‘What will it take’: addressing alcohol use among people living with HIV in South Africa

Abstract

Given that hazardous and harmful alcohol use has been identified as a significant barrier to adherence to antiretroviral therapy (ART) in South Africa, alcohol reduction interventions delivered within HIV treatment services are being investigated. Prior to designing and implementing an alcohol-focused screening and brief intervention (SBI), we explored patients’ perceptions of alcohol as a barrier to HIV treatment, the acceptability of providing SBIs for alcohol use within the context of HIV services and identifying potential barriers to patient uptake of this SBI. Four focus groups were conducted with 23 participants recruited from three HIV treatment sites in Tshwane, South Africa. Specific themes that emerged included: (1) barriers to ART adherence, (2) available services to address problematic alcohol use and (3) barriers and facilitators to delivering a brief intervention to address alcohol use within HIV care. Although all participants in the present study unanimously agreed that there was a great need for SBIs to address alcohol use among people living with HIV and AIDS, our study identified several areas that should be considered prior to implementing such a programme.

Keywords

Africa high-risk behaviour HIV

Background

The advent of antiretroviral therapy (ART) has shifted HIV from a devastating epidemic to a controllable chronic disease.¹ To maintain the optimal benefits of ART, lifelong adherence to the prescribed treatment regimen is crucial.² Unfortunately, like many African countries where the burden of HIV is considerable, in South Africa a substantial proportion of people living with HIV (PLWH) do not achieve or sustain undetectable viral loads.³ Several barriers to achieving and sustaining undetectable viral loads have been described in the literature including forgetting, side effects and mental health problems,⁴ with hazardous and harmful alcohol use often being cited as a major barrier.⁵

Hazardous and harmful alcohol use is implicated in viral suppression failure and HIV disease progression through a combination of biological and behavioural processes. Studies have found that hazardous/harmful alcohol use directly affects the immune system through poor virological control of PLWH and damage to the liver impacts on the metabolism of ART resulting in reduced effectiveness.⁶ Alcohol use has also emerged as a strong barrier to ART adherence.^7,8 Sub-optimal adherence to ART regimens reduces the likelihood of viral suppression and may result in the development of resistance to ART, and ultimately poorer treatment outcomes for PLWH.⁹

Given that hazardous/harmful alcohol use is a behaviour that is amenable to change, screening and brief interventions (SBIs) for alcohol use delivered in HIV treatment settings provide an opportunity to identify current or potential problems with alcohol use among PLWH, and intervene accordingly. Several studies have investigated the effectiveness of brief interventions to address alcohol use among PLWH^10–12 and have resulted in mixed, yet promising findings. The few studies that were conducted in South Africa to address alcohol use among HIV populations were relatively short in duration (1–2 sessions) and the long-term effects were not evaluated.¹³

In 2013, the South African Medical Research Council funded a randomized controlled trial to assess the efﬁcacy of an alcohol-focused brief intervention for reducing alcohol consumption (primary outcome) and improving adherence to ART and HIV treatment outcomes (secondary outcomes).¹⁴ This four-session blended motivational interviewing and problem-solving therapy intervention has been shown to be successful in reducing substance use among patients presenting to emergency services who screen at risk.¹⁵ Prior to implementing this alcohol-focused SBI trial in the South African healthcare system for PLWH, formative work was needed to explore patients’ perceptions of alcohol as a barrier to treatment, the acceptability of providing SBIs for alcohol within the context of HIV services and potential barriers to patient uptake of this SBI.

Materials and methods

Setting

The study was conducted at two district hospitals in the Tshwane Metropolitan Municipality. Both district hospitals serve a high number of ART patients from free-standing HIV clinics on the hospital premises. One of the hospitals is in the urban area, while the other is in the peri-urban area.

