Binge drinking and HIV/AIDS risk in Africa

Sir: At the risk of suggesting yet another entry to the list of horrors - e.g. HIV, malaria, tuberculosis, poverty, drought, food shortages - bedevilling a region that, at this point, deserves only relief, it should be noted that the paper by Chersich et al. ¹ in the November issue of International Journal of STD and AIDS generally substantiates the conclusions of a recent spate of papers ^{2 8} that have called attention to the role of hazardous drinking in sub-Saharan HIV/AIDS spread. This is an issue that received far too little attention from the local and international HIV prevention and policy-making community during earlier years of the pandemic. It is difficult to say whether this myopia toward alcohol's role in heightening risk for HIV acquisition and transmission in Africa is largely traceable to an underlying assumption that beverage consumption simply constitutes behavioural ‘background noise’ and, thus, is unworthy of the same concerned reaction from public health authorities attendant on, say, illicit drug use or gay/bisexual sex (engaged in by easily stigmatized and marginalized societal groups), or whether it reflects a conviction that at least some forms of alcohol - i.e. traditional ‘home brew’ - may provide some modest nutritional benefit for rural Africans ⁹ that should outweigh any concerns about other drinking-related outcomes. Or perhaps this oversight reflects the received wisdom, carried forward from an earlier generation of anthropologists, that traditional drinking in Africa - which typically was shared with fellow villagers and often done as part of a feast offering tribute to notables or giving thanks to ancestors, ^{10 12} or in celebration of a successful grain harvest^13,14 or completion of some type of collective endeavour (e.g. construction of a wood shed or preparation of a garden) ⁹ - served essential social functions for the village ¹⁵ that, on balance, overshadowed any ancillary problems for the individual stemming from excessive consumption. ¹⁶ Possibly, too, the fact that a relatively large segment of the population in many African countries reportedly abstains from alcohol use ^{17 19} may be counted as a reason for the relative lack of attention paid to drinking as a factor in HIV spread in the region, although this should not blind us to the fact that - among those who do drink - levels often can be dangerously high. ¹⁸

Whatever the reasons, it appears that the HIV/AIDS interventionist community in Africa may only now be coming to fully appreciate the particularly important role of what must undoubtedly rank as the most harmful of drinking patterns - heavy episodic, or binge, drinking - in facilitating HIV-risky behaviours in this part of the world. Commonly defined as consumption of 5+ drinks on a single drinking occasion, ²⁰ the binge-drinking pattern is wonderfully designed to elevate the blood alcohol concentration levels well above the 0.08 g-percent level at which cognitive abilities most necessary for engagement in safe sex and/or adherence to highly active antiretroviral therapy regimen are likely to be compromised.

To be sure, a full account of binge drinking's trajectory on the African continent remains elusive: considered scientific elaborations of the ‘binge’ term and careful empirically based delineations of its medical and behavioural consequences have appeared only recently, of course, and reliable longitudinal data bearing upon the prevalence of this drinking pattern in the African context is difficult to come by, whereas any analysis of drinking in Africa must account for the estimated high levels of unrecorded per capita alcohol consumption in many countries stemming from home production of beverages. ¹⁸ Moreover, comparisons of African drinking patterns across time periods must consider that villagers in earlier times undoubtedly often took full advantage of the chance to drink heartily whenever the opportunity arose insofar as grain beer was highly perishable and only sporadically available.^13,21 Further muddying the picture is the fact that a wide variety of drinking patterns, evolving alongside urbanization and economic class formation processes, have been identified across many African counties in recent years.^13,19

That being said, it seems difficult to overlook the myriad observations that suggest that the relatively recent commercialization of the sub-Saharan alcohol production process has resulted in an increase in the proportion of the population engaging in heavy or heavy episodic drinking,^{13,14,18,19,21-25} predominantly among males,^3,26-28 but with some reports noting a somewhat wider diversity of heavy drinkers.^29,30 It would seem likely that the large-scale development of this style of drinking in Africa cannot be understood apart from the various macro-level forces that have been wrenching that continent into its new niche in the global international commercial network, ^{31 33} resulting in the monetarization of the rural economy and the movement of young adults away from the rural areas and into the cities, ^{34 36} where they are likely to fall under the sway of increasingly aggressive global alcohol marketers. ^{37 39}

Making this scenario doubly explosive, for HIV spread, is the appearance in the last two decades of substantial numbers of disadvantaged individuals - including AIDS orphans and widows, ^{40 42} as well as those who have been displaced by the gyrations of the industrializing processes in these nations - whose bartering of sexual services is now often done in close proximity to the very alcohol retail establishments where high-risk drinking occurs.^43,44 Indeed, in at least some countries, many of the bar workers are known to be sex workers. ^{45 47} Prevention, of course, remains the best hope for stemming the tide of the pandemic, but toward this end HIV prevention interventionists ultimately will have to confront the behavioural fallout from the widespread adoption of the binge pattern of drinking in sub-Saharan Africa. Insofar as this behaviour - and associated high-risk sex - often tends to occur in specific locales, a prevention approach that creatively targets such ‘hot spot’ venues ^{48 52} would appear to merit strong consideration.