South Africa has one of the world’s worst HIV epidemics, with nearly 5 million people living with HIV/AIDS. Reducing unprotected sexual behavior among HIV-positive individuals is recognised by international organisations as an essential HIV-prevention strategy. Understanding the dynamics of unprotected sexual behavior among this population is a necessary step in this strategy. In South Africa, alcohol is thought to lead to unprotected sexual behavior, yet there is limited empirical evidence supporting this notion. Situational and psychosocial circumstances may influence the likelihood of an individual using a condom. According to alcohol expectancy theory, alcohol leads to unprotected sex among individuals who believe that alcohol makes them more likely to have unprotected sex. According to alcohol myopia theory, alcohol influences unprotected sexual behavior when individuals possess both inhibitory and instigatory cues for this behavior. The current study used a daily diary methodology to investigate the event-level association between a discrete instance of drinking prior to sex and subsequent unprotected sex and possible moderators of this association among HIV-positive individuals in South Africa. Interviewers called 82 HIV-positive participants in Cape Town, South Africa every day for 42 days. Participants reported their daily inhibitory cues for having unprotected sex and their alcohol consumption and sexual behavior during two time periods: the prior evening and today. Alcohol outcome expectancies and global inhibitory cues were measured at baseline. Multilevel regressions revealed that consuming alcohol before sex increased the proportion of sex events that were unprotected, and increased the number of unprotected sex events that occurred during both daytime and evening hours. Partner type, daily inhibitory cues, alcohol outcome expectancies and global inhibitory cues were found to moderate the event-level association between alcohol and unprotected sex in certain situations. Most striking were the nearly 4,000 unprotected sex events, over half of which were with presumed HIV-negative and HIV-serostatus unknown partners, that occurred during the brief course of this study. These data indicate a critical need for the widespread implementation of HIV-prevention efforts that address the role of alcohol in precipitating unprotected sex among HIV-positive individuals in order to avoid a ballooning of the already devastating HIV-epidemic in South Africa. Susan M. Kiene, PhD, is Assistant Professor of Medicine and Community Health (Research) at the Substance Abuse Research Unit at Brown Medical School in Providence, Rhode Island, USA where she is affiliated with the Brown/Tufts Center for AIDS Research (CFAR). She received her PhD training under the direction of Jeffrey D. Fisher at the University of Connecticut. Dr Kiene’s research includes studies investigating the dynamics of unprotected sexual behavior and applications of these findings to design HIV-prevention interventions. She is also interested in multilevel modeling and related longitudinal data analytic techniques. Her current research focuses on how situational and psychosocial factors, including affective states, stress and coping, and alcohol use influence unprotected sexual behavior. During the past 5 years she has conducted several daily diary studies of unprotected sexual behavior in a variety of populations including HIV-positive individuals in the US and South Africa and adolescents in the US. She has also been heavily involved in HIV risk reduction interventions conducted in the US and in South Africa. Dr Kiene recently completed an NIMH (NIH) supported daily diary study in Cape Town, South Africa, that investigated the roles of alcohol use, psychosocial, and social cognitive factors in unprotected sexual behavior among people living with HIV. She has published on the dynamics of HIV risk behavior and on HIV prevention interventions in a variety of populations. Currently she is involved with an NIMH funded RCT “Integrating HIV Prevention into Clinical Care for PLWHA in South Africa” that is underway in KwaZulu-Natal, South Africa.
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