Article

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

Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA 94720-7360, USA.
Sex Transm Dis (Impact Factor: 2.84). 12/2005; 32(11):685-90. DOI: 10.1097/01.olq.0000175405.36124.3b
Source: PubMed
ABSTRACT
We investigated whether men who were under the influence of alcohol when visiting female sex workers (FSW) were at greater risk for sexually transmitted infections (STI) and human immunodeficiency virus (HIV).
A cross-sectional analysis using baseline data from a randomized controlled trial of an HIV prevention intervention for high-risk men in Mumbai, India.
The overall HIV prevalence among 1741 men sampled was 14%; 64% had either a confirmed STI or HIV; 92% reported sex with an FSW, of whom 66% reported having sex while under the influence of alcohol (SUI). SUI was associated with unprotected sex (odds ratio [OR]: 3.1; 95% confidence interval [CI], 2.3-4.1), anal sex (OR: 1.5; 1.1-2.0), and more than10 FSW partners (OR: 2.2; 1.8-2.7). SUI was independently associated with having either an STI or HIV (OR: 1.5; 1.2-1.9).
Men who drink alcohol when visiting FSWs engage in riskier behavior and are more likely to have HIV and STIs. Prevention programs in India need to raise awareness of this relationship.

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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
PURNIMA MADHIVANAN, MBBS, MPH,* ALEXANDRA HERNANDEZ, MPH,† ALKA GOGATE, MD,‡
ELLEN STEIN, MPH,† STEVEN GREGORICH, P
HD,¶ MANINDER SETIA, MD, SAMEER KUMTA, MD,**
MARIA EKSTRAND, P
HD,¶ MEENAKSHI MATHUR, MD,§ HEMA JERAJANI, MD,§ AND CHRISTINA P. LINDAN, MD†
Objective: We investigated whether men who were under the in-
fluence of alcohol when visiting female sex workers (FSW) were at
greater risk for sexually transmitted infections (STI) and human
immunodeficiency virus (HIV).
Study: A cross-sectional analysis using baseline data from a ran-
domized controlled trial of an HIV prevention intervention for high-
risk men in Mumbai, India.
Results: The overall HIV prevalence among 1741 men sampled was
14%; 64% had either a confirmed STI or HIV; 92% reported sex with
an FSW, of whom 66% reported having sex while under the influence
of alcohol (SUI). SUI was associated with unprotected sex (odds ratio
[OR]: 3.1; 95% confidence interval [CI], 2.3– 4.1), anal sex (OR: 1.5;
1.1–2.0), and more than10 FSW partners (OR: 2.2; 1.8 –2.7). SUI was
independently associated with having either an STI or HIV (OR: 1.5;
1.2–1.9).
Conclusion: Men who drink alcohol when visiting FSWs engage in
riskier behavior and are more likely to have HIV and STIs. Prevention
programs in India need to raise awareness of this relationship.
AN ESTIMATED 4.1 TO 9.6 million adults and children are
living with HIV/AIDS in South and Southeast Asia.
1
India dom-
inates the epidemic, with up to 5.1 million people infected, of
whom 86% are thought to have acquired human immunodeficiency
virus (HIV) through sexual transmission. Mumbai, the capital of
Maharashtra state, has some of the highest HIV infection rates of
any urban area in the country.
2,3
Surveillance data from the Mum-
bai District AIDS Control Society for 2003 reported that 54% of
female commercial sex workers (FSW), 18% of men who have sex
with men, 18% of sexually transmitted infections (STIs) clinic
attendees, and 1.3% of antenatal clinic women were HIV infected
(Dr Alka Gogate, personal communication). Social, economic, and
gender-related issues that influence the spread of HIV in India
have received attention in numerous studies.
4–8
However, the role
that noninjection substance use, particularly alcohol, may play in
the epidemic in South Asia has not been evaluated in detail.
Alcohol consumption among men in India has been shown in a
number of surveys to be common.
5,9 –11
In a country as large and
diverse as India, however, estimates of the overall prevalence of
drinking varies, from 17% of men who were surveyed in Tamil
Nadu to 50% in rural Punjab.
11
Drinking was more frequent among
those with less education and lower socioeconomic status.
9,12,13
Among those who drank, the amount of alcohol consumed was
high. A survey sponsored by the World Health Organization in
south India revealed that 50% of male alcohol users drank to
intoxication, consuming more than 5 drinks per session (Dr. Vivek
Benegal, personal communication).
Only a few studies reported from India have demonstrated that
alcohol users are likely to engage in risky sex, but these reports are
primarily among those either being treated for alcohol abuse or for
psychiatric disease.