Participants

To be eligible to participate in the study, participants had to be over 18 years of age; fluent in English, Setswana, Sesotho or Sepedi; a resident in Tshwane municipality; be HIV-positive and be taking ART for a minimum of three months. They also needed to meet AUDIT criteria for harmful/hazardous drinking. Those meeting criteria for alcohol dependence were not included in the study.¹⁶

Procedure

Potential participants were approached to participate in the study by a research assistant as they waited for their usual HIV clinical consultation. Information pertaining to the study was provided and participants were invited to be screened for potential study eligibility. Those that provided informed consent for screening and met criteria to participate in the study were asked to return to the clinic at a later date to take part in one of four focus group discussions comprising between five and eight participants. During the informed consent process, the concept of confidentiality was described, and group rules were discussed with participants. We encouraged confidentiality but highlighted that given the nature of focus groups, personal information and stories should only be described in detail if they felt comfortable to share with the public. An open-ended semi-structured questionnaire was used to guide the discussions led by KS and BM, trained psychologists with significant experience in qualitative methods. The semi-structured questionnaire explored issues around alcohol use among PLWH, availability of services to address alcohol use, and perceptions of the acceptability and feasibility of delivering an alcohol-focused intervention within HIV care. The discussions were conducted in English and/or Setswana, in accordance with the preference of the group. They were audiotaped and transcribed verbatim. The English discussions were transcribed verbatim while the Setswana spoken discussions were translated during transcription. Although we anticipated three focus groups were required to meet data saturation, an additional focus group was required. Ethical approval for this study was obtained from the Research Ethics Committee of the South African Medical Research Council who also sponsored the study. Participants were provided with refreshments and a R100 (∼US$10) gift voucher for participating in the group discussion.

Data management and analysis

The qualitative data analysis for this study was conducted using the framework approach (familiarization, identifying a thematic framework, indexing, charting, mapping and interpretation).¹⁷ Initially, interview transcripts were read for emergent themes, which were then coded. Two investigators used NVivo 11.0 to code transcripts, with coding discrepancies resolved through discussion. A Kappa score of 0.88 was obtained, indicating excellent intercoder reliability.

Results

The research results are presented according to the major themes that emerged from the data analysis. Results are divided into: (a) characteristics of participants, (b) barriers to ART adherence, (c) available services to address problematic alcohol use and (d) barriers and facilitators to delivering a brief intervention to address alcohol use within HIV care.

Characteristics of participants

A total of 23 participants took part in the four FGDs with 5–6 participants in each group. There were 10 males and 13 females. Their age range was 21–52 years, most (18/23) were in their 30s and 40s, and their highest level of education was matriculation (83%). Their marital status was as follows: 6 were married or living as married and 17 were single. Just over half of the participants were unemployed (57%). The average score on the AUDIT was 14.4 (SD = 6.4).

Barriers to ART adherence

Participants in the present study identified numerous barriers to both accessing and adhering to ART. First, facility-related barriers such as long queues and long waiting times were frequently reported, often resulting in many leaving the facility before obtaining their medication. This viewpoint was encapsulated in the words of one participant:

They say at the clinic you will wait. You will wait forever, and the sisters don’t think that we need to eat. These are the things that bother people. You will come early in the morning and you will leave at 16:00. This is why some people will never come to the clinic. They will get tested but will not take treatment. (FGD 3, Participant 3)

Second, barriers relating to people’s daily routines and process of scheduling clinic appointments were highlighted. In these HIV services, clients who are fairly new on the treatment regimen are required to attend their clinic appointment monthly on a pre-scheduled day to obtain repeat prescriptions of their ART. Some clients who are more stable tend to get a three-month supply. Many of the participants who were employed found this process problematic due to the unpredictable nature of their employment and difficulties in getting time off work. In these instances, medications were not accessed resulting in non-adherence. One participant stated:

For example, you have to come to the clinic on the 28th and then you find out on the 20th you are busy and committed. You have to talk to the people at work, so you can manage to come, something like that. (FGD 4, Participant 2)

Third, stigma was frequently reported as a major barrier to accessing and adhering to treatment. For many, going to the clinic monthly to collect their antiretrovirals (ARVs) was stressful. There is a designated area for PLWH to wait for their appointment and a designated line where ARVs are dispensed at the pharmacy. Due to the segregation of HIV treatment from other services, some feared that their HIV status would be exposed to people in their community members, including family and friends. This barrier is illustrated by one participant who said:

Some people find it difficult because they are afraid to be in a group that has stigma. Some people have to come to the clinic, maybe they came with a family member and then they see me in the treatment line. It’s obvious that I am sick, because we know that when you come here it’s just for ARVs. That is just for the people who are sick. (FGD 3, Participant 3)

Finally, medication and health concerns were discussed as barriers to non-adherence among participants. Many reported that ARVs had negative side effects. These included gaining weight, skin problems, feeling nauseous and vomiting. Concerns regarding the implications of taking ARVs without food as prescribed, the interaction between ARVs and other medications, and the interaction between ARVs and alcohol use were also identified by a few participants as major barriers to ARV adherence.

