- Open Access
Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa
© Chersich et al; licensee BioMed Central Ltd. 2009
- Received: 18 August 2009
- Accepted: 17 November 2009
- Published: 17 November 2009
Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked. Physiological and behavioural research indicates that alcohol independently affects decision-making concerning sex, and skills for negotiating condoms and their correct use. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care), must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.
Globally, HIV and other sexually-transmitted infections (STI) account for 6.3% of the burden of disease and alcohol for 4%, similar to that caused by tobacco (4.1%) and high blood pressure (4.4%) . In some sub-Saharan countries, such as South Africa, for example, the burden attributable to these conditions is even greater - HIV and other STI constitute about a third of disease and alcohol an estimated 7.9% . Overall, much of sub-Saharan Africa carries a massive burden of HIV and of alcohol disease, and these pandemics are inextricably linked. The conditions share many common determinants and together exacerbate the underlying socio-economic inequalities in this region. As we discuss in this article, alcohol disease and HIV have an especially intimate link: alcohol has independent effects on decision-making concerning sex, and on skills for negotiating condoms and their correct use. Thus far global initiatives to prevent HIV and other sexually transmitted infections (STI) have largely ignored the potential mediatory role of alcohol in unsafe sex (for example, note that the list of WHO HIV prevention priorities does not mention alcohol) .
Alcohol use results in a considerable range of diseases, the occurrence of which is contingent upon three factors: lifetime cumulative volume consumed; patterns of drinking; and drinking contexts [4, 5]. Overall lifetime volume of alcohol is linked to chronic social problems (such as unemployment) and to chronic diseases such as alcoholic liver cirrhosis. By contrast, pattern of drinking (amount per drinking episode), in particular frequent episodes of intoxication, is a powerful mediator of acute problems such as accidents, interpersonal violence and high-risk sexual behaviour [5, 6]. Context of alcohol use is also a critical determinant of its consequences, as opportunities for sexual encounters and for drinking alcohol often co-exist in both social dynamics and physical locations [7–10]. This means that the impact of alcohol use on acute social behaviours (including sexual behaviours ) is shaped more by the 'how' and 'where' of alcohol consumption,  than by the frequency of drinking or cumulative lifetime volume of alcohol.
Unlike settings with low-risk drinking patterns (classically southern European patterns of drinking with meals), sub-Saharan Africa is characterised by harmful patterns of drinking. This includes the use of large quantities of alcohol per occasion, but also drinking to intoxication in public spaces, heavy drinking during cultural festivals and drinking outside of mealtimes [12, 13]. These patterns often take the form of weekend binge drinking [6, 13] and are true of both rural and urban areas, and across all social strata [14, 15]. It follows that acute rather than chronic alcohol problems predominate in sub-Saharan Africa, and include road traffic accidents, crime, interpersonal violence and unsafe sex, afflicting harm to self and others. Globally, drinking alcohol has been linked with an increased number of sexual partners, regretted sexual relations, inconsistent condom use, condom accidents and an increased incidence of STI [6, 16–19]. Studies in sub-Saharan Africa, in particular , have found strong associations between alcohol consumption and unprotected sex, early sexual debut, multiple sex partners and having an STI [6, 8, 11, 20].
HIV and alcohol also share common ground with sexual violence. A person's risk of rape or of perpetrating rape increases during heavy drinking episodes. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, possibly because alcohol intoxication makes the drinker an easier target for potential perpetrators .
More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking [8, 11, 20, 22, 23]. A meta-analysis of these studies found that compared with non-drinkers, non-problem drinkers had 1.6 fold higher HIV prevalence, while problem drinkers had a 2.0 fold higher prevalence . This finding is strongly consistent across studies and is similar among women and men.
