Background

Unhealthy alcohol use is common among people affected by HIV and is associated with poor treatment outcomes, but its impact among adolescents and young adults living with HIV (AYAH) in Africa is rarely explored. This study aimed to estimate the prevalence of unhealthy alcohol use and examine its association with HIV viral suppression among AYAH in Uganda and Kenya.

Methods

We conducted a cross-sectional survey among AYAH enrolled in the intervention arm of the SEARCH Youth study, a life stage based trial evaluating an intervention to improve viral suppression among youth aged 15 to 24 years. At their 30 to 36 month follow-up visit, AYAH were interviewed for self-reported alcohol consumption using the Alcohol Use Disorders Identification Test—Consumption (AUDIT-C, modified to cover the last 3 months) and tested for phosphatidylethanol (PEth), a blood-based biomarker of prior month alcohol consumption. Unhealthy alcohol use was defined as AUDIT-C ≥ 3 for females, ≥4 for males or PEth≥50 ng/mL. We estimated underreporting of alcohol use among those with PEth ≥50 ng/mL and examined the association between unhealthy alcohol use and viral non suppression (≥400 copies/mL) using logistic regression, adjusting for gender, age, and country.

Results

Unhealthy alcohol use was assessed in 715 AYAH; 409 (57.0%) in Uganda and 309 (43.0%) in Kenya. Eighty percent were female, median age at the time of the survey was 24 years (interquartile range: 21-26), and 95.0% were virally suppressed. The prevalence of unhealthy alcohol use was 25% overall, higher among males than females, Ugandan than Kenyan AYAH and increased with age. Unhealthy alcohol use was associated with nearly 3-fold higher odds of viral nonsuppression (adjusted odds ratio = 2.80, 95% CI [1.19-6.58], P = .02). Almost half (46.0%) of those with PEth≥50 ng/mL underreported unhealthy alcohol consumption.

Conclusions

After adjusting for sex, age, and country, unhealthy alcohol use was associated with viral nonsuppression among AYAH receiving the multilevel SEARCH Youth intervention, suggesting a need for targeted interventions. However, underreporting of unhealthy alcohol use may be a barrier to identifying those at risk. The rising prevalence of unhealthy alcohol use with age suggests there may be a window for early intervention.

Plain Language Summary Title

The Effect of Unhealthy Alcohol use on HIV Viral Suppression Among Adolescents and Young Adults Living with HIV in Kenya and Uganda

Plain Language Summary Why did we conduct this study?

Unhealthy alcohol use is common among people living with HIV, and is known to interfere with treatment in adults, but it has rarely been explored among youth in Africa with HIV. Unhealthy alcohol use means drinking in a manner or quantities that increase health risks. In this study we examined how common unhealthy alcohol use was among youth living with HIV in Kenya and Uganda, and whether it was linked to viral non suppression. We also compared self reported use with blood tests to see if young people report their drinking accurately.

How was the study conducted?

We studied youth who started receiving improved HIV services when they were between 15 and 24 years. We asked them to answer questions about their drinking over the past three months and also tested them using a blood test that can detect recent unhealthy drinking. We then estimated how common unhealthy drinking was based on age, sex and country as well as its connection with viral suppression.

What did we find?

We found that one in four youth engaged in unhealthy drinking which was more common among males, and Ugandan youth, and increased with age. Nearly half did not report their alcohol use accurately when asked about it. Unhealthy alcohol use was linked to a much higher likelihood of having viral non suppression.

What lessons do we learn from these findings?

These findings show that unhealthy alcohol use is common and undermines HIV control warranting inclusion of alcohol use interventions in HIV services. However, underreporting could undermine interventions. The fact that unhealthy alcohol use increases with age suggests that there is room for early intervention.