In many instances, PLWH who use alcohol would often unintentionally miss taking their ARVs. Several participants shared experiences where they missed taking their ARVs when they were out socializing with friends and would either not prioritize, forget or were not prepared to be away from home when they were scheduled to take their ARVs. The effects of alcohol use on adherence would sometimes linger on to the next day. For example, if they were hungover, they may feel too ill to take their medications as prescribed. For some, not taking ARVs while drinking was intentional. A few believed that mixing alcohol with ARVs was harmful and could lead to adverse reactions, resulting in some deliberately not taking their medication while alcohol was in their system. The belief is conveyed by the following statement: ‘Stopping alcohol is the safest way to go because the pills that we are taking do not work with alcohol. If you can drink a pill with alcohol, it makes acid and that acid doesn’t work properly inside’ (FGD 2, Participant 3).

Although most participants acknowledged that problematic alcohol use could negatively impact the health and HIV disease of PLWH, many continued to drink. A few reported that they enjoyed drinking. They noted the social aspects of alcohol use, reporting that when they drink they feel part of a social group and more integrated in the community. Many also turned to alcohol as a way of managing stress, their HIV diagnosis and to cope with problems of everyday life. Although some felt they should stop drinking or reduce their use, others felt alone and vulnerable after being diagnosed and believed that if they stopped drinking they would be further isolated from family and friends and unable to cope with stress:

It could be that I want to stop drinking alcohol but I have stress from home they are making noise at me, shouting at me and at that time I have money with me and they are shouting at me making me have stress I feel oppressed so let me just go and have one beer. So saying I will stop but it is the more if I have one drink I can’t stop drinking it, you see. (FGD 1, Participant 6)

Available services to address problematic alcohol use

Only a few participants mentioned the availability of specialist substance use treatment programmes, such as the South African National Council on Alcoholism and Drug Dependence or Alcoholism Anonymous. However, all participants discussed the mandatory basic HIV education session that they receive when initiating ART. They indicated that the risks and negative impact of alcohol use on adherence and HIV disease are highlighted in this session with specific recommendations given for patients to abstain from drinking. Many participants noted that this educational session was not ideal, given they were adjusting to their diagnosis and treatment regimen potentially resulting in a lack of desire to stop drinking. As one participant stated: ‘When you start taking ARVs, you attend a class whereby they tell you not to drink alcohol or imbiza, but us as people we don’t listen’ (FGD 2, Participant 2).

A few participants described some of the more empathic nurses or ‘soft nurse’ that they felt they could approach to discuss some of these problems. It was highlighted that only on rare occasions would the healthcare provider ask about health issues unrelated to HIV (such as alcohol use or other mental health concerns). In most instances, the patient rather than provider would need to initiate an alcohol-related discussion.

Barriers and facilitators to delivering an SBI to address alcohol use in HIV care

All participants in the present study felt that a programme that incorporates SBIs to address alcohol use among PLWH is important and should be prioritized. However, they identified several potential barriers to implementing this programme in HIV services. To begin with, reluctance to disclose alcohol use to a healthcare provider in the facility was reported by many, which would limit patients’ access to an alcohol-related intervention. The main reason for non-disclosure was a perceived fear of judgment and reprimand from the healthcare providers, as is portrayed in the following example: ‘The person feels ashamed. Obviously, the doctor or nurse will shout at you, they yell at you not to abuse you but because they care for your life’ (FGD 3, Participant 3).

Given these fears, it was felt that primary healthcare providers such as doctors and nurses were not ideal to deliver the counselling interventions. Although a few participants did highlight that social workers could potentially act as delivery agents, most felt that a peer, notably someone who is HIV-positive themselves or has struggled with alcohol use previously, would be an ideal person to deliver the counselling intervention:

I think it should be someone who has experienced it. It will be much easier. You cannot tell me about marriage when you have not been married. I think it would be easier if you tell me about something you have experienced. How did you manage to stop, you used to be a heavy drinker. Those will be the relevant people. (FGD 4, Participant 3)

A number of structural barriers to access an SBI programme for alcohol use were also highlighted. First, transportation barriers to the health facility to attend the counselling sessions were frequently reported. Access to transport itself was not the issue, rather the financial implications of having to pay for public transport. This is encapsulated by the following statement:

