Couple Interdependence Impacts Alcohol Use and Adherence to Antiretroviral Therapy in Malawi

Abstract

In sub-Saharan Africa, harmful alcohol use among male drinkers is high and has deleterious consequences on adherence to antiretroviral therapy (ART), HIV clinical outcomes, and couple relationship dynamics. We conducted in-depth qualitative interviews with 25 Malawian couples on ART to understand how relationships influence adherence to ART, in which alcohol use emerged as a major theme. Almost half of men (40%) reported current or past alcohol use. Although alcohol use was linked to men's non-adherence, women buffered this harm by encouraging husbands to reduce alcohol use and by offering adherence support when men were drinking. Men's drinking interfered with being an effective treatment guardian for wives on ART and also weakened couple support systems needed for adherence. Relationship challenges including food insecurity, intimate partner violence, and extramarital relationships appeared to exacerbate the negative consequences of alcohol use on ART adherence. In this setting, alcohol may be best understood as a couple-level issue. Alcohol interventions for people living with HIV should consider approaches that jointly engage both partners.

A Mixed-Methods Systematic Review: Infidelity, Romantic Jealousy and Intimate Partner Violence against Women

“…Participants reported that male alcohol consumption, phone calls and community gossip triggered female RJ [100,103], and that women confronting their partners about infidelity led to arguments about whether the infidelity had occurred [92,99], which in turn escalated to physical and psychological IPV [80,87,88,92,95,100,102,103].…”

“…Reports of bidirectional IPV (male-to-female and female-to-male) triggered by infidelity or RJ also emerged [87,89,90,95,100,102]. These confrontations usually included alcohol consumption, and increasingly severe physical IPV against women [87,89,102], sometimes resulting in femicide [90].…”

“…Participants noted that when men drank alcohol and used drugs, women became more suspicious of infidelity, and men became more violent, leading to increased IPV [80,85,87,90,95,99,102,103], and likewise when men decreased their consumption, suspicions of male infidelity and male violence decreased [87].…”

“…In studies from India and Puerto Rico women reported that they had no power to negotiate condom use in their relationships, but underlying this lack of control was an inability to voice their suspicions of infidelity for fear of physical violence (Pathway 2) [78,103]. Evidence that infidelity, HIV and physical violence were intertwined also emerged in sub-Saharan Africa, and in one instance a woman was reportedly murdered after rebuffing her husband's sexual advances and telling him she feared he had been unfaithful and contracted HIV [79,87].…”

Navigating intimate sexual partnerships in an era of HIV: dimensions of couple relationship quality and satisfaction among adults in Eswatini and linkages to HIV risk

“…Researchers have also explored relationship quality among African couples in the context of HIV prevention (Belus, Kline, Carney, Myers, & Wechsberg, 2018), uptake and experience of HIV testing and counselling (Conroy, 2014, 2015; Darbes et al., 2014; Maman, Mbwambo, Hogan, Kilonzo, & Sweat, 2001; Tabana et al., 2013), and adherence to HIV treatment (Conroy, McKenna, & Ruark, 2019; Conroy et al., 2017). A qualitative study with young South African couples found that relationships characterised by mistrust, poor communication, and violence placed them at greater risk of HIV infection (Parker, Pettifor, Maman, Sibeko, & MacPhail, 2014), and young South African men who reported having positive dating relationships were more likely to report condom use (Gevers, Jewkes, & Mathews, 2013).…”