Challenging evidence for a causal relationship between alcohol, unsafe sex and HIV, are some studies which suggest that personality factors such as impulsivity or sensation seeking, as well as contextual factors confound the alcohol and sex relationship [24–26]. It must be acknowledged that the relationship between alcohol use and risky sex is complex and that associations between HIV and alcohol use may, at least in part, be accounted for by the fact that heavy drinkers are inherently different from other population groups [27, 28]. Overall, however, in recent years the causal pathway between alcohol intoxication, unsafe sex and HIV acquisition has become more clearly defined and the evidence increasingly compelling .
Reducing alcohol harms necessitates both population and individual-level interventions, which will have marked health and social benefits beyond a reduction in the burden of HIV, sexual violence and unintended pregnancy. Policies such as increased taxation and limitations on the availability of alcohol, which are highly effective in lowering alcohol harm, are often strongly contested by the alcohol industry . Not unlike the tobacco industry, the alcohol industry shifts the onus of alcohol control towards individuals who are encouraged to adopt "responsible behaviour", and away from controls on alcohol marketing and availability . Interestingly, the alcohol industry, through its marketing efforts and easy availability, does its utmost to subvert the ability of individuals to be responsible. By analogy, it's like a parent encouraging an obese child to take responsibility for their diet, but then stocking the fridge with chocolates and pasting posters depicting the glamour of sugar on the wall.
Given the substantial contribution of the industry to the GDP of many countries , the alcohol industry can almost certainly yield substantial political power. Yet, while it is recognized that control of alcohol is difficult and politically charged, increased interventions to control harmful use of alcohol are urgently needed.
Universal community-wide interventions can increase knowledge of the harmful effects of alcohol use and change community norms and values [32, 33]. It is critical that these interventions make explicit links between alcohol use, unsafe sex and HIV. Policies and interventions targeting establishments which serve alcohol are especially important because of the overlap between drinking and the dense sexual networks in these contexts . Implementing HIV prevention activities within drinking venues, such as bars, beer halls and taverns could reach large numbers of persons at greatest risk for HIV infection. Importantly, evidence indicates that these interventions are feasible . Condoms can be made accessible within drinking venues, for example, with minimal disruption to retail activities and can be promoted with simple messaging using media such as posters or stickers. Though general public education and warning labels on drinks are obvious interventions and generally uncontested by the alcohol industry, they are poorly effective in their current form . Evidence from use of warning labels in tobacco control suggests that the use of more graphic and larger warnings can influence behaviour.
The health sector has a critical role to play in mitigating alcohol-related harm, especially in the form of selective alcohol interventions, such as Brief Interventions for people with problem drinking. The term "Brief Intervention" refers to time-limited, patient-centred counselling that focuses on changing patient behaviour and has been shown to empower people to control their alcohol use and its effects on sexual behaviour . Such services are an important component of primary health care, and can be configured to include specific discussion of links between alcohol and unsafe sex and consequences thereof. Research in Kenya has shown that alcohol-HIV counselling interventions can be included within services provided at HIV voluntary counselling and testing centres . In part, this intervention is feasible because routine provider-initiated screening for alcohol use is analogous to provider-initiated HIV testing. Here, the AUDIT screening interview or similar tools could be used to identify whether a person has hazardous drinking (patterns of drinking that increase the risk of harmful consequences for the user and others), harmful drinking (alcohol consumption that results in consequences to social, physical and mental health) or alcohol dependence (behavioural, cognitive, and physiological phenomena, such as increased alcohol tolerance and a physical withdrawal reaction when alcohol is discontinued) . While alcohol treatment services are indicated for people who are alcohol dependant, individuals with hazardous or harmful drinking patterns require Brief Interventions or similar services, which are highly cost effective . These Brief Interventions fill the key gap between community-level prevention efforts and more intensive treatment for persons who are physically or psychologically dependant on alcohol. Access to public-sector services for substance abuse treatment is low in resource-constrained settings, with inadequate government funding of these services . Overall, with alcohol use, as with sexual behaviour, promotion of safer behaviours and contexts is more effective than promotion of total abstinence.
