Summary:
- HIV risk behaviors may intersect with other risky patterns of behavior, including drinking to excess, to compound the spread of HIV/AIDS.
- The relationship between risky drinking, injection drug–risk behaviors, and unsafe sex is both context- and community-specific.
- Persons at risk of experiencing problems relating to their drinking patterns may also be at risk for HIV infection, especially among groups whose behaviors, context, or lifestyles already place them at risk of acquiring the virus.
- While interventions focused on reducing alcohol misuse are helpful, they alone may not address the underlying sociocultural context, personality, and situational and structural factors that simultaneously influence patterns of risk behaviors.
- Interventions that target potentially high-risk sites, where patterns of excessive alcohol consumption may increase the likelihood of unsafe sex or sexual contact with multiple partners, can provide a unique opportunity to strengthen HIV/AIDS prevention activities.
- For Examples of Targeted Interventions, see the Blue Book index page of www.icap.org.
The spread of HIV, the virus that causes AIDS, is not only a challenge to public health but also to the social and economic wellbeing of individuals, families, communities, and countries.1 With this in mind, one positive step toward reducing the transmission of HIV has included assessing the roles of risky behavioral patterns (e.g., risky drinking) in the spread of the disease. To that end, the intersection of risky drinking patterns with high-risk injection and/or sex-related practices—two major modes of HIV transmission—must be thoroughly examined.
HIV risk-taking behaviors and harmful drinking patterns
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HIV is spread via unprotected sexual contact with an infected person, by direct blood contact through contaminated needles (primarily for illicit drug injection or in healthcare settings without proper sterilization procedures), during birth or breastfeeding (for infants born to HIV-infected mothers), or through transfusions of infected blood.2 Unsafe sex, identified by the World Health Organization (WHO) as one of ten leading risk factors for harm globally, is the most common mode of HIV transmission (World Health Organization [WHO], 2002). “Unsafe sex” refers to sexual contact with partners of unknown HIV status without the use of condoms. Its toll is particularly great in developing countries that are characterized by high mortality rates, where unsafe sex is the second highest risk factor for harm, accounting for 10.2% of the total disease burden.3
There is much debate in the scientific literature about the relationship between certain risky drinking patterns and sexual risk-taking. It has been suggested that heavy drinking patterns may influence sexual risk-taking by affecting judgment and reducing inhibitions, thereby diminishing perceived risk or excusing behaviors otherwise considered socially unacceptable (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2002).
For example, a study undertaken by WHO in eight countries4 found that inebriation was considered a culturally acceptable excuse for acting irresponsibly (including engaging in unsafe sexual activities) in Belarus, Kenya, Mexico, Romania, the Russian Federation, and South Africa. In Romania, this conceptualization was exclusive to men, implying that such behavior was correlated with an assertion of masculinity (WHO, 2005).
Research indicates that the relationship between alcohol and sexual conduct is context- and community-specific. Outcomes are likely to vary, depending on situation, gender, sexual and alcohol experiences, cultural norms and practices, drinking patterns, and individual physiological responses to alcohol (e.g., Cooper, 2002; Corte & Sommers, 2005; Markos, 2005; McNair, Carter, & Wlliams, 1998; Poulson, Eppler, Satterwaite, Wuensch, & Bass, 1998). Expectations surrounding the effects of alcohol (e.g., the perception that alcohol enhances sexual arousal and performance)5 and personality traits associated with both drinking and sexual risk-taking (e.g., impulsive decision-making, stimulus- and sensation-seeking)6 may also influence unsafe sexual practices. The WHO study supports this assertion, reporting that in the Russian Federation “there was a common misconception that a person without alcohol was incapable of engaging in sex” (WHO, 2005, p. 46).
These factors are, however, subjective and difficult to quantify. In addition, the important and multi-faceted role alcohol plays in various cultures, traditions, and social contexts does not afford an easy comparative analysis across borders or even within a given country (e.g., Heath, 1995, 2000). A consistent methodology for measuring an association between drinking patterns and the transmission of HIV/AIDS has not yet been developed.