Some stay far and don’t have transport. Some are walking from wherever because they don’t have their own transport. So, they have to get a taxi from here to station and from station to here which is double transport [costs]. (FGD 3, Participant 3)

Second, the operating hours of the healthcare facility were identified as a barrier to attending counselling, particularly for students or those who were employed. Discussions regarding whether it was possible to offer the counselling later in the afternoon or even on Saturday morning, outside of participants’ working hours occurred. It was also highlighted that Monday would not be an ideal day for people with hazardous/harmful patterns of alcohol use to attend counselling sessions due to the increased likelihood of hangovers from heavy drinking on the weekends resulting in non-attendance:

But not on Monday. I don’t want to say much but not on Monday. It is obvious that everybody is tired and some have hangovers on Monday. People won’t come they will say they want to sleep. Monday is hectic, people struggle. (FGD 1, Participant 7)

Discussion

This paper is among the first to examine the acceptability of providing SBIs for alcohol use within the context of HIV services in South Africa and identifying potential barriers to patient uptake of this SBI. Although all participants in the present study unanimously agreed that there was a great need for SBIs to address alcohol use among PLWH, our study identified several areas that should be considered prior to implementing such a programme.

First, it appears that PLWH are receiving conflicting messages about alcohol use generally, and specifically the interaction of alcohol with ART. Participants were unsure whether they had to abstain completely from alcohol or whether low-risk drinking is permitted, impacting on adherence behaviours. This is consistent with previous research conducted in the United States, where it was reported that many PLWH believed that mixing alcohol and ARVs was prohibited as the resulting toxicity can harm the immune system and interfere with the effectiveness of the medication.^18,19 To reduce this confusion, any intervention that focuses on alcohol use among PLWH should highlight the importance of taking ART regardless of whether alcohol is consumed, discuss short- and long-term health risks associated with various levels of alcohol use, and describe in detail what constitutes low-risk drinking in the context of HIV. Further, to ensure continuity of care, modifications to the current provision of services at the healthcare facility are recommended such as ensuring the current education delivered is accurate and that healthcare providers are using a client-centred approach.

Second, our findings suggest that to increase the likelihood of intervention uptake by PLWH, careful consideration needs to be given to the choice of SBI delivery agent. Participants did not support the idea of using nurses or doctors to deliver the SBI programme due to fear of being judged and possibly the more traditional authoritative advice giving.²⁰ There is some evidence in the literature that patient–counsellor matching may help establish a therapeutic alliance²¹ and emerging evidence in support of the use of peer recovery coaches for the delivery of substance-related interventions in healthcare settings.²² Participants’ recommendation to use categories of staff to conduct SBIs who are not traditionally employed in primary healthcare services supports the notion of task-sharing, that is ‘delegating tasks to existing or new cadres with either less training or narrowly-tailored training’.²³ Task-sharing translates into more cost-effective ways of delivering health services to more people, ultimately providing viable strategies for reducing the large substance use treatment gap.²⁴

Third, respondents identified a few other barriers that would need to be considered when implementing SBIs for alcohol use in HIV settings. Specifically, transport costs and days and hours of clinic operations were highlighted. Although these logistic barriers could be overcome for research purposes to test the efficacy of an intervention, they would be difficult to address if the South African Department of Health implements this intervention as part of standard HIV care. It is important to be cognizant of these barriers as we consider the move from research to implementation of this programme at a later stage.

Findings from this study should be considered in the light of several limitations. Given the nature of qualitative studies, the sample was small and participants were likely not representative of all patients receiving ART in Tshwane. We also do not have the response rate for those approached for the focus group and those that actually attended. Given the strict inclusion criteria imposed in this study, our sample may be biased towards participants who were more favourable of integrating an SBI programme into HIV services.

Conclusion

Despite these limitations, the findings of the present study provide valuable insight into the development of an SBI programme to address alcohol use among PLWH on ART and what barriers might need to be addressed to implement such an intervention in HIV care settings. Integrating alcohol-focused interventions into HIV services has been identified as a way of expanding access to care. This research adds to the growing body of research on integrated services by highlighting barriers that must be considered before scaling up the provision of these services. Given the findings of this study point to a task-sharing approach to the delivery of SBIs, future research should explore effective approaches to training and supervising non-specialist workers to deliver SBIs.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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