الگوهای مصرف الکل و رفتارهای جنسی در بین مصرف کنندگان فعلی در شهر کیپ تاون، آفریقای جنوبی

Abstract Objective This study examined the association between alcohol use and sexual behaviors among South African adults who reported current drinking. Method Street-intercept surveys were administered to adults residing in neighborhoods in a South African township. Results Analyses were restricted to participants reporting current drinking (N = 1285; mean age = 32; 27% women; 98% Black). Most participants (60%) reported heavy episodic drinking (i.e., 5 or more drinks on a single occasion) at least once per week in the past 30 days. Compared to non-heavy episodic drinkers, participants who reported heavy episodic drinking were more likely to drink before sex (79% vs. 66%) and have sex with a partner who had been drinking (59% vs. 44%). Overall, drinking before sex (self or partner) and heavy episodic drinking was associated with multiple sexual partners, discussing condom use with sexual partner(s), and proportion of protected sex. The frequency of condom use varied among participants with steady, casual, or both steady and casual sexual partners. Conclusions Alcohol use among South African adults is associated with sexual risk behaviors, but this association differs by partner type. Findings suggest the need to strengthen alcohol use components in sexual risk reduction interventions especially for participants with both steady and casual sex partners.

South Africa has the highest prevalence of HIV in the world with an estimated 5.6 million South Africans living with HIV (UNAIDS, 2010). In addition to bearing the heaviest HIV burden, South Africa also has the highest levels of alcohol consumption per adult drinker than any other region in the world (Rehm et al., 2003). According to the 2003 South African Demographic and Health Survey, 30% of South African men and 17% of women report current alcohol use with 12% of men and 14% of women reporting hazardous or harmful levels of alcohol consumption (South African Medical Research Council, 2007). Approximately one-third of South African adults reported heavy episodic drinking (Peltzer & Ramlagan, 2009). Heavy episodic drinking (HED) is defined as drinking 5 or more drinks on a single occasion during the past week ( World Health Organization, 2011). The HIV epidemic in South Africa is associated, in part, with alcohol use (Fisher, Bang, & Kapiga, 2007). Risky alcohol consumption in South Africa has increased in recent years, partially due to the increased consumption of commercial alcoholic beverages with higher alcohol content than traditional homebrews (Parry et al., 2005 and Peltzer and Ramlagan, 2009). Environments where alcohol is consumed, such as drinking venues, are frequently associated with sexual behaviors conferring risk for HIV infection (Fritz, Morojele, & Kalichman, 2010). Research shows that participants who meet sexual partners at drinking venues are more likely to have multiple sexual partners and more unprotected sex than those who did not meet their partners at drinking venues (Kalichman, Simbayi, Vermaak, Jooste, & Cain, 2008). Informal alcohol serving establishments, such as small bars and private homes where alcoholic beverages are sold and served, popularly known as “shebeens,” are often places where sex partners meet (Kalichman, Simbayi, Vermaak, Jooste and Cain, 2008, Morojele et al., 2006 and Weir et al., 2003). Furthermore, sex between new or casual partners often occurs at or around drinking venues (Kalichman, Simbayi, Vermaak, Jooste and Cain, 2008, Morojele et al., 2006 and Myer et al., 2002). Finally, Kalichman, Simbayi, Vermaak, Jooste, et al. (2008) showed that meeting sexual partners in shebeens is associated with problem drinking. The association between alcohol use and sexual risk behaviors suggests that importance of examining high risk alcohol use (i.e., HED) as well as contextual factors (i.e., drinking before sex or partner drinking before sex) associated with sexual risk and prevention behaviors. Consuming large quantities of alcohol (e.g., HED), but not the frequency of drinking, is associated with having more sexual partners, unprotected sex, and concurrent sexual partners (Kalichman, Simbayi, Kaufman, Cain, & Jooste, 2007). A recent meta-analysis examining the association between alcohol use and HIV from studies conducted in Africa (Fisher et al., 2007) found drinker status to be associated with HIV infection such that drinkers were 70% more likely to be HIV-positive than non-drinkers. Risk of HIV was notably higher among problem drinkers vs. non-problem drinkers. Baliunas, Rehm, Irving, and Shuper (2010) found the incidence of HIV was associated with overall level of alcohol consumption. Moreover, risk of HIV infection among heavy episodic drinkers was double that of non-heavy episodic drinkers. HED is a risk factor in the transmission of HIV. Efforts to understand alcohol-related risks must also take into account the context in which alcohol is consumed. Alcohol consumption, before or during sex, is associated with sexual behaviors that may increase the risk of acquiring HIV infection (Baliunas et al., 2010). For example, Simbayi et al. (2004) found alcohol use before sex was associated with multiple sexual partners and more unprotected sexual occasions among patients at a South African sexually transmitted disease (STD) clinic. Among HIV+ South Africans, drinking before sex was associated with unprotected sex but only when participants consumed greater amounts of alcohol (Kiene et al., 2008). Heavy episodic drinkers may consume more alcohol during sexual events because they drink more alcohol in all contexts. Furthermore, Kiene et al. found drinking before sex was associated with a higher likelihood of unprotected sex when participants reported having sex with a casual rather than a steady sexual partner. Thus, the association between contextual alcohol use and risky sexual behavior may be moderated by sexual partner type. The primary purpose of this study was to use cross-sectional data to examine the association between alcohol use and sexual risk behaviors among South Africans. Specifically, we examined individual (HED) and contextual (self or partner drinking before sex) factors that may influence the association between alcohol use and sexual risk behavior among current drinkers. We expected that both individual and contextual alcohol use would be associated with multiple sexual partners, failure to discuss condom use with sexual partners, and fewer condom-protected events. A secondary purpose was to explore the alcohol-risky sexual behavior association by partner type (steady partners only, casual partners only, or both steady and casual partners). We expected individual alcohol use would predict risky sexual behavior with steady partners, whereas the context of alcohol use would be associated with risky sexual behavior with casual partners given that alcohol use prior to sex is more common with casual rather than steady sexual partners (Myer et al., 2002). Examining the association between alcohol use and sexual risk behavior can guide intervention development to avert new infections among South Africans who consume alcohol.

This research carries implications for sexual risk and alcohol use reduction; in particular, these findings suggest that risk reduction strategies in South Africa should address the important role of alcohol use in the context of sex. Interventionists might seek to increase awareness of the effects of alcohol use on risk perception, decision-making, and interpersonal and self-management skills (cf. Kalichman, Simbayi, Vermaak, Cain, et al., 2008). Implementing sexual risk reduction interventions at drinking venues may reach those at greatest need but will need to be cleverly implemented; that is, they are more likely to be welcomed by shebeen owners if they do not jeopardize alcohol sales. Interventions might focus on both individual as well as community level sexual risk reduction. The latter may be achieved, for example, by making condoms available and by modifying norms associated with risky sexual behavior (especially in the vicinity of drinking venues). Implementing intervention strategies in frequently attended drinking venues that service people engaging in unsafe sexual behaviors may reduce the impact of the HIV epidemic in South Africa.