Multiple-risk groups and HIV/AIDS
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Several studies have linked alcohol intoxication with greater injection drug risk behaviors, including the sharing of needles or other injection equipment (e.g., Robles et al., 2004; Stein, Charuvastra, Anderson, Sobota, & Friedmann, 2002; Stein, Hanna, et al., 2000). HIV transmission rates through sexual contact are also shown to be higher in the presence of harmful drinking patterns, especially among groups whose behaviors, context, or lifestyles already place them at risk of acquiring the virus. Therefore, many of those persons at risk of experiencing alcohol-related problems (see Module 8: “At-Risk” Populations)
The intersection between alcohol misuse and HIV risk behaviors is particularly visible among populations disproportionately affected by poverty, inequality, discrimination, instability, insecurity, and limited opportunities, lacking social or institutional support. These factors may expose individuals to co-occurring risks such as sexual coercion and violence and/or contribute to the incidence of transactional sex for drugs, money, or shelter. For example, many young women around the globe (and, to a lesser extent, young men) encounter personal danger while trying to secure monetary or material resources for themselves and their families. This is especially the case in the context of extreme poverty, where many girls and young women are forced to trade sex as a means of survival (Gregson et al., 2002; UN Secretary General’s Task Force on Women, Girls and HIV/AIDS in Southern Africa, 2004). A recent study of a refugee camp in Kakuma, Kenya, described the link between women brewing, selling, and consuming illegal forms of traditional alcohol (MODULE 21: Noncommercial Alcohol) and transactional sex (Adelekan, 2006). Sex work was frequently exchanged for money or alcohol, often in an inebriated state, with “lack of condom use being the rule rather than the exception” (Adelekan, 2006, p. 46). The report also detailed the increased vulnerability of women, while intoxicated, to forms of gender-based sexual violence and rape.
Some studies have also shown a higher rate of HIV infection among individuals with problem drinking, such as persons in alcohol abuse treatment. One such study based in San Francisco, California, identified HIV prevalence rates in alcohol treatment facilities to be several times higher than local published estimates, irrespective of injection drug use (Avins, Woods, Lindan, Hudes, Clark, & Hulley, 1994; see also Mahler et al., 1994, Petry, 1999). However, due to the concurrence of social, economic, and personality factors, this is likely to be a correlative, not causative, relationship. The potential link between sexual risk-taking and problem drinking in HIV-positive individuals could have significant implications for the spread of the virus (Parsons, Vicioso, Kutnick, Punzalan, Halkitis, & Velasquez, 2004, Kalichman et al., 2003, Bouhnik et al., 2007); therefore, dyadic interventions may prove most effective in mitigating harm.
High-risk settings and sexual networks
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Understanding sexual networks is crucial to reducing transmission rates of HIV, as an individual’s risk is greatly influenced by his or her location within a sexual network.7 In drinking establishments where sexual networking is likely to occur, sexual contact may be facilitated by particular drinking patterns. Two studies in South Africa reported that 75% of respondents identified local drinking places as public venues where people went specifically to meet new sexual partners and with the intention to engage in sex (Morojele et al., 2006; Weir, Pailman, Mahlalela, Coetzee, Meidany, Boerma, 2003). Research participants reported that low lighting, seductive music, unisex toilets, and lack of condoms were conducive to sexual intercourse. When combined with heavy alcohol consumption, these factors were stated to contribute to the incidence of unsafe sex. In both studies, condoms were seen by the participants as less important or even forgettable when drinking, and alcohol was perceived by many male respondents to improve sexual performance. Further research conducted in sub-Saharan Africa has linked risky drinking places, sexual networking, and increased prevalence of HIV/AIDS. In Tanzania, for example, local brew sellers and female workers in bars, guesthouses, and restaurants were found to be at high risk for STI/HIV exposure (Ao, Sam, Masenga, Seage, & Kapiga, 2006; Hoffman et al., 2004).