Adolescents, sex workers, migrant labourers and those who work in the transport industry are particularly vulnerable to the effects of alcohol on sexual behaviour and require targeted interventions. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. A study in Cape Town, South Africa, showed that almost one in five adults with HIV infection also have alcohol abuse or dependence . Similar findings have been reported in other countries [42, 43]. HIV-positive men, among whom heavy drinking before sex remains common, are in particular need of intervention [41, 44]. Adoption of safer drinking patterns would have marked benefits for themselves, but also would assist them to enact safer sex decisions and reduce risk of further transmission of HIV to their partners [45, 46].
• Measure the proportion of unsafe sex that is attributed to alcohol, and consequently what portion of the burden of HIV and other STI, sexual violence and unintended pregnancy is attributable to alcohol use. Even though global figures already show that alcohol harm is high, they underestimate its effects as they exclude the considerable social harms of alcohol . Though it is difficult to make precise estimates at a population-level of the effects of alcohol on social behaviours and on an individual's interaction with their sexual partner(s) and family, this does not justify ignoring such effects; especially in high HIV burden countries. Inclusion of standardised measures of alcohol use within future national household surveys could provide data necessary for estimating alcohol-attributable fractions.
• Establish global mechanisms for alcohol control, similar to those used for tobacco control. Lessons could be learnt from the control of other potentially harmful substances, such as infant formula and tobacco.
• HIV-alcohol links must be clearly articulated within national strategies for HIV prevention and for alcohol control. Given the burden of HIV in many African countries and causal links with alcohol, drunk sex should be considered as dangerous as drunk driving or tobacco use and warrants equal preventive efforts. HIV-alcohol links must therefore be clearly articulated within national HIV prevention strategies, but also within alcohol control policies. The South African government HIV and STI National Strategic Plan 2007-2011 places alcohol control among the key interventions required to reduce sexual transmission of HIV .
• Develop clear public messaging that unsafe alcohol use can lead to HIV transmission. In addition to alcohol-HIV messaging on warning labels on drinks for example, combining alcohol and sex topics within educational initiatives among youth appears effective [48–50]. Soul City, a South African multi-media health promotion project, has frequently focused on the relationship between alcohol and HIV, especially in its popular television series .
• Restrict advertising of alcohol. This is analogous to bans on tobacco advertising, and could include banning alcohol adverts on billboards, or allowing TV alcohol adverts only after 21:00 to avoid youth being exposed to alcohol marketing .
• Raise taxes on alcohol. This reduces alcohol harm, increases government revenue and assists in recouping the costs of alcohol harm. Levels of alcohol taxation in South Africa are still below international standards, and lower than the neighbouring country Botswana which is pioneering alcohol control in the region . Increases in taxation of alcohol in South Africa are only marginally above inflation rates  and there remains little evidence that a reduction in national alcohol consumption is a prominent policy goal for the South African government . Taxation is especially effective among young drinkers who are most price sensitive.
• Health-care providers should screen for hazardous or harmful use of alcohol at the time of diagnosing HIV and in later visits for HIV care and treatment. As an HIV diagnosis commonly leads to changes in sexual behaviour, this is a critical opportunity to provide Brief Interventions or similar services to further support adoption of safer sexual practices. Both HIV testing and receipt of ART are key life stages or transition points for many people, and signify important moments of opportunity for intervention by health workers .
• Large-scale research is needed to document whether HIV incidence is lowered by interventions to reduce high-risk drinking, as well as the feasibility of changing drinking patterns and making drinking contexts safer in sub-Saharan Africa. Though evidence suggests that adoption of safer drinking patterns may reduce unsafe sex [55–58], additional research is needed to demonstrate that HIV incidence is lowered by alcohol-reduction interventions. By satisfying the important reversibility criteria of causality, this evidence is important for more definitively substantiating a causal association between alcohol and HIV. A large trial assessing this is warranted, given the major policy implications of such a finding.
