HIV / STI
Hazardous Alcohol Use, Sexual Behavior, and HIV Incidence across 11 Eastern and Southern African Countries Domonique M. Reed* Domonique M. Reed Reed Harvard T.H. Chan School of Public Health
Alcohol use has broadly been associated with HIV acquisition through its influence on sexual risk behaviors, but evidence distinguishing different use patterns across Africa remains limited. We estimated the prevalence of hazardous and binge alcohol consumption and their association with high-risk sexual behaviors and HIV incidence proxies.
We analyzed data on sexually active adults aged ≥15 years from 16 nationally representative household surveys in 11 Eastern and Southern African countries (2015-2023). Alcohol use patterns were classified using the AUDIT-C (non-drinkers/low risk users/hazardous drinkers without binge/binge use). Outcomes included sexual risk behaviors, lab-determined recent HIV infection, and undiagnosed HIV infection. We estimated survey-weighted alcohol use prevalence, logistic regression models, and population attributable fractions by gender, adjusting for sociodemographic covariates.
Analyses included 251,931 adults (HIV-negative, n=245,253; recent or undiagnosed HIV infection, n=6,678). Between 5.75%-21.12% reported binge alcohol use, and 3.70%-15.7% reported hazardous use across countries, with large gender differences. Sexual risk increased progressively with drinking severity among both men and women. Compared to non-drinkers, alcohol use was associated with higher odds of undiagnosed HIV infection; adjusted ORs ranged from 1.32 (1.16-1.50) for low-risk users to 1.52 (1.34-1.72) for binge users among men and 1.28 (1.13-1.46) to 1.55 (1.31-1.82) among women. Alcohol use accounted for 16.7% of infections among men and 16.2% among women (Figure), with contributions across drinking categories. Estimates for associations with recent HIV infection followed a similar pattern, with wider uncertainty.
Both hazardous and binge alcohol use are associated with sexual risk and HIV incidence in Eastern and Southern Africa. Integrating HIV prevention into alcohol-reduction strategies may address around 16% of HIV acquisition risk across the region.