4,6–8
Studies have not been performed among a
more general population of those who drink, or have examined
whether there is a specific relationship between using alcohol with
sex and being more likely to acquire HIV or STIs. In contrast,
numerous studies from elsewhere in the developing and developed
world have identified a relationship between alcohol use and
high-risk sexual behavior.
14 –22
For example, a recent evaluation by
Simbayali et al.
23
conducted in South Africa revealed that those
who suffered from problem drinking had a greater number of sex
partners, history of condom failure, and STIs. In Zimbabwe, men
The authors would like to thank all the participants who generously gave
their time to participate in this research; the staff and management of the
research study team in Sion and BMC hospital, Mumbai; and Megan
McGuire for editorial assistance.
Ethical clearance: All participants completed a signed informed consent.
This study was approved by the institutional review boards of the Univer-
sity of California, San Francisco, and LTMG Medical School in Mumbai,
which is covered by a US National Institutes of Health Federal Wide
Assurance. The study was supported by the National Institute of Allergy
and Infectious Diseases, National Institutes of Health, grant number 5 R01
AI043914-04; Purnima Madhivanan from the NIH Fogarty AIDS Interna-
tional Training and Research Program (1-D43-TW0003-15).
Correspondence: Dr. Purnima Madhivanan, School of Public Health,
University of California, Division of Epidemiology, 140 Warren Hall
#7360, Berkeley, CA 94720-7360. E-mail: mpurnima@berkeley.edu.
Received for publication December 29, 2004, and accepted April 5,
2005.
From the *Division of Epidemiology, School of Public Health,
University of California Berkeley, Berkeley, California; †Department
of Epidemiology and Biostatistics, University of California, San
Francisco, California; ‡Mumbai District AIDS Control Society,
Mumbai, India; §Lokmanya Tilak Municipal Medical College and
General Hospital, Mumbai, India; ¶Department of Medicine,
University of California, San Francisco, California; School of
Public Health, University of California Berkeley, Berkeley,
California; and the **School of Public Health, Brown University,
Providence, Rhode Island
Sexually Transmitted Diseases, November 2005, Vol. 32, No. 11, p.685–690
DOI: 10.1097/01.olq.0000175405.36124.3b
Copyright © 2005, American Sexually Transmitted Diseases Association
All rights reserved.
685
Page 1
attending beer halls had a twofold higher HIV prevalence then men
who had not attended such venues.
14
Alcohol use can contribute to risky behavior in numerous ways;
for example, by causing sexual disinhibition, leading to more
sexual partners, difficulty in remembering to use a condom, or
being unable to use it correctly. Drinking may promote a social
environment in which unprotected sex is more likely to occur or is
acceptable. Persons may also use alcohol because they have an
expectation that it will enhance their sexual experience or decrease
stress and anxiety around seeking sex.
24
As part of an HIV behavioral intervention trial, we evaluated the
reported use of alcohol by Indian men when visiting FSWs. We
sought to determine whether men who were under the influence of
alcohol were more likely to have a STI or HIV and whether this
relationship was mediated by an increase in specific sexual
behaviors.
Methods
Study Design
A cross-sectional analysis was conducted on baseline data from
an ongoing randomized controlled trial of an HIV prevention
intervention among men attending 2 public STI clinics in Mumbai.
All participants completed an interviewer-administered question-
naire after signing informed consent. Subjects underwent a clinical
examination and laboratory evaluation for STIs and received treat-
ment according to US CDC guidelines.
25
HIV testing was offered
with pre- and posttest counseling, and HIV-positive men were
referred for further evaluation and care.
Between March 2002 and November 2003, 1968 participants
were enrolled into the trial. In this paper, we present information
on a subset of 1741 participants. Two hundred twenty-seven men
were excluded from the analysis because they reported sex under
the influence of drugs but not alcohol, had used intravenous drugs
in the past, or had missing information. None of the subjects
reported receiving a blood transfusion, and the presence of tattoos
was not associated with HIV infection. Therefore, we considered
HIV to be a STI for the purposes of this analysis.
Evaluation of Alcohol Use and Risk Behavior
The interview included questions about sociodemographics,
lifetime and most recent sexual behavior with FSW and other
partner types, condom use, alcohol use with or without drugs
during sex, and HIV knowledge and attitudes. We focused the
analysis on sex with FSWs, as this was the most common partner
type reported. We obtained data on self-reported condom use with
FSWs both over a lifetime and during the prior 3 months. Lifetime
condom use was reported and analyzed as being either “consistent”
(always) or “inconsistent” (less than always or never). Condom use
during the last 3 months was analyzed as the total number of
unprotected sex acts, calculated by subtracting the number of times
condoms were used from the total number of reported sex acts.