A substantial proportion of unsafe sex occurs due to alcohol-related disinhibition, diminished rational capacity and impaired decision-making. Reduction in cognitive restraint with alcohol use also hampers skills for condom negotiation and their correct use. For communities and individuals in sub-Saharan Africa, interventions are thus needed to change the way alcohol is used, so that hazardous drinking patterns are shifted to safer patterns.
Control of alcohol use, including alcohol-sex linkages, has been prioritised by the World Health Assembly . International frameworks for alcohol control are now required, building on lessons learnt in tobacco control. Urgency for prevention interventions is clear, as are the drinking venues where such interventions are most needed. Campaigns against alcohol harm may take time to bring about change, but are equally essential as more immediate priorities for HIV prevention, such as condom promotion. Far-reaching structural measures like alcohol control create the conditions necessary for achieving sustained HIV prevention results. Implementing these measures to reduce the chronic burden of alcohol and its mediatory effects on unsafe sex and HIV will take political courage, but could have notable long-range effects.
- World Health Report 2002. Reducing risks, promoting healthy life. http://www.who.int/whr/2002/en/whr02_en.pdfGoogle Scholar
- Schneider M, Norman R, Parry C, Bradshaw D, Pluddemann A: Estimating the burden of disease attributable to alcohol use in South Africa in 2000. S Afr Med J. 2007, 97 (8 Pt 2): 664-672.PubMedGoogle Scholar
- WHO: Priority interventions: HIV/AIDS prevention, treatment and care in the health sector. 2007Google Scholar
- Rehm J, Gmel G, Room R, Frick U: Average volume of alcohol consumption, drinking patterns and related burden of mortality in young people in established market economies of Europe. Eur Addict Res. 2001, 7 (3): 148-151.View ArticlePubMedGoogle Scholar
- Rehm J, Room R, Graham K, Monteiro M, Gmel G, Sempos CT: The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction. 2003, 98 (9): 1209-1228.View ArticlePubMedGoogle Scholar
- Surveys of drinking patterns and problems in seven developing countries. WHO monograph on alcohol epidemiology in developing countries. http://www.unicri.it/min.san.bollettino/dati/AlcBrochur.pdfGoogle Scholar
- Kapiga SH, Sam NE, Shao JF, Masenga EJ, Renjifo B, Kiwelu IE, Manongi R, Fawzi WW, Essex M: Herpes simplex virus type 2 infection among bar and hotel workers in northern Tanzania: prevalence and risk factors. Sex Transm Dis. 2003, 30 (3): 187-192.View ArticlePubMedGoogle Scholar
- Lewis JJ, Garnett GP, Mhlanga S, Nyamukapa CA, Donnelly CA, Gregson S: Beer halls as a focus for HIV prevention activities in rural Zimbabwe. Sex Transm Dis. 2005, 32 (6): 364-369.View ArticlePubMedGoogle Scholar
- Morojele NK, Kachieng'a MA, Mokoko E, Nkoko MA, Parry CD, Nkowane AM, Moshia KM, Saxena S: Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa. Soc Sci Med. 2006, 62 (1): 217-227.View ArticlePubMedGoogle Scholar
- Kalichman SC, Simbayi LC, Vermaak R, Jooste S, Cain D: HIV/AIDS risks among men and women who drink at informal alcohol serving establishments (Shebeens) in Cape Town, South Africa. Prev Sci. 2008, 9 (1): 55-62.View ArticlePubMedGoogle Scholar
- Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S: Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings. Prev Sci. 2007, 8 (2): 141-151.View ArticlePubMedGoogle Scholar
