Abstract
In sub-Saharan Africa, harmful alcohol use among male drinkers is high and has deleterious consequences on adherence to antiretroviral therapy (ART), HIV clinical outcomes, and couple relationship dynamics. We conducted in-depth qualitative interviews with 25 Malawian couples on ART to understand how relationships influence adherence to ART, in which alcohol use emerged as a major theme. Almost half of men (40%) reported current or past alcohol use. Although alcohol use was linked to men’s non-adherence, women buffered this harm by encouraging husbands to reduce alcohol use and by offering adherence support when men were drinking. Men’s drinking interfered with being an effective treatment guardian for wives on ART and also weakened couple support systems needed for adherence. Relationship challenges including food insecurity, intimate partner violence, and extramarital relationships appeared to exacerbate the negative consequences of alcohol use on ART adherence. In this setting, alcohol may be best understood as a couple-level issue. Alcohol interventions for people living with HIV should consider approaches that jointly engage both partners.
Similar content being viewed by others
References
Galvan FH, Bing EG, Fleishman JA, et al. 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):179–86.
Hendershot CS, Stoner SA, Pantalone DW, et al. Alcohol use and antiretroviral adherence: review and meta-analysis. J Acquir Immune Defic Syndr. 2009;52(2):180–202.
Giordano TP, Hartman C, Gifford AL, et al. Predictors of retention in HIV care among a national cohort of US veterans. HIV Clin Trials. 2009;10(5):299–305.
Chander G, Lau B, Moore RD. Hazardous alcohol use: a risk factor for non-adherence and lack of suppression in HIV infection. J Acquir Immune Defic Syndr. 2006;43(4):411.
Baum MK, Rafie C, Lai S, et al. Alcohol use accelerates HIV disease progression. AIDS Res Hum Retroviruses. 2010;26(5):511–8.
Hahn JA, Samet JH. Alcohol and HIV disease progression: weighing the evidence. Curr HIV/AIDS Rep. 2010;7(4):226–33.
Braithwaite RS, Bryant KJ. Influence of alcohol consumption on adherence to and toxicity of antiretroviral therapy and survival. Alcohol Res Health. 2010;33(3):280.
Kekwaletswe CT, Morojele NK. Alcohol use, antiretroviral therapy adherence, and preferences regarding an alcohol-focused adherence intervention in patients with human immunodeficiency virus. Patient Prefer Adherence. 2014;8:401–13.
Conroy AA, McKenna SA, Leddy A, et al. “If she is drunk, I don’t want her to take it”: partner beliefs and influence on use of alcohol and antiretroviral therapy in South African couples. AIDS Behav. 2017;21(7):1885–91.
Fatch R, Emenyonu NI, Muyindike W, et al. Alcohol interactive toxicity beliefs and ART non-adherence among HIV-infected current drinkers in Mbarara, Uganda. AIDS Behav. 2016;21(7):1812–24.
Kalichman SC, Amaral CM, White D, et al. Prevalence and clinical implications of interactive toxicity beliefs regarding mixing alcohol and antiretroviral therapies among people living with HIV/AIDS. AIDS Patient Care STDS. 2009;23(6):449–54.
Kalichman SC, Amaral CM, White D, et al. Alcohol and adherence to antiretroviral medications: interactive toxicity beliefs among people living with HIV. J Assoc Nurses AIDS Care. 2012;23(6):511–20.
Levitt A, Derrick JL, Testa M. Relationship-specific alcohol expectancies and gender moderate the effects of relationship drinking contexts on daily relationship functioning. J Stud Alcohol Drugs. 2014;75(2):269–78.
Levitt A, Cooper ML. Daily alcohol use and romantic relationship functioning: evidence of bidirectional, gender-, and context-specific effects. Pers Soc Psychol Bull. 2010;36(12):1706–22.
Homish GG, Leonard KE. Marital quality and congruent drinking. J Stud Alcohol. 2005;66(4):488–96.
Rodriguez LM, Neighbors C, Knee CR. Problematic alcohol use and marital distress: an interdependence theory perspective. Addict Res Theory. 2014;22(4):294–312.
