Alcohol, Partner violence and HIV Lori Heise, Senior Lecturer L ondon School of Hygiene and Tropical Medicine Chief Executive, STRIVE: Tackling the Structural Drivers of HIV

Trouble Brewing

HIV and Alcohol Consumption in Southern Africa Systematic review in SSA (n=86 studies) found alcohol consumption consistently associated with unprotected sex, multiple partners, coercive sex and transactional sex Meta-analysis (Fisher, Bang & Kapiga, 2007) –Drinkers have 1.57 times risk of HIV compared to abstainers, –“Problem drinkers” have 2.04 times the risk (CI: 1.61,1.85) Two event level studies in SSA demonstrate significant association between alcohol consumption before sex and unprotected sex acts (Kiene et al JAIDS, 2008; Myer STDs, 2002)

HIV infection Alcohol consumption Unprotected sex Partner selection Partner turnover Access to info & services Biologic susceptibility Sexual frequency Immune function Cognitive impairment Drinking norms Partner violence Drinking venue Alcohol myopia Risk taking personality HIV Acquisition

Alcohol use and anal sex among US HIV+ individuals attending primary care clinics Hutton et al AIDS &Behaviour, 2012

Potential impacts of alcohol on HIV+ individuals HIV positive Alcohol HIV testing Linkage to Care HIV Adherence Disease progression Alcohol Sexual Behavior Onward transmission

Alcohol and HIV adherence A meta-analysis found that ART non-adherence was almost twice as high in drinkers as in non-drinkers (Hendershot et al. JAIDS, 2009) Self report studies likely underestimate the association –In Uganda, a highly specific biomarker for heavy alcohol consumption indicated that 15% of HIV+ people on ART reported no alcohol consumption, despite heavy drinking Despite evidence of the role of drinking in ART adherence, alcohol is not mentioned in most ART guidelines

Trouble Brewing

* Strongest data comes from South Africa: Jewkes et al, The Lancet, 2010; Cross sectional data more mixed; methodological limitations Consistent association found between more severe IPV and HIV risk 3 prospective studies link IPV with Incident HIV or STI Evidence of Impact: Partner violence

RISK FACTORS FOR PERPETRATION OF INTIMATE PARTNER VIOLENCE Potential pathways between IPV & women’s risk of HIV Early experiences or witnessing of violence Genital trauma Partner physically and/or sexually violent Poverty & economic stresses Gender inequality & social norms condoning some use of violence Social constructions of masculinity Problematic alcohol use Low or inconsistent condom use Increased probability partner has HIV and/or STI Reduced access to info & HIV services Increased likelihood that woman is HIV infected PhysicalSexual Partner has concurrent sexual partners Woman has concurrent sexual partners DETERMINANTS OF HIV RISK FROM PARTNER

Trouble Brewing

Role of alcohol and IPV Evidence of causal link STRONG Role of alcohol long contested especially by women’s groups Alcohol is neither necessary nor sufficient to cause abuse, but where present it increases frequency and severity Drinking, especially binge drinking meets all scientific criteria of being a “contributing cause” of IPV Women & men widely associate IPV with drinking making it a natural point of entry for discussing marital relations, violence and coerced sex

Ecological Model of Partner Violence IPV MacrosocialCommunityMale Partner Woman Relationship Conflict Arena The Woman

Insights from evaluation research: Promising Early identification and brief counselling by health workers –Shown in meta-analysis of 22 trials to significantly reduce men’s drinking at one year post intervention Reduce alcohol availability –US and Australian studies found clear link between outlet density and domestic violence –Meta-analysis of 122 studies confirms that increasing alcohol taxes decreases harmful drinking even among dependent drinkers and youth Community based interventions –RISHTA programme in Mumbai –Phuza Wize campaign implemented by Soul City in South Africa Alcohol treatment has been shown to reduce domestic violence

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