- Demers A, Bourgault RR: Surveys of Drinking Patterns and Problems in Seven Developing Countries. 2001, Geneva: Department of Mental Health and Substance Dependence, World Health Organization, http://www.unicri.it/min.san.bollettino/dati/AlcBrochur.pdfGoogle Scholar
- Rehm J, Rehn N, Room R, Monteiro M, Gmel G, Jernigan D, Frick U: The global distribution of average volume of alcohol consumption and patterns of drinking. Eur Addict Res. 2003, 9 (4): 147-156.View ArticlePubMedGoogle Scholar
- Peltzer K: Prevalence of alcohol use by rural primary care outpatients in South Africa. Psychol Rep. 2006, 99 (1): 176-178.View ArticlePubMedGoogle Scholar
- Peltzer K, Seoka P, Mashego TA: Prevalence of alcohol use in a rural South African community. Psychol Rep. 2004, 95 (2): 705-706.View ArticlePubMedGoogle Scholar
- Kaljee LM, Genberg BL, Minh TT, Tho LH, Thoa LT, Stanton B: Alcohol use and HIV risk behaviors among rural adolescents in Khanh Hoa Province Viet Nam. Health Educ Res. 2005, 20 (1): 71-80.View ArticlePubMedGoogle Scholar
- Madhivanan P, Hernandez A, Gogate A, Stein E, Gregorich S, Setia M, Kumta S, Ekstrand M, Mathur M, Jerajani H: Alcohol use by men is a risk factor for the acquisition of sexually transmitted infections and human immunodeficiency virus from female sex workers in Mumbai, India. Sex Transm Dis. 2005, 32 (11): 685-690.PubMed CentralView ArticlePubMedGoogle Scholar
- Parsons JT, Vicioso K, Kutnick A, Punzalan JC, Halkitis PN, Velasquez MM: Alcohol use and stigmatized sexual practices of HIV seropositive gay and bisexual men. Addict Behav. 2004, 29 (5): 1045-1051.View ArticlePubMedGoogle Scholar
- Smith Fawzi MC, Lambert W, Singler JM, Tanagho Y, Leandre F, Nevil P, Bertrand D, Claude MS, Bertrand J, Louissaint M: Factors associated with forced sex among women accessing health services in rural Haiti: implications for the prevention of HIV infection and other sexually transmitted diseases. Soc Sci Med. 2005, 60 (4): 679-689.View ArticlePubMedGoogle Scholar
- Zablotska IB, Gray RH, Serwadda D, Nalugoda F, Kigozi G, Sewankambo N, Lutalo T, Mangen FW, Wawer M: Alcohol use before sex and HIV acquisition: a longitudinal study in Rakai, Uganda. Aids. 2006, 20 (8): 1191-1196.View ArticlePubMedGoogle Scholar
- Koenig MA, Lutalo T, Zhao F, Nalugoda F, Kiwanuka N, Wabwire-Mangen F, Kigozi G, Sewankambo N, Wagman J, Serwadda D: Coercive sex in rural Uganda: prevalence and associated risk factors. Soc Sci Med. 2004, 58 (4): 787-798.View ArticlePubMedGoogle Scholar
- Mbulaiteye SM, Ruberantwari A, Nakiyingi JS, Carpenter LM, Kamali A, Whitworth JA: Alcohol and HIV: a study among sexually active adults in rural southwest Uganda. Int J Epidemiol. 2000, 29 (5): 911-915.View ArticlePubMedGoogle Scholar
- Fisher JC, Bang H, Kapiga SH: The association between HIV infection and alcohol use: a systematic review and meta-analysis of African studies. Sex Transm Dis. 2007, 34 (11): 856-863.View ArticlePubMedGoogle Scholar
- Kalichman SC, Cain D, Zweben A, Swain G: Sensation seeking, alcohol use and sexual risk behaviors among men receiving services at a clinic for sexually transmitted infections. J Stud Alcohol. 2003, 64 (4): 564-569.View ArticlePubMedGoogle Scholar
- Morrison DM, Gillmore MR, Hoppe MJ, Gaylord J, Leigh BC, Rainey D: Adolescent drinking and sex: findings from a daily diary study. Perspect Sex Reprod Health. 2003, 35 (4): 162-168.View ArticlePubMedGoogle Scholar