When assessing the nature and risks associated with drinking patterns and sexual networking, it is necessary to consider the influence of cultural beliefs and expectations surrounding drinking and sex. For example, certain ingrained gender norms about masculinity and cultural practices, such as intergenerational marriage, contribute to and even condone sexual coercion. One Ugandan study found that perceptions surrounding women’s acceptance of drinks from men in a bar was viewed by men as signifying consent to sex and that refusal could then “justify” resorting to sexual coercion (Wolff, Busza, Bufumbo, & Whitworth, 2006). In this context, frequenting drinking venues may promote sexual risk for many young girls and women (see also MODULE 9: Women and Alcohol). Simply reducing alcohol misuse in and of itself—while helpful—would not address the underlying sociocultural context and therefore would be insufficient to lower sexual risks in all circumstances. As one study concluded, “heavy drinking seems to exacerbate rather than cause the sexual risk behaviors in question (Morojele et al., 2006, p. 226).
Heavy drinking and progression of HIV/AIDS
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Heavy alcohol use has been shown to negatively impact the body’s immune function. By suppressing the normal responses that protect it from disease, alcohol misuse may decrease the body’s ability to defend itself upon exposure to the HIV virus. Moreover, chronic heavy alcohol consumption and HIV infection each can compromise the immune system; in combination, they may also increase the risk of subsequent opportunistic infections and accelerate progression of HIV to AIDS (see Bryant, 2006).8
For individuals living with HIV, problem drinking may also contribute to delays in seeking treatment and deter adherence to antiretroviral (ARV) drugs.9 A range of factors such as lack of housing, drug use, social stigma, and lack of support for infected individuals are known to deter compliance with HIV/AIDS treatments among problem drinkers (Berg, Demas, Howard, Schoenbaum, Gourevitch, & Arnsten, 2004). Patient non-compliance to ARV therapy not only results in poorer HIV treatment outcomes but can also lead to drug resistance (Lucas, Gebo, Chaisson, & Moore, 2002; Meyerhoff, 2001; Palepu, Raj, Horton, Tibbetts, Meli, & Samet, 2005). Treating HIV-positive individuals with a history of alcohol abuse calls for special attention to these patients’ drinking problems and may require going beyond motivational interviewing to include supervised medication delivery or simplified dosing regiments to enhance adherence to treatment (e.g., Samet et al., 2005).
Implications for policy and prevention
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In developing policies to address HIV/AIDS within a given society, it is vital to explore patterns of risky behavior. This is impossible without government commitment to and coordination of relevant political, economic, and social interventions. Unfortunately, governments in many countries are reluctant or even unwilling to address HIV/AIDS as a matter of urgency. While the private sector cannot compensate for a lack of political will in reforming specific national health and education frameworks and policies, it can contribute to prevention, treatment, and/or education within areas relevant to its core business interests and activities.
An open dialogue at both the national and local levels is essential in developing appropriate, responsive, sustainable, and robust policy change. By engaging various stakeholders—such as civil society groups, the private sector, municipal and/or national governments—local knowledge can be drawn from the community and assimilated into policy-making activities. In this context, successful programs that are focused on behavior modification require the approval and participation of local leaders and public figures influencing popular opinion (e.g., Kelly et al., 1992; Sikkema et al., 2000; Woelk, Fritz, Bassett, Todd, & Chingono, 2001; Sivaram et al., 2007). For instance, effecting behavioral change in the workplace (e.g., in convincing people to step forward for voluntary HIV testing) requires the buy-in of (local) management. Finding appropriate ways to expand successful workplace programs into surrounding communities to include customers, suppliers, and consumers is also desired, but may again be difficult unless all local leadership is enthusiastic about addressing such issues.
The beverage alcohol sector—defined broadly to include producers, retailers, sellers, distributors, and others—is particularly well placed to access multiple risk populations. Potential routes to prevention, education, and treatment exist within the sector’s broad supply and transportation networks, its available skills and resources, and along its supply and production chains. These may include rural and urban communities, migrant labor/truckers and community-based employees, small and medium-sized businesses, management and staff divided by differing socioeconomic levels, and both male and female workers. Alcohol distribution points within communities, such as shebeens,10 bars, hotels, and guesthouses, can often be fertile grounds for intervention programs based on community-specific patterns of alcohol purchases and drinking (see MODULE 4: Responsible Hospitality). In the Indian city of Chennai, for example, community-based HIV educational interventions led by local opinion leaders have targeted wine shops (Sivaram et al., 2007), a practice endorsed by other research, in order to address and reduce the role risky drinking plays in transmitting HIV (Weir et al., 2003).
