Heavy drinking linked to risky sex in Botswana

Heavy and problem alcohol consumption are associated with HIV sexual risk behaviours in both men and women in Botswana, according to a population-based study published in the October edition of the online journal PloS Medicine. The investigators found that men and women defined as either problem or heavy drinkers were significantly more likely to have unprotected sex with a non-monogamous partner, have multiple sexual partners, or buy or sell sex than individuals who did not drink. The investigators call for HIV prevention initiatives to be integrated into programmes targeting alcohol abuse.

Several studies have found an association between alcohol consumption and HIV incidence and prevalence in sub-Saharan Africa. However, these studies have been conducted using either clinic-based samples or samples recruited from drinking venues. To gain a better understanding of the relationship between alcohol consumption and HIV sexual risk behaviours, investigators from the United States and Botswana conducted a population-based study involving almost 1,300 individuals recruited from both rural and urban areas of Botswana between 2004 and 2005. All the individuals were aged between 18 and 49 years – HIV prevalence amongst this age group in Botswana is estimated to be 24%, one of the highest in the world.

The participants were asked about their alcohol consumption and sexual behaviour by trained staff. On the basis of their answers about alcohol consumption, participants were divided into one of four categories: no drinking; moderate drinking (under seven drinks a week for women, and 14 a week for men); problem drinking (eight – 14 drinks a week for women, and 15 – 21 for men); and heavy drinking (over 14 drinks a week for women, or 21 drinks or more a week for men).

Alcohol consumption was then correlated with three indicators of risky sex: intercourse without a condom with a non-monogamous partner; multiple sexual partners; and paying for or selling sex.

A total of 39% of men and 25% of women met the criteria for problem or heavy drinkers.

Men and women who were heavy drinkers were three times more likely than non-drinkers or moderate drinkers to report unprotected sex with a non-monogamous partner (adjusted odds ratio for men, 3.48; for women, 3.28).

Having multiple sexual partners was also associated with problem or heavy alcohol consumption for both men and women (adjusted odds ratio, 3.05 for women; 3.08 for men). An even stronger association was found between problem or heavy drinking and selling sex for women, with problem drinkers twelve times more likely than women who did not drink to report selling sex (adjusted odds ratio, 12.59), and heavy drinkers eight times more likely to sell sex (adjusted odds ratio, 8.50). Amongst men, problem drinkers were five times more likely to buy or sell sex than none-drinkers (adjusted odds ratio, 5.29), and heavy drinkers were over three times more likely to engage in these risk behaviours (adjusted odds ratio, 3.65).

The investigators also found that intergenerational sex, and a feeling of a lack of control in a sexual relationship were also important predictors of sexual risk behaviour for both men and women.

“Heavy alcohol consumption was a strong and consistent correlate of all sexual risk behaviours examined for both men and women”, write the investigators. They note that few policies have tried to address both problematic alcohol consumption and HIV risk. For these integrated policies to stand any chance of success, the investigators stress that they must take into account alcohol’s “deep-seated cultural and social meanings, related to social status, gender identity, and family and communal structures” in Botswana and elsewhere in Africa.