Depending on whether analyses focused on behavior over a life-
time or during the prior 3 months, “unprotected sex” was defined
as either “inconsistent” condom use with FSWs (lifetime) or having
at least 1 episode of sex without a condom (prior 3 months).
Alcohol use during sex was determined by asking: How often
were you high or feeling the effects of alcohol alone? and How
often were you high or feeling the effects of alcohol and drugs
while having sex with an FSW? Possible responses included never;
less than half the time; more than half the time; or always. Sex
under the influence of alcohol (SUI) was defined as using alcohol
or alcohol and drugs with sex “less than half the time; more than
half the time or always.” Men who were not under the influence of
alcohol or alcohol and drugs were considered to have “sober sex.”
STI and HIV Evaluation
Diagnostic testing for STIs and HIV was carried out in the
microbiology laboratory at LTMG Hospital, Mumbai. All men
regardless of signs or symptoms underwent serologic testing for
syphilis using the Venereal Disease Research Laboratory (VDRL)
test and the Treponema pallidum (TP) haemagglutination assay
(TPHA) (Immutrep TPHA, Omega Diagnostics, Alloa, Scotland);
for herpes simplex virus-2 (HSV2) using IgG serology (Herpe-
Select 2 Elisa, Focus Technologies, Cypress, CA); for HIV anti-
bodies using ELISA (Biokit Elisa, Labsystems, Helsinki, Finland)
and a confirmatory Western blot for HIV-1 or 2 (Chiron
RIBA*HIV-1/HIV-2 SIA, Ortho Clinical Diagnostics, Emeryville,
CA). Urine was collected from all men for polymerase chain
reaction (PCR) detection of Neisseria gonorrhea (GC) and Chla-
mydia trachomatis (CT) (Amplicor CT/NG, Roche Diagnostics,
Indianapolis, IN). Men with genital ulcers (GUDs) or vesicles
were swabbed for detection of T pallidum, HSV2, and Hemophilus
ducreyi using a home-brew multiplex PCR test (Roche Amplicor
reagents). Men with urethral discharge provided a specimen for
Gram stain and for culture of GC on chocolate agar plates using
standard procedures. The spun urine sediment from men with
dysuria but without urethral discharge was evaluated for the pres-
ence of white blood cells.
Men were considered to have specific STIs based on the fol-
lowing algorithms. Primary syphilis was defined as having a GUD
on physical examination, with a clinical diagnosis of a primary
chancre, confirmed with either a positive VDRL and TPHA or a
positive PCR test. Secondary syphilis was defined as having signs
of secondary disease or Condyloma lata with positive VDRL and
TPHA tests; latent or previously treated syphilis was defined as a
positive TPHA in the absence of clinical signs of primary or
secondary disease. Incident HSV2 infection was defined as having
a GUD or vesicles on examination, a positive HSV2 PCR test, and
absence of HSV2IgG antibodies. Recurrent HSV2 infection was
defined as having a GUD or vesicles, presence of HSV2IgG
antibodies, and a positive HSV2 PCR test. Men with a clinical
diagnosis of HSV2 with positive serology but a negative PCR test
were considered to have recurrent HSV2. Chronic HSV2 infection
was defined as having HSV2IgG antibodies in the absence of a
clinical diagnosis of HSV and, if in the presence of a GUD, a
negative HSV2 PCR. Chancroid was defined by a positive PCR
test; we also included those men who had a clinical diagnosis of
chancroid and negative serological tests for HSV2 IgG, VDRL,
and TPHA. Those GUDs for which PCR tests were positive for
more than 1 organism were considered dually infected. Gonococ-
cal urethritis was defined as having either a positive urine PCR test
for GC, Gram-negative intracellular diplococci (GND) on smear of
urethral discharge, or a positive GC culture. Chlamydial urethritis
was defined as having a positive PCR urine test. Nongonococcal
urethritis was defined as having symptoms of urethritis, Gram stain
without GND, negative culture and PCR tests for GC, but with 10
white blood cells per high-powered field on Gram stain or spun
urine sediment. The diagnoses of Lymphogranuloma venereum
(LGV), Condyloma acuminata, and Molluscum contagiosum were
made clinically.