The same India-based study emphasized the use of men as a target for HIV education interventions in risky drinking settings, underscoring the often dominant role men play in sexual partnerships (Sivaram et al., 2007). Men are important stakeholders in effective alcohol–HIV/AIDS interventions as concepts of masculinity generally afford them more social liberties with respect to alcohol use and sex (WHO, 2005). Community settings can also be utilized to provide social skills training for women, affecting their ability to negotiate condom use and increasing awareness of testing/counseling on alcohol and STI/HIV issues. For example in Mariakani, Kenya, the ROADS Project11 is working through local women’s groups to reach out to women who brew mnazi (an inexpensive and strong form of alcohol) in a program that focuses primary prevention measures for HIV and discusses the link between HIV transmission and alcohol abuse. The brewers are trained in addressing gender-based violence, to be peer leaders, to promote condoms in their informal establishments, and to refer customers and peers for HIV counseling, testing, care, and treatment. The project is also working to promote alternative economic activities for these women (Family Health International & USAID, 2007; see TARGETED INTERVENTIONS).
Innovative HIV/AIDS prevention and treatment programs can address the ramifications of intersecting patterns of risky behavior and, therefore, incorporate messages about alcohol misuse and its potential adverse outcomes to effect behavior change. In one such example, the Society to Help Rural Empowerment & Education (STHREE) in Andhra Pradesh, India, promotes behavioral change in remote rural communities, along the highways and at truck stops (a particular source of HIV/AIDS infections in India), using various forms of traditional and interactive media including plays, songs, and folk dancing (Bedi, 2002). Through these culturally familiar media, STHREE delivers educational, consequential, and remedial information on HIV/AIDS, STIs, alcohol abuse, violence, and sexual coercion (see TARGETED INTERVENTIONS).
In complementary activities, educational and informational campaigns that are principally focused on responsible drinking can incorporate messages for the general public and targeted subgroups about the risks associated with unsafe sex (e.g., MODULE 2: Life Skills). HIV/AIDS education and prevention programs implemented in alcohol treatment facilities also present a unique and multi-faceted approach to mitigating harm in multiple-risk groups (Brems & Dewane, 2007). Though there is wider agreement about such programs, few have been executed, and more research is needed to confirm their efficacy (Palepu et al., 2005). Such multi-component interventions can help mitigate the complex intersection of problem alcohol consumption and HIV transmission. However, to be successful, policy and prevention strategies must also consider and address the broader underlying issues of poverty, culture, education, alcohol and sexual expectations, and inequality.
Conclusions
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Risky patterns of drinking may overlap with other risky patterns of behavior to compound the spread of HIV/AIDS. According to WHO, “the synergy between sexual behavior and alcohol use enormously multiplies the potential negative consequences of the two behaviors separately” (WHO, 2005, p. vii). To tackle the relationship between problem drinking and HIV/AIDS, interventions must consider individual/group perceptions and expectations surrounding alcohol use and sex in the context of the broader socioeconomic conditions that simultaneously influence risk behaviors. Prevention initiatives must identify key patterns of alcohol misuse and sexual risk behaviors (e.g., the acceptance of alcohol as a facilitator for sex or conceptualizing drinking as an expression of masculinity) and address underlying notions of risk (e.g., unwanted pregnancy, STIs, losing a partner, economic loss, etc.) to foster behavior change (WHO, 2005).
Research-based interventions that target these overlapping behaviors can provide a unique opportunity to strengthen HIV/AIDS prevention activities. For example, prevention education in treatment facilities or high-risk sites such as bars, nightclubs, and guesthouses can address both problem drinking and risky sexual behaviors. More general educational programs will inform local communities about the potential intersection of alcohol and HIV/AIDS and the merit of responsible drinking, thereby reducing problem drinking behaviors.
