Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It?

Abstract

This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.

Recent Alcohol Use Is Associated With Increased Pre-exposure Prophylaxis (PrEP) Continuation and Adherence Among Pregnant and Postpartum Women in South Africa

“…However, our recently published study using baseline data from the same study found that pregnant women reporting any alcohol use in the year before pregnancy had greater odds of being at high risk of HIV (aOR 1.33, 95% CI: 1.05-1.68), using a proxy measure that consisted of several sexual HIV risk factors, which included awareness of partner HIV status (as well as presence of an STI, multiple sexual partners, and condom use). 7 In this study, alcohol use before pregnancy was associated with higher perceived risk of HIV acquisition. Pregnant women who use alcohol may thus recognize that they are at increased risk of HIV because of other sexual risk behaviors and therefore be more likely to adopt PrEP as their preferred prevention strategy and adhere to it well.…”

“…Although our study collected data on alcohol use since learning one was pregnant, we used measures of any alcohol use and hazardous alcohol use in the past year before pregnancy as our exposure variables of interest. We report past year alcohol use before pregnancy for several reasons: (1) consistency with our previous sensitivity analysis of alcohol use measures among pregnant women, 7 (2) sensitivity analysis in the present analysis of women who reported continued alcohol use in the sample at 3-month follow-up which was very small (5%), (3) the high potential for underreporting alcohol use while pregnant because of social desirability bias, (4) additional previous work suggesting that alcohol use before pregnancy is a good predictor of continued alcohol use during pregnancy, 26 and (5) the late median gestational age at first antenatal care visit of 21 weeks (the fifth month of pregnancy) and high prevalence of unplanned pregnancies reported in previous analyses of this cohort, both of which suggest participants were unaware they were pregnant for several months of the pregnancy and may have continued drinking during this time. 27 The Alcohol Use Disorders Identification Test—Consumption (AUDIT-C) 28 was used to measure recalled and self-reported alcohol use in the year before pregnancy (range 0–12).…”

“…This cutoff has previously been used to classify hazardous alcohol use among pregnant women in South Africa. 7 Consistent with our previous work, 25 we measured PrEP continuation at 3 months by participant return to clinic and receipt of a PrEP prescription refill (those who initiated PrEP at baseline and did not return or did not refill when they returned were classified as "discontinued" and placed in the reference group). Self-reported adherence was measured using the question, "In the last 7 days, on how many days did you miss at least one dose of your PrEP?".…”

“…Perinatal alcohol use is a significant public health problem in South Africa that threatens the well-being of both mother and fetus. [7][8][9][10] In addition, it is well-established that alcohol use is associated with HIV risk behaviors, including multiple sex partners [11][12][13] and condomless sex, 11,14 and results in increased risk of HIV acquisition. [15][16][17][18] A limited body of evidence suggests alcohol use is also associated with barriers to PrEP initiation, continuation, and adherence.…”

“…5 The World Health Organization (WHO) and the South African Department of Public Health recommend offering PrEP to pregnant and postpartum women who are at high risk of HIV acquisition, and a recent systematic review identified no safety-related reasons for not offering PrEP to this population. 6 As an individually controlled (and when used by women, female-initiated) HIV prevention method, PrEP also offers user autonomy in a setting where condom use is low (especially during pregnancy 7 ), and women may lack agency to advocate for safer sexual practices in their intimate partnerships. Given that PrEP scale-up may be essential to reducing incident HIV cases among pregnant and breastfeeding women—and the elimination of mother-to-child transmission in this setting—it is critical to identify barriers to optimal PrEP care outcomes.…”