- Fortenberry JD, Orr DP, Katz BP, Brizendine EJ, Blythe MJ: Sex under the influence. A diary self-report study of substance use and sexual behavior among adolescent women. Sex Transm Dis. 1997, 24 (6): 313-319.View ArticlePubMedGoogle Scholar
- Cooper LM: Does Drinking Promote Risky Sexual Behavior? A Complex Answer to a Simple Question. Current directions in psychological science. 2006, 15 (1): 19-23. 10.1111/j.0963-7214.2006.00385.x.View ArticleGoogle Scholar
- Parry C, Rehm J, Poznyak V, Room R: Alcohol and infectious diseases: an overlooked causal linkage?. Addiction. 2009, 104 (3): 331-332.View ArticlePubMedGoogle Scholar
- Botswana: KBL Consults Govt on Alcohol Tax. http://allafrica.com/stories/200807281268.htmlGoogle Scholar
- WHO: WHO Public Hearing on Harmful Use of Alcohol. Department of Mental Health and Substance Abuse. Volume IV: Received contributions from: - Alcohol industry, trade and agriculture. 2009Google Scholar
- Parry C, Myers B, Thiede M: The Case for an Increased Tax on Alcohol in South Africa. South African Journal of Economics. 2003, 71 (2): 137-145. 10.1111/j.1813-6982.2003.tb01308.x.View ArticleGoogle Scholar
- Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K: Alcohol: No ordinary commodity. Research and public policy. 2003Google Scholar
- Parry C: A review of policy-relevant strategies and interventions to address the burden of alcohol on individuals and society in South Africa. South African Psychiatry Review. 2005, 8: 20-24.Google Scholar
- Fritz KE, Woelk GB, Bassett MT, McFarland WC, Routh JA, Tobaiwa O: The association between alcohol use, sexual risk behavior, and HIV infection among men attending beer halls in Harare, Zimbabwe. AIDS and Behavior. 2002, 6 (3): 221-228. 10.1023/A:1019887707474.View ArticleGoogle Scholar
- Babor TF, Caetano R, Casswell S, Edwards GN, Giesbrecht N, Graham K, Grube J, Gruenewald P, Hill L, Holder H: Alcohol: no ordinary commodity. Research and Public Policy. 2003, Oxford, Oxford University PressGoogle Scholar
- Fleming M, Manwell LB: Brief intervention in primary care settings. A primary treatment method for at-risk, problem, and dependent drinkers. Alcohol Res Health. 1999, 23 (2): 128-137.PubMedGoogle Scholar
- Mackenzie Caroline and Karusa Kiragu: "Should voluntary counseling and testing counselors address alcohol use with clients? Findings from an operations research study in Kenya, " Horizons Research Update. 2007, Nairobi: Population CouncilGoogle Scholar
- AUDIT: The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care. http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdfGoogle Scholar
- Chisholm D, Rehm J, Van Ommeren M, Monteiro M: Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. J Stud Alcohol. 2004, 65 (6): 782-793.View ArticlePubMedGoogle Scholar
- Myers B, Parry C: Access to substance abuse treatment services for black South Africans: findings from audits of specialist treatment facilities in Cape Town and Gauteng. South African Psychiatry Review. 2005, 8: 15-19.Google Scholar
- Olley BO, Gxamza F, Seedat S, Theron H, Taljaard J, Reid E, Reuter H, Stein DJ: Psychopathology and coping in recently diagnosed HIV/AIDS patients--the role of gender. S Afr Med J. 2003, 93 (12): 928-931.PubMedGoogle Scholar
