Issues
Sub‐Saharan Africa (SSA) has long been characterised as a region with weak alcohol policies, high proportions of abstainers and heavy episodic drinkers (among drinkers), and as a target for ...market expansion by global alcohol producers. However, inter‐regional analyses of these issues are seldom conducted.
Approach
Focusing mainly on the period 2000–2016, we compare alcohol consumption and harms, alcohol policy developments and alcohol industry activities over time and across the four sub‐regions of SSA.
Key Findings
Per‐capita consumption of alcohol and alcohol‐related disease burden have increased in Central Africa but stabilised or reduced in other regions, although they are still high. Most countries have implemented tax policies, but they have seldom adopted other World Health Organization ‘best buys’ for cost‐effective alcohol control policies. Countries range from having minimal alcohol controls to having total bans (e.g. some Muslim‐majority countries); and some, such as Botswana, have attempted stringent tax policies to address alcohol harm. Alcohol producers have continued their aggressive marketing and policy interference activities, some of which have been highlighted and, in a few instances, resisted by civil society and public health advocates, particularly in southern Africa.
Implications
Increased government support and commitment are needed to be able to adopt and implement effective alcohol policies and respond to pressures from alcohol companies to which SSA remains a target market.
Conclusion
SSA needs effective alcohol control measures in order to reverse the trajectory of worsening alcohol harms observed in some countries and reinforce improvements in alcohol harms observed in others.
The body of knowledge on alcohol use and communicable diseases has been growing in recent years. Using a narrative review approach, this paper discusses alcohol's role in the acquisition of and ...treatment outcomes from four different communicable diseases: these include three conditions included in comparative risk assessments to date-Human Immunodeficiency Virus (HIV)/AIDS, tuberculosis (TB), and lower respiratory infections/pneumonia-as well as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) because of its recent and rapid ascension as a global health concern. Alcohol-attributable TB, HIV, and pneumonia combined were responsible for approximately 360,000 deaths and 13 million disability-adjusted life years lost (DALYs) in 2016, with alcohol-attributable TB deaths and DALYs predominating. There is strong evidence that alcohol is associated with increased incidence of and poorer treatment outcomes from HIV, TB, and pneumonia, via both behavioral and biological mechanisms. Preliminary studies suggest that heavy drinkers and those with alcohol use disorders are at increased risk of COVID-19 infection and severe illness. Aside from HIV research, limited research exists that can guide interventions for addressing alcohol-attributable TB and pneumonia or COVID-19. Implementation of effective individual-level interventions and alcohol control policies as a means of reducing the burden of communicable diseases is recommended.
Although alcohol use is associated with depression, it is unclear if brief alcohol reduction interventions can ameliorate depression and psychological distress among people with HIV (PWH). We use ...data from a two-arm randomised controlled trial to examine this question. PWH on antiretroviral treatment (ART) were randomly assigned to receive a brief intervention or treatment as usual (n = 622). Screening was done with the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, Centre for Epidemiological Studies Depression inventory and Kessler Psychological Distress Scale, at baseline and at 3- and 6-months post-baseline. Changes in depression and psychological distress was assessed using analysis of covariance models with baseline measures of alcohol consumption, sex and age included as covariates and adjusting for baseline symptom severity. Changes in alcohol consumption between baseline and follow-up were included in the analysis to establish if this affected outcomes. For both the intervention and control groups, there were significant reductions in symptom severity at 3-months and 6-months for depression and psychological distress, but no significant between group differences were observed. Reductions in alcohol consumption were significantly associated with reductions in depression and psychological distress, supporting the hypothesis that alcohol use is linked to depression among PWH.
Trial Registration
Pan African Clinical Trials Register, PACTR201405000815100.nh
Background
Accurately quantifying alcohol use among persons with HIV (PWH) is important for validly assessing the efficacy of alcohol reduction interventions.
Methods
We used data from a randomized ...controlled trial of an intervention to reduce alcohol use among PWH who were receiving antiretroviral therapy in Tshwane, South Africa. We calculated agreement between self‐reported hazardous alcohol use measured by the Alcohol Use Disorders Identification Test (AUDIT; score ≥8) and AUDIT‐Consumption (AUDIT‐C; score ≥3 for females and ≥4 for males), heavy episodic drinking (HED) in the past 30 days, and heavy drinking in the past 7 days with a gold standard biomarker‐‐phosphatidylethanol (PEth) level (≥50 ng/mL)‐‐among 309 participants. We used multiple logistic regression to assess whether underreporting of hazardous drinking (AUDIT‐C vs. PEth) differed by sex, study arm, and assessment time point.