POLICY OPTIONS: HIV/AIDS Risks and Drinking Patterns
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In developing policies and approaches, several key components need to be taken into consideration. While some may be necessary under most conditions, others may not be appropriate or may be difficult to implement in all cases. The list below offers a menu of areas that need to be addressed, based on effective approaches that have been implemented elsewhere. Specific examples are provided in the Examples of Targeted Interventions section of the ICAP Blue Book.
Program planning
- Design research-based, comprehensive, and equitable programs that identify population-specific influences on HIV risk behaviors, target multiple needs, and, in particular, address stigma and discrimination associated with HIV/AIDS.
- Address underlying issues of poverty, culture, education, expectancies, and inequality.
- Consider the dangerous intersection of risky patterns of behavior, including drinking to excess.
- Promote greater understanding of local sexual networks that put individuals at risk for HIV/AIDS.
- Adopt bottom-up and top-down approaches that engage local knowledge and community-based organizations in the design of a coordinated national and regional approach.
- Incorporate surveillance, monitoring, and reporting requirements to strengthen actions and guide the development of more responsive strategies.
Education and prevention
Information for the general population:
- Provide accurate STIs/HIV information and materials with sensitivity to local language and context.
- Use trusted information and communication channels to broadcast health messages.
- Use culturally appropriate and interactive media, such as plays, songs, and folk dancing.
- Provide social skills-training and HIV risk reduction strategies in community settings (e.g., to affect condom use, empower women, and increase awareness of testing/counseling on alcohol and STI/HIV issues).
Information for specific populations:
professions (e.g., commercial sex workers, truck drivers).
- Train health professionals, social workers, educators, and others.
- Educate young people in schools and universities.
- Educate patients in emergency rooms, STI clinics; combine education with brief interventions and counseling.
- Educate individuals working in high-risk venues (e.g., bar staff, guesthouses) and high-risk
- Special consideration should be given to women and girls in general health and prenatal care, schools, and other settings.
Information and prevention in specific settings:
- Informational targeting of the venues where alcohol is supplied and distributed.
- Public/private partnership with bar owners, employers, trade unions, local officials, community-based organizations, and other concerned parties.
- Encourage provision of workplace health and wellness programs that would include HIV/AIDS and alcohol education and confidential counseling.
- Interventions in high-risk places such as hotels, bars, and other drinking establishments (especially focusing on male clientele).
Intervention and treatment
- Access to voluntary testing and confidential treatment for STIs/HIV and individuals.
- Availability of appropriate screening instruments and integrated alcohol–HIV/AIDS intervention approaches.
- Multi-component interventions and tailored treatment options that respond to the specific needs of multiple-risk groups or heavy drinkers with HIV/AIDS.
References
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Adelekan, M. (2006). Rapid assessment of substance use and HIV vulnerability in Kakuma refugee camp and surrounding community, Kakuma, Kenya. Unpublished paper, joint UNHCR/WHO project on rapid assessment of substance use in conflict-affected and displaced populations.
Ao, T., Sam, N., Masenga, E., Seage, G. 3rd., & Kapiga, S. (2006). Human immunodeficiency virus type 1 among bar and hotel workers in northern Tanzania: The role of alcohol, sexual behavior, and herpes simplex virus type 2. Sexually Transmitted Diseases, 33, 163–169.
Avins, A., Woods, W., Lindan, C., Hudes, E., Clark, W., & Hulley, S. (1994). HIV infection and risk behaviors among heterosexuals in alcohol treatment programs. Journal of the American Medical Association 271, 515– 518.
Berg, K., Demas, P., Howard, A., Schoenbaum, E., Gourevitch, M., & Arnsten, J. (2004). Gender differences in factors associated with adherence to antiretroviral therapy. Journal of General Internal Medicine, 19, 1111–1117.
Bouhnik, A., Préau, M., Lert, F., Peretti-Watel, P., Schiltz, M., Obadia, Y., et al. (2007). Unsafe sex in regular partnerships among heterosexual persons living with HIV: Evidence from a large representative sample of individuals attending outpatients service in France (ANRS-EN12-VESPA Study). AIDS, 21(Suppl. 1), S57–S62.