- Ehrenstein V, Horton NJ, Samet JH: Inconsistent condom use among HIV-infected patients with alcohol problems. Drug Alcohol Depend. 2004, 73 (2): 159-166.View ArticlePubMedGoogle Scholar
- Galvan FH, Bing EG, Fleishman JA, London AS, Caetano R, Burnam MA, Longshore D, Morton SC, Orlando M, Shapiro M: The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study. J Stud Alcohol. 2002, 63 (2): 179-186.View ArticlePubMedGoogle Scholar
- Kalichman SC: Psychological and social correlates of high-risk sexual behaviour among men and women living with HIV/AIDS. AIDS Care. 1999, 11 (4): 415-427.View ArticlePubMedGoogle Scholar
- Olley BO, Seedat S, Gxamza F, Reuter H, Stein DJ: Determinants of unprotected sex among HIV-positive patients in South Africa. AIDS Care. 2005, 17 (1): 1-9.View ArticlePubMedGoogle Scholar
- Sarna A, Chersich M, Okal J, Luchters SM, Mandaliya KN, Rutenberg N, Temmerman M: Changes in sexual risk taking with antiretroviral treatment: influence of context and gender norms in Mombasa, Kenya. Cult Health Sex. 2009, 1-Google Scholar
- HIV & AIDS and STI Strategic plan for South Africa 2007-2011. http://www.info.gov.za/otherdocs/2007/aidsplan2007/index.htmlGoogle Scholar
- Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, Duvvury N: Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ. 2008, 337: a506-PubMed CentralView ArticlePubMedGoogle Scholar
- Stanton BF, Li X, Kahihuata J, Fitzgerald AM, Neumbo S, Kanduuombe G, Ricardo IB, Galbraith JS, Terreri N, Guevara I: Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study. AIDS. 1998, 12 (18): 2473-2480.View ArticlePubMedGoogle Scholar
- Visser MJ: HIV/AIDS prevention through peer education and support in secondary schools in South Africa. SAHARA J. 2007, 4 (3): 678-694.View ArticlePubMedGoogle Scholar
- Soul City. http://www.soulcity.org.za/
- Global status report: alcohol policy. http://www.who.int/substance_abuse/publications/en/Alcohol%20Policy%20Report.pdf
- Revenue trends and tax proposals. http://www.treasury.gov.za/documents/national%20budget/2009/review/chap4.pdf
- Seedat M, Van Niekerk A, Jewkes R, Suffla S, Ratele K: Violence and injuries in South Africa: prioritising an agenda for prevention. Lancet. 2009, 374 (9694): 1011-1022.View ArticlePubMedGoogle Scholar
- Kalichman SC, Simbayi LC, Cloete A, Clayford M, Arnolds W, Mxoli M, Smith G, Cherry C, Shefer T, Crawford M: Integrated Gender-Based Violence and HIV Risk Reduction Intervention for South African Men: Results of a Quasi-Experimental Field Trial. Prev Sci. 2009Google Scholar
- Kalichman SC, Simbayi LC, Vermaak R, Cain D, Smith G, Mthebu J, Jooste S: Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town South Africa. Ann Behav Med. 2008, 36 (3): 270-279.View ArticlePubMedGoogle Scholar
- Lugalla J, Emmelin M, Mutembei A, Sima M, Kwesigabo G, Killewo J, Dahlgren L: Social, cultural and sexual behavioral determinants of observed decline in HIV infection trends: lessons from the Kagera Region, Tanzania. Soc Sci Med. 2004, 59 (1): 185-198.View ArticlePubMedGoogle Scholar
- Cooperman NA, Falkin GP, Cleland C: Changes in women's sexual risk behaviors after therapeutic community treatment. AIDS Educ Prev. 2005, 17 (2): 157-169.View ArticlePubMedGoogle Scholar
- 61st World Health Assembly. Strategies to reduce the harmful use of alcohol: report by the Secretariat. Accessed: August 2008, http://www.who.int/gb/ebwha/pdf_files/A61/A61_13-en.pdfGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.