Leonard KE, Rothbard JC. Alcohol and the marriage effect. J Stud Alcohol (supplement). 1999;13:139–46.
Gotlib IH, McCabe SB. Marriage and psychopathology. In: Fincham F, Bradbury T, editors. The psychology of marriage. New York: Guilford; 1990. p. 226–57.
Halford WK, Bouma R, Kelly A, et al. Individual psychopathology and marital distress: analyzing the association and implications for therapy. Behav Modif. 1999;23(2):179–216.
O’Farrell T, Rotunda R. Couples interventions and alcohol abuse. In: Halford W, Markman H, editors. Clinical handbook of marriage and couples interventions. Chichester: Wiley; 1997. p. 555–88.
Homish GG, Leonard KE. The drinking partnership and marital satisfaction: the longitudinal influence of discrepant drinking. J Consult Clin Psychol. 2007;75(1):43.
World Health Organization. Global status report on alcohol and health. Geneva, Switzerland: World Health Organization; 2014.
Morojele NK, Kekwaletswe CT, Nkosi S. Associations between alcohol use, other psychosocial factors, structural factors and antiretroviral therapy (ART) adherence among South African ART recipients. AIDS Behav. 2014;18(3):519–24.
Sileo KM, Simbayi LC, Abrams A, et al. The role of alcohol use in antiretroviral adherence among individuals living with HIV in South Africa: event-level findings from a daily diary study. Drug Alcohol Depend. 2016;167:103–11.
Denison JA, Koole O, Tsui S, et al. Incomplete adherence among treatment-experienced adults on antiretroviral therapy in Tanzania, Uganda and Zambia. AIDS (London, England). 2015;29(3):361.
Ruark A, Kajubi P, Ruteikara S, et al. Couple relationship functioning as a source or mitigator of HIV risk: associations between relationship quality and sexual risk behavior in peri-urban Uganda. AIDS Behav. 2017;22(4):1273–87.
Woolf-King S, Conroy A, Fritz K, et al. Alcohol use and relationship quality among South African couples: implications for couples-based HIV interventions. In: International AIDS conference, 18–22 July 2016, Durban, South Africa; 2016.
Kelley HH, Thibalt JW. Interpersonal relations: a theory of interdependence. New York: Wiley; 1978.
Karney BR, Hops H, Redding CA, et al. A framework for incorporating dyads in models of HIV-prevention. AIDS Behav. 2010;14(2):189–203.
Rusbult C, Arriaga X. Interdependence theory. In: Duck S, editor. Handbook of personal relationships. 2nd ed. London: Wiley; 1997.
Conroy A, Leddy A, Johnson M, et al. ‘I told her this is your life’: relationship dynamics, partner support and adherence to antiretroviral therapy among South African couples. Cult Health Sex. 2017;19(11):1239–53.
Conroy AA, McKenna SA, Comfort ML, et al. Marital infidelity, food insecurity, and couple instability: a web of challenges for dyadic coordination around antiretroviral therapy. Soc Sci Med. 2018;214:110–7.
Singer M. A dose of drugs, a touch of violence, a case of AIDS, part 2: further conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 2006;34(1):39–53.
Singer M. A dose of durgs, a touch of violence, a case of AIDS: conceptualizing the SAVA epidemic. Free Inq Creat Sociol. 1996;24(2):99–110.
Russell BS, Eaton LA, Petersen-Williams P. Intersecting epidemics among pregnant women: alcohol use, interpersonal violence, and HIV infection in South Africa. Curr HIV/AIDS Rep. 2013;10(1):103–10.
Hatcher AM, Colvin CJ, Ndlovud N, et al. Intimate partner violence among rural South African men: alcohol use, sexual decision-making, and partner communication. Cult Health Sex. 2014;16(9):1023–39.
Tsai A, Burns B. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139:26–35.
Parsons JT, Grov C, Golub SA. Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health. 2012;102(1):156–62.
