Alcohol, HIV and Public Health
The 2nd International Conference on Alcohol and HIV hosted by the International Center for Research on Women was held in New Delhi in September 2010
Dr K J Bryan, Alcohol HIV AIDS Co-ordinator at NIAAA launched at the conference Alcohol, Research and Health Vol 33 (3) Pages 165-288 Special Supplement on Alcohol & HIV AIDS
Here Adrian Bonner reviews the latest knowledge.
Hazardous drinkers have a significantly higher risk of HIV/ AIDS and tuberculosis (TB) than the general population. In the case of TB the risks have been attributed to a reduction in efficiency of the immune system and social exclusion. The underlying drivers of the increased risk of HIV/AIDS and alcohol use appear to be more complex than is the case for TB, in that a range of personality factors, unsafe sex and poor compliance with antiretroviral therapy have been implicated. An understanding of these causal factors is important in developing effective interventions.
Alcohol and HIV in India
The second international conference on alcohol and HIV, September 20101, provided an opportunity to review the current state of our understanding of alcohol, which is associated with increased risky sexual practices, increasing the probability of sexually transmitted infections. One of the main conclusions from the conference was that traditional HIV prevention programmes will not be effective without addressing the underlying potentiation of alcohol, particularly by vulnerable groups such as young people, sex workers and homosexual males.
In India, research into alcohol and HIV prevalence during recent years includes alcohol as a predictor of HIV or other sexually transmitted infections and alcohol use and sexual risk in special populations, in particular tea estate workers, migrants, injecting drug users and commercial sex workers. Gender violence, alcohol use and sexual risk and the role of alcohol in treatment adherence have also been studied. An understanding of the complex interplay between cultural and biomedical dimensions of sexual behaviour is essential to increase the potential outcomes of tailored public health strategies geared to specific regions in India.
Since the Vedic period (1500 to 700 BCE) the Islamic invasions (1100 to 1800 CE), the period of British rule (1800 to 1947) and the period of post-independent India, the consumption of alcoholic beverages has changed considerably. Hazardous and excessive drinking is commonplace in India and various researchers have indicated that moderate social drinking is a minority practice. These drinking patterns are clearly important in developing programmes which seek to combat the spread of HIV/AIDS. The consumption of strong distilled alcoholic beverages is deeply embedded in cultural patterns in both tribal and non-tribal people in nearly all regions of India. The preference for strong drinks is partly due to the complex history of Government programmes and alcohol manufacturing policies during the colonial and post-colonial periods. Alcohol consumption in many parts of India is influenced not only by the spread of modern lifestyles but also through the needs of local State Governments to increase revenue from taxation.
Current statistical analysis has shown a steady increase in alcohol production, supply availability and consumption from 1990 onwards. During this period, international and domestic alcohol manufacturers were expanding their markets to an ever-increasing Indian middle- and upper-class with resources to spend on leisuretime activity. In parallel with the significant growth in alcohol consumption, the HIV/AIDS epidemic is believed to be accelerating dramatically, with concern for vulnerable, highrisk populations such as sexworkers, truckers and injecting drug users. There is a reported high frequency of homosexual behaviour in migrants in South India, increasing the spread of HIV infections.
Alcohol and HIV South Africa
From a global perspective sub- Saharan Africa (SSA) is the region with 67% of all HIV infections. Within SSA, South Africa, there were reportedly 350,000 deaths due to AIDS in 2007 (WHO, UNAIDS and UNICEF, 2008). Paradoxically, although 55% of males and 69% of females abstain from alcohol, annual per capita consumption, per drinker, is very high. Charles Parry2, has reviewed the linkages between alcohol and HIV. Whilst there appears to be a consistent association between alcohol use and the incidence of HIV, the relative contribution of personality traits, such as sensation seeking, psychiatric dimensions of impulsivity and other situational factors, is presently unknown. A number of individual studies and a meta-analysis by Fisher et al3, (2007) point to a variety of HIV risk behaviours and problematic alcohol use. There appears to be an increasing risk of HIV infection due to alcohol consumption before sexual activity, which is related to the amount of alcohol consumed. This risk is reduced with moderated alcohol consumption and abstinence. As in the case of TB, the immune system is compromised by alcohol consumption. Despite the potential confounding influence of other psychological and psychiatric variables, Shuper et al5,(2010) in a systematic review, concluded that alcohol alone is the predominant factor in the progression of and remission from the disease. Abnormalities in T and B lymphocytes, depression of CD4 count, and decreased lymphocyte function to produce Interleukin-2 have all been implicated in the biological effect of alcohol on the incidence of HIV/AIDS.
Deaths due to alcohol attributable HIV/AIDS are the fourth highest cause (12%) of mortality in South Africa, and one fifth highest alcohol-related disability adjusted life years lost (DALYS)4 in males. In males, 29% of all alcohol-related DALYs result from alcohol-related injuries, 9.7% are lost due to alcohol-attributable HIV/AIDS. However, in females, the greatest number of alcohol-related DALYS lost (27.8%) are due to alcohol-attributable HIV/AIDS.
In reviewing the implications of this research, Parry et al2 have drawn attention to the WHO Global Strategy to reduce the harmful use of alcohol by implementing strategies to “… reduce availability ...” and “... pricing policies ...”, “... regulating marketing ...”, “ developing effective systems of surveillance of marketing …”. These brief reviews from India and South Africa also suggest that targeted interventions in high risk venues and high risk populations, such as peer-education facilitation, should be considered. The impact of “... server intervention ...” and “... bar-based brief interventions” appear to be minimal.
In summary, the authors suggest that a combined intervention mode, the need to include alcohol issues in HIV/AIDS treatment programmes, and HIV/AIDS prevention activities, should all underpin the development of future strategies. Although there are large differences in socio-cultural and public health practices in India and South Africa, there is an urgent need to consider the Global Strategy for Reducing Harmful use of Alcohol, as endorsed by WHO as a key component of a public health approach to tackling HIV/AIDS. Clearly evidencebased interventions are needed but identifying region-specific differences will be important in the effective reduction of alcoholrelated harm.
References
1. Kalichman S.C., (Ed) 2010. Current Issues in Alcohol Use and HIV Research and Prevention in India. Aids and Behaviour 14, Supplement 1, August 2010-11-29
2. Parry C., J.Rehm, N.K. Morojele (2010). Is there a causal relationship between alcohol and HIV? Implications for Policy, Practice and Future Research. African Journal of Drug and Alcohol Studies 9 (2)
3. Fisher, J.C., H.Bang, S.H. Kapiga (2007). The association between HIV infection and alcohol use: A systematic review and meta-analysis of African studies. Sexually Transmitted Diseases, 34. 856-63.
4. Rehm,J., T. Kehoe, M. Rehm, J. Patra (2009) Alcohol Consumption and related harm in WHO Africa region in 2004. Toronto, Canada: Centre for Addiction and Mental Health
5. Shuper, P.A., M. Neuman, F. Kanteres, D.Baliunas, N. Joharchi, J. Rehm (2010) Causal considerations on alcohol and HIV/Aids – a systematic review. Alcohol and Alcoholism, 45 , 159-166.