Results
Participants' mean age was 40.6 years, 43% were males, and 48% were in the intervention arm. At 6 months, 51% had PEth ≥50 ng/mL, 38% and 76% had scores indicative of hazardous drinking on the AUDIT and AUDIT‐C, respectively, 11% reported past 30‐day HED, and 13% reported past 7‐day heavy drinking. At 6 months, there was low agreement between AUDIT‐C scores and past 7‐day heavy drinking relative to PEth ≥50 (sensitivities of 83% and 20% and negative predictive values of 62% and 51%, respectively). Underreporting of hazardous drinking at 6 months was associated with sex (OR = 3.504. 95% CI: 1.080 to 11.364), with odds of underreporting being greater for females.
Conclusions
Steps should be taken to decrease underreporting of alcohol use in clinical trials.
Improving validity of self‐reported alcohol use in clinical settings is essential. Using the biomarker, phosphatidylethanol, as a gold standard, this study aimed to assess the agreement with popular, self‐report measures of drinking and harmful alcohol use. Under‐reporting of hazardous drinking at 6 months was associated with sex, with odds of under‐reporting being greater for women. This suggests that efforts are needed to create a non‐stigmatizing environment to ensure that women patients are put at ease when enquiring about alcohol use.
Alcohol, tobacco, and other drug (ATOD) use by adolescents are major contributors to death and disability in sub‐Saharan Africa (SSA). This paper reviews the extent of adolescents’ ATOD use, risk and ...protective factors, and studies evaluating prevention interventions for adolescents in SSA. It also describes the harms associated with adolescents’ ATOD use in SSA, which mainly include interpersonal violence, sexual risk behaviours, and negative academic outcomes. We use the socio‐ecological model as our framework for understanding ATOD use risk and protective factors at individual, interpersonal, peer/school, and societal/structural levels. We used two strategies to find literature evaluating ATOD interventions for adolescents in SSA: (a) we sought systematic reviews of adolescent ATOD interventions in SSA covering the period 2000–2020; and (b) we used a comprehensive evidence review strategy and searched for studies that had evaluated ATOD interventions in all SSA countries between 2000 and 2020. Only two community interventions (a brief intervention and an HIV prevention intervention), out of four that were identified, were partially effective in reducing adolescent ATOD. Furthermore, only one school‐based intervention (HealthWise), out of six that we uncovered, had any effect on ATOD use among adolescents. Possible reasons why many interventions were not effective include methodological limitations, involvement of non‐evidence‐based education‐only approaches in some studies, and shortcomings in adaptations of evidence‐based interventions. The scale of ATOD and related problems is disproportionate to the number of evaluated interventions to address them in SSA. More ATOD interventions need to be developed and evaluated in well‐powered and well‐designed studies.
Excessive alcohol consumption constitutes a significant public health problem for South Africans. Alcohol use by South African (SA) adolescents is characterised mainly by binge/heavy episodic ...drinking. Levels of binge drinking have been high, but relatively stable, among males since 2002, while there has been a significant increase in binge drinking by females since then. Binge drinking is a major risk factor for a range of alcohol-related harms in SA, including traffic-related accidents and deaths, interpersonal violence, fetal alcohol spectrum disorder (FASD), crime, sexual risk behaviour, HIV, tuberculosis and the resultant burden of all of these on the economy. Clinicians may play a key role in addressing adolescent alcohol use and alcohol-related harm. Such a role may involve screening, brief interventions and referrals to treatment. There are several assessment, screening and diagnostic tools to detect alcohol use and misuse, specifically among adolescents. Furthermore, various pharmacological and psychological approaches are available to treat adolescent alcohol problems. Special issues to consider when dealing with alcohol use problems among adolescents in SA include recognising the risk factors, and acknowledging and addressing the harms associated with alcohol use (including sexual risk behaviour and FASD) and the possible existence of comorbid mental health problems.