Brems, C., & Dewane, S. (2007). Hearing consumer voices: Planning HIV/sexually transmitted infection prevention in alcohol detoxification. Journal of the Association of Nurses in AIDS Care, 18, 12– 24.
Bryant, K. (2006). Expanding research on the role of alcohol consumption and related risks in the prevention and treatment of HIV/AIDS. Substance Use & Misuse, 41, 1465–1507.
Cooper, M. (2002). Alcohol use and risky sexual behaviour among college students and youth: Evaluating the evidence. Journal of Studies on Alcohol, (Suppl. 14), 101–117.
Corte, C., & Sommers, M. (2005). Alcohol and risky behaviors. Annual Review of Nursing Research,23, 327–360.
Family Health International & USAID. (2007). Roads signs: Recent highlights from the ROADS project. Nairobi, Kenya: Family Health International.
Gregson, S., Nyamukapa, C., Garnett, G., Mason, P., Zhuwau, T., Caraël, M., et al. (2002). Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. The Lancet, 359, 1896–1903.
Greig, F., & Koopman, C. (2003). Multilevel analysis of women’s empowerment and HIV prevention: Qualitative survey. Results from a preliminary study in Botswana. AIDS and Behavior, 7, 195–208.
Haworth, A., & Simpson, R. (2004). Moonshine markets: Issues in unrecorded alcohol beverage production and consumption. Washington, DC: Brunner-Routledge.
Heath, D. B. (Ed.). (1995). International handbook on alcohol and culture. Westport, CT: Greenwood Press.
Heath, D. B. (2000). Drinking occasions: Comparative perspectives on alcohol and culture. Philadelphia: Brunner/Mazel.
Hoffmann, O., Zaba, B., Wolff, B., Sanga, E., Maboko, L., Mmbando, D., et al. (2004). Methodological lessons from a cohort study of high-risk women in Tanzania. Sexually Transmitted Infections, 80(Suppl. 2), ii69–ii73.
Kalichman, S., Cain, D., Zweben, A., & Swain, G. (2003). Sensation seeking, alcohol use and sexual risk behaviors among men receiving services at a clinic for sexually transmitted infections. Journal of Studies on Alcohol, 64, 564–569.
Kalichman, S., Simbayi, L., Kaufman, M., Cain, D., Cherry, C., Jooste, S., et al. (2005). Gender attitudes, sexual violence and HIV/AIDS risks among men and women in Cape Town, South Africa. Journal of Sex Research, 42, 299–305.
Kapiga, S., Sam, N., Shao, J., Masenga, E., Renjifo, B., Kiwelu, I., et al.(2003). Herpes simplex virus type 2 infection among bar and hotel workers in northern Tanzania: Prevalence and risk factors. Sexually Transmitted Diseases, 30, 187–192.
Kelly, J., St. Lawrence, J., Stevenson, Y., Hauth, A., Kalichman, S., Diaz, Y., et al. (1992). Community AIDS/HIV risk reduction: The effects of endorsements by popular people in three cities. American Journal of Public Health, 82, 1483–1489.
Lucas, G., Gebo, K., Chaisson, R., & Moore, R. (2002). Longitudinal assessment of the effects of drug and alcohol abuse on HIV-1 treatment outcomes in an urban clinic. AIDS, 16, 767–774.
Mahler, J ., Yi, D ., Sacks, M ., Dermatis, H ., Stebinger,A ., Card, C ., et al. (1994). Undetected HIV infection among patients admitted to an alcohol rehabilitation unit. American Journal of Psychiatry, 151, 439–440.
Markos, A. (2005). Alcohol and sexual behavior. International Journal of STD & AIDS, 16, 123–127.
McNair, L., Carter, J., & Williams, M. (1998). Self-esteem, gender, and alcohol use: Relationships with HIV risk perception and behaviors in college students. Journal of Sex and Marital Therapy, 24, 29–36.
Meyerhoff, D. J. (2001). Effects of alcohol and HIV infection on the central nervous system. Alcohol Research and Health, 25, 288–298.
