International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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W.M. Wechsberg et al. / International Journal of Drug Policy 25 (2014) 583–590 589 p-value = 0.10) compared with males who were not heavy alco- hol users. However, heavy alcohol use was not associated with the likelihood of being HIV infected among females. Increasing preva- lence of HIV-infection in the neighbourhood elevated the likelihood of being HIV-infected among females. Compared with neighbour- hoods where the HIV-prevalence was low (<10%), the likelihood of being HIV-infected was 3.28 (95% CI [1.14, 9.46]) and 5.33 (95% CI [1.88, 15.08]) in neighbourhoods where the prevalence of HIV was moderate (11–20%) and high (21–50%), respectively. In neighbour- hoods where the prevalence of methamphetamine use was at least 1%, females experienced a 1.49 (95% CI [0.87, 2.53], p-value = 0.143) increased risk of infection compared with females recruited from neighbourhoods within which no respondents reported metham- phetamine use. Neither neighbourhood-level HIV prevalence nor methamphetamine use was associated with HIV infection among males. Having multiple sex partners within the previous three months was not associated with HIV infection for either men or women. Discussion We conducted cross-sectional analyses of baseline data to exam- ine differences in correlates of HIV infection among men and women. Women were twice as likely as men were to test positive for HIV. We also assessed the association between individual HIV status and neighbourhood level measures of methamphetamine use and HIV prevalence while adjusting for individual level risk. In the bivariate and in the multivariable analyses, older age and having an HIV-infected partner were associated with HIV infection among men and women. Age is a proxy measure for duration of exposure (i.e. sexual activity) and having a main partner who is HIV positive is a direct marker of HIV exposure through sex, so these findings are expected. Men were more likely than women to report heavy alcohol use and methamphetamine use. Heavy alcohol use was marginally associated with HIV infection among men and it was not associ- ated with HIV infection among women. This gender difference is consistent with other studies documenting that South African men are significantly more likely to drink alcohol at harmful or haz- ardous levels than South African women (Peltzer, Davids, & Njuho, 2011). These findings were as expected. Methamphetamine use was not associated with HIV infection among men or women at the individual level or at the neighbourhood level. Compared with women, men were significantly more likely to report having more than one sex partner in the previous three months. In bivariate analyses, men who reported having multi- ple sex partners were significantly less likely to be HIV positive than men who did not have multiple partners. This was unex- pected. There was no association between having more than one sex partner and HIV infection among women in the bivariate anal- yses. Reporting more than one sex partner was not associated with HIV infection in the multivariable models for men or women. These findings are counterintuitive. It is possible that behaviours changed since they were infected with HIV. Alternatively, among HIV dis- cordant couples, sex outside a relationship may not increase risk for the HIV negative partner. To the extent that current behaviours reflect those at the time of infection, these findings suggest that individual risk behaviours do not explain fully HIV infection in this context. At the partnership level, HIV infected women were about four times as likely to have an HIV negative male partner than vice versa. However, because we analyzed cross-sectional data, we are unable to determine if one partner infected the other or if they were infected by someone else before or during the current partnership. In bivariate analy- ses, neighbourhood level HIV prevalence was associated with HIV infection among both women and men. In the multivariable mod- els, neighbourhood HIV prevalence was significantly associated with HIV infection among women but not among men. The associ- ation between neighbourhood HIV prevalence and HIV infection among women is as we hypothesized. The association between neighbourhood HIV prevalence and HIV infection among men was in the same direction, so the lack of statistical significance may be due to the much smaller number of HIV infected men in the sample. Although only marginally significant, the direction of the associ- ation between heavy alcohol use and HIV among men is consistent with findings from previous South African studies conducted among patrons of shebeens in township communities. These ear- lier studies reported that men who drink heavily in shebeens had multiple sex partners, casual partners, and unprotected sex with these partners more than men who do not drink heavily (Cain et al., 2012; Kalichman et al., 2008, 2013; Scott-Sheldon et al., 2012). As with most studies of sex risk behaviours, this study is based on self-reports that are difficult to verify. In addition, causal asso- ciations between risk behaviours and HIV infection cannot be established from cross-sectional analyses. Although we tested all participants for HIV, we do not know how long they may have been infected with HIV, what their behaviours were like at the time they were infected, where they were living at the time of infection or who was their partner. Further, as this study was clustered randomized field experiment designed to target high risk couples to assess the efficacy of an intervention, it is not generalizable to the townships or other populations. Strict eli- gibility criteria helped ensure that the sample was somewhat homogenous. Nevertheless, the prevalence of HIV in our sam- ple was similar to other reports from Khayelitsha (Garone et al., 2011). Findings from this study underscore the need for policy mak- ers to direct scarce resources to the communities, places within communities, and populations where they will have the greatest impact on HIV prevention and onward transmission. The prolifera- tion of shebeens in townships such as Khayelitsha, as noted in this manuscript, has profound economic and health consequences. The vast majority of shebeens in townships are unlicensed and as such, operate outside the regulations imposed by the provincial liquor act and are untaxed. Although the new National Drug Master Plan (2013–2017) recognizes the role of the environment and context on alcohol and drug use in South Africa, it does not identify spe- cific strategies for addressing these factors. (South African National Department of Social Development, 2013). At a policy level, new strategies are needed to help reduce the influence of contextual and environmental influences on alcohol and other drug use in these townships. Acknowledgements Funding for this research was provided by National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant number R01 AA018076. We wish to thank Jeffrey Novey for editorial assistance. Conflict of interest statement The authors have no conflict of interest to report. References Bradshaw, D., Norman, R., & Schneider, M. (2007). A clarion call for action based on refined DALY estimates for South Africa. South African Medical Journal, 97(6), 438–440.

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