Miller CL, Bangsberg DR, Tuller DM, et al. Food insecurity and sexual risk in an HIV endemic community in Uganda. AIDS Behav. 2011;15:1512–9.
Weiser SD, Palar K, Frongillo EA, et al. Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda. AIDS. 2014;28:115–20.
Weiser SD, Tuller DM, Frongillo EA, et al. Food insecurity as a barrier to sustained antiretroviral therapy adherence in Uganda. PLoS ONE. 2010;5(4):e10340.
Friedman MR, Stall R, Plankey M, et al. Effects of syndemics on HIV viral load and medication adherence in the multicenter AIDS cohort study. AIDS (London, England). 2015;29(9):1087.
Blashill AJ, Bedoya CA, Mayer KH, et al. Psychosocial syndemics are additively associated with worse ART adherence in HIV-infected individuals. AIDS Behav. 2015;19(6):981–6.
Kuhns LM, Hotton AL, Garofalo R, et al. An index of multiple psychosocial, syndemic conditions is associated with antiretroviral medication adherence among HIV-positive youth. AIDS Patient Care STDS. 2016;30(4):185–92.
Starks TJ, Tuck AN, Millar BM, et al. Linking syndemic stress and behavioral indicators of main partner HIV transmission risk in gay male couples. AIDS Behav. 2016;20(2):439–48.
Msyamboza KP, Ngwira B, Dzowela T, et al. The burden of selected chronic non-communicable diseases and their risk factors in Malawi: nationwide STEPS survey. PLoS ONE. 2011;6(5):e20316.
Bush K, Kivlahan D, McDonell M, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789–95.
National Statistical Office (NSO) [Malawi] and ICF. Malawi Demographic and Health Survey 2015–2016. Zomba: NSO and ICF; 2017.
UNAIDS. UNAIDS Country Report on Malawi. http://www.unaids.org/en/regionscountries/countries/malawi. 2018.
Ministry of Health Malawi. 3rd Edition of the Malawi Guidelines for Clinical Management of HIV in Children and Adults. Malawi: Lilongwe; 2016.
Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–62.
Ritchie J, Lewis J, Nicholls CM, et al. Qualitative research practice: A guide for social science students and researchers. London: Sage; 2013.
Starmann E, Collumbien M, Kyegombe N, et al. Exploring couples’ processes of change in the context of SASA! A violence against women and HIV prevention intervention in Uganda. Prev Sci. 2017;18(2):233–44.
Mugweni E, Pearson S, Omar M. Concurrent sexual partnerships among married Zimbabweans—implications for HIV prevention. Int J Women’s Health. 2015;7:819.
Lyimo RA, de Bruin M, van den Boogaard J, et al. Determinants of antiretroviral therapy adherence in northern Tanzania: a comprehensive picture from the patient perspective. BMC Public Health. 2012;12(1):716.
Powers MB, Vedel E, Emmelkamp PM. Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis. Clin Psychol Rev. 2008;28(6):952–62.
Fals-Stewart W, Clinton-Sherrod M. Treating intimate partner violence among substance-abusing dyads: the effect of couples therapy. Prof Psychol Res Pract. 2009;40(3):257.
Wechsberg WM, Zule WA, El-Bassel N, et al. The male factor: outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township. Drug Alcohol Depend. 2016;161:307–15.
Timko C, Young LB, Moos RH. Al-Anon family groups: origins, conceptual basis, outcomes, and research opportunities. J Groups Addict Recov. 2012;7(2–4):279–96.
Acknowledgements
The authors would like to thank the tireless efforts of the research staff at Invest in Knowledge in Malawi for data collection.
Funding
This study was funded by the National Institutes of Health under Grants K01MH107331 and T32DA13911.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
There are no conflicts of interest for any of the study authors.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Rights and permissions
About this article
Cite this article
Conroy, A.A., McKenna, S.A. & Ruark, A. Couple Interdependence Impacts Alcohol Use and Adherence to Antiretroviral Therapy in Malawi. AIDS Behav 23, 201–210 (2019). https://doi.org/10.1007/s10461-018-2275-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-018-2275-2