People living with HIV (PLWH) who drink alcohol and use tobacco are particularly vulnerable to tobacco-induced diseases due to an already compromised immune system. This study investigated the ...prevalence and factors associated with tobacco use (cigarette and snuff) among PLWH who drink heavily.
Participants (n = 623) on antiretroviral therapy for HIV who reported heavy drinking using the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C were recruited from six hospitals in Gauteng Province, South Africa. The Fagerström test was used to assess nicotine dependence. Chi Square tests and modified Poisson regression analyses were conducted to identify factors associated with tobacco use.
Almost half of the participants reported ever smoking (44.0%; CI: 40.1-47.9) and about a quarter reported ever using snuff (25.5%; CI: 22.2-29.1). Current smokers and current snuff users comprised 27.3% (CI: 23.9-30.9) and 19.1% (CI: 16.2-22.3) of all participants respectively. Among current smokers, 37.9% (CI: 30.8-45.3) were moderately/highly dependent on nicotine. Current 'any tobacco product users' (ATPU: use cigarettes or snuff) were 45.4% (CI: 41.5-49.3) while 1.0% (CI: 0.4-2.0) currently used cigarettes and snuff. Adjusted regression analyses showed that, compared to males, females were less at risk of being: ever smokers (Relative Risk Ratio RRR = 0.33; CI: 0.27-0.41), current smokers (RRR = 0.18; CI: 0.12-0.25), and ATPU (RRR = 0.75; CI: 0.63-0.89) but were more at risk of ever snuff use (RRR = 5.23; CI: 3.31-8.25), or current snuff use (RRR = 26.19; CI: 8.32-82.40) than males. Ever snuff users (RRR = 1.32; CI: 1.03-1.70), current snuff users (RRR = 1.40; CI: 1.03-1.89) and ATPU (RRR = 1.27; CI: 1.07-1.51) were more at risk of reporting significant depressive symptoms. We found no significant associations between smoking status and years on ART and viral load.
There is a high prevalence of cigarette and snuff use among PLWH who drink heavily. Tobacco use cessation interventions tailored specifically for this population and according to their tobacco product of choice are urgently needed given their vulnerability to ill-health.
We examined whether alcohol use is associated with antiretroviral therapy (ART) adherence independently of structural and psychosocial factors among 304 male and female ART recipients in ART sites in ...Tshwane, South Africa. ART adherence was assessed by the CASE Adherence Index. Independent variables were demographic, structural, psycho-social, and alcohol use (AUDIT score) factors. In hierarchical multiple regression, demographic variables (Step 1) explained 4 % of variance in ART adherence (
p
≤ 0.01). Variance explained increased to 16 % (
p
≤ 0.001) after entering structural variables (Step 2); 19 % (
p
≤ 0.001) after entering psychosocial variables (Step 3); and 24 % (
p
≤ 0.001) after entering AUDIT score (Step 4). Alcohol use is independently associated with ART adherence.
To understand alcohol use trends and alcohol-related harm among youth in South Africa (SA) between 1998 and 2008, and discuss implications for the current alcohol policy process.
A review was ...conducted of 4 national prevalence and 2 sentinel surveillance studies. Data were extracted to Epi Info (version 7) and chi-square analyses undertaken. RESULTS. Lifetime alcohol use remained stable but high at 20 - 25% and 49.1 - 49.6% according to South African Demographic and Health Survey (SADHS) and Youth Risk Behaviour Survey (YRBS) data, respectively. Age of initiation remained stable; 12% of adolescents initiated alcohol use prior to age 13 years. Significant gender differences existed with more males having ever consumed alcohol, engaged in binge drinking, and driven or walked under the influence of alcohol (DUI and WUI, respectively). Binge drinking among females increased significantly from 27% to 36% (SADHS) and 18% to 27% (YRBS). DUI and WUI increased. Homicide/violence, suicide and unintentional deaths were significantly associated with blood alcohol concentration (BAC).
Although SA has made significant strides in alcohol control and prevention of alcohol-related harm over the past decade, early alcohol initiation remains a concern and binge drinking is increasing, especially among females. Significant associations exist between BAC and alcohol-related fatalities. Findings imply that regulatory policies are inadequate; additional efforts are required to ensure that control strategies translate into a reduction in harmful alcohol use by SA youth.
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