Weir SS, Pailman C, Mahlalela X, Coetzee N, Meidany F, Boerma JT. From people to places: Focusing AIDS prevention efforts where it matters most. AIDS 2003;17:895-903.
- Kelly JA, Murphy D, Sikkema K, et al. Outcomes of a randomized comparison-led community-level HIV prevention intervention: Effects on behavior among at-risk gay men in small U.S. cities. Lancet 1992;350:1500-5.
- Sweat M, Denison J. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS 1995;9 Suppl A:S251-57.