Morojele, N., Kachieng’a, M., Mokoko, E., Nkoko, M., Parry, C., Nkowane, A., et al. (2006). Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa. Social Science and Medicine, 62, 217–227.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2001). Alcohol & AIDS: A guide to research issues and opportunities. Retrieved June 27, 2007, from http://www.niaaa.nih.gov/ResearchInformation/ExtramuralResearch/NIAAAResearchAreas/contents.htm .
National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2002, September). Alcohol and HIV/AIDS. Alcohol Alert, No. 57. Retrieved June 27, 2007, from http://pubs.niaaa.nih.gov/publications/aa57.htm .
Palepu, A., Raj, A., Horton, N., Tibbetts, N., Meli, S., & Samet, J. (2005). Substance abuse treatment and risk behaviors among HIV-infected persons with alcohol problems. Journal of Substance Abuse Treatment, 28, 3–9.
Parsons, J., Vicioso, K., Kutnick, A., Punzalan, J., Halkitis, P., & Velasquez, M. (2004). Alcohol use and stigmatized sexual practices of HIV seropositive gay and bisexual men. Addictive Behaviors, 29, 1045–1051.
Petry, N. (1999). Alcohol use in HIV patients: What we don’t know may hurt us. International Journal of STD & AIDS, 10, 561–570.
Poulson, R., Eppler, M., Satterwhite, T., Wuensch, K., & Bass, L. (1998). Alcohol consumption, strength of religious beliefs, and risky sexual behavior in college students. Journal of American College Health, 46, 227–232.
Robles, R.., Matos, T., Colón, H., Reyes, J., Marrero, C., Sahai, H., et al. (2004). HIV risk behaviors and alcohol intoxication among injection drug users in Puerto Rico. Drug and Alcohol Dependence, 76, 229–234.
Samet, J., Horton, N., Meli, S., Dukes, K., Tripps, T., Sullivan, L., et al. (2005). A randomized controlled trial to enhance antiretroviral therapy adherence in patients with a history of alcohol problems. Antiviral Therapy, 10, 83–93.
Sikkema, K. J., Kelly, J. A., Winett, R. A., Solomon, L. J., Cargill, V. A., Roffman, R., et al. (2000). Outcomes of a randomized community-level HIV prevention intervention for women living in 18 low-income housing developments. American Journal of Public Health, 90, 57–63.
Sivaram, S., Johnson, S., Bentley, M., Srikrishnan, A., Latkin, C., Go, V., et al. (2007). Exploring “wine shops” as a venue for HIV prevention interventions in urban India. Journal for Urban Health, 84, 563–576.
Stein, M., Charuvastra, A., Anderson, B., Sobota, M., & Friedmann, P. (2002). Alcohol and HIV risk taking among intravenous drug users. Addictive Behaviors, 27, 727–736.
Stein, M., Hanna, L., Natarajan, R., Clarke, J., Marisi, M., Sobota, M., et al. (2000). Alcohol use patterns predict high-risk HIV behaviors among active injection drug users. Journal of Substance Abuse Treatment, 18, 359–363.
UN Secretary General’s Task Force on Women, Girls and HIV/AIDS in Southern Africa. (2004). Facing the future together: Report of the United Nations Secretary-General’s Task Force on Women, Girls and HIV/AIDS in southern Africa. New York: Author.
Weir, S., Pailman, C., Mahlalela, X., Coetzee, N., Meidany, F., & Boerma, J. (2003). From people to places: Focusing AIDS prevention efforts where it matters most. AIDS, 17, 895–903.
Wolff, B., Busza, J., Bufumbo, L., & Whitworth, J. (2006). Women who fall by the roadside: Gender, sexual risk and alcohol in rural Uganda. Addiction, 101, 1277–1284.
Woelk, G., Fritz, K., Bassett, M., Todd, C., & Chingono, A. (2001). A rapid assessment in relation to alcohol and other substance use and sexual behavior in Zimbabwe. Harare, Zimbabwe: University of Zimbabwe.
World Health Organization (WHO). (2002). The World Health Report 2002: Reducing risks, promoting healthy life. Geneva, Switzerland: Author.
World Health Organization (WHO). (2005). Alcohol use and sexual risk behaviour: A cross-cultural study in eight countries. Geneva, Switzerland: Author.