Data Analyses
Data were entered in MS Access (Microsoft Access, Seattle,
WA) and cleaned onsite by trained staff. Data management oc-
curred both onsite and at the University of California, San Fran-
686 Sexually Transmitted Diseases
November 2005MADHIVANAN ET AL
Page 2
cisco. Data were analyzed using SAS (Version 9.0, SAS Institute).
A combined variable “STI/HIV” was created as the primary outcome
variable. This variable was defined as the presence or combination of
any of following infections: HIV, primary syphilis, secondary or
latent syphilis, incident, recurrent or chronic HSV2, chancroid, gon-
orrhea, chlamydia, nongonoccal urethritis, LGV, C acuminata,orM
contagiosum. Subjects who were missing either an HIV test (N
58) or any one of the STI test results were still included in the
analysis using the combined outcome variable. However, in Table
1, we evaluated the relationship of specific STIs to HIV infection,
and therefore those who were missing HIV test results are ex-
cluded from the table. We examined the relationship of demo-
graphic variables, risk behaviors, and SUI to STI/HIV using Pear-
son’s
2
statistic, and calculated odds ratios (OR) and 95%
confidence intervals (CIs) using logistic regression analyses. A
2-sided P value of 0.05 was considered statistically significant.
We also evaluated the association of SUI with risk behaviors using
logistic regression analysis. Differences in the number of unpro-
tected sex acts during the last 3 months among men having SUI,
compared to those having sober sex, were tested using Wilcoxon
rank sum test. We used stratified analysis to determine if specific
risk behaviors were confounders: unprotected sex with FSW, anal
sex with FSW, and more than 10 FSW partners. Since these 3 risk
behaviors could be on the causal pathway in the relationship of
SUI to STI/HIV, we evaluated them as potential mediators.
Mediation Analysis
We sought to determine whether any of the following 3 primary
risk behaviors could be mediating the relationship between SUI
and STI/HIV: unprotected sex with an FSW, anal sex with an
FSW, and more than 10 FSW partners, all reported over a lifetime.
Being a mediating variable implies that the factor is in the casual
pathway between predictor and outcome; that is, that SUI causes
specific risk behaviors, which in turn increase the possibility of
acquiring STI/HIV. This hypothesis is evaluated statistically by
observing whether a significant decrease in the OR between the
primary predictor (SUI) and outcome (HIV/STI) occurs when both
predictor and the mediating variables are included in a logistic
model.
We performed a series of bivariate logistic regression analyses.
We first determined the bivariate association between SUI and
STI/HIV as a direct effect. Second, we analyzed the relationship
between SUI and the hypothesized mediators or risk behaviors. We
then evaluated the association of each of the risk behaviors with
the outcome, adjusting for SUI. The presence of a mediated effect
was defined as a statistically significant decrease in the OR of SUI
to STI/HIV and an insignificant change in the OR of a risk
behavior to STI/HIV in the final adjusted model. Demographic
factors were considered to be upstream variables in the relation-
ship between SUI and STI/HIV and therefore were excluded from
this analysis.
Results
Table 1 presents the relationship between specifically diagnosed
STIs and HIV infection among subjects. Of the 1683 participants
who had HIV test results, 14% had HIV antibodies and 60% had
a confirmed STI. HSV2 infection was the most prevalent genital
infection (41%) and was also most strongly associated with HIV.
Men with incident infections or recurrent HSV2 lesions at presen-
tation were even more likely to have HIV antibodies, compared to
those who were diagnosed only by the presence of positive serol-
ogy. Syphilis was the second most prevalent STI (21% positive).
The relationship between demographic characteristics and hav-
ing either HIV or an STI, present among 64% of men in the
sample, is shown in Table 2. The median age was 26 years; 66%
of men were Hindu and 25% were Muslim. The majority (68%)
originally came from a state other than Maharastra. Only 31% of
men were married, and of those, 22% lived with their wives in
Mumbai. One third of men reported little or no education. Only
33% lived in stable housing, while the remainder lived in slums, a
footpath, or in a shop or bar.
Men who were 26 years or older, married, Hindu, living in a
slum, or who had less than 4 years of education were more likely
to have an STI or HIV infection. Over 90% of men reported sex
with an FSW in their lifetime, and 70% had seen a sex worker in
the prior 3 months (Table 3). Having more than 10 lifetime FSW
partners increased the risk of infection. Seventy-six percent of men
reported unprotected sex in the prior 3 months. Almost all men
TABLE 1. Prevalence of STIs and Relationship to HIV Infection
Among Patients Screened at Baseline Visit
All Patients HIV Infected
N (%) n (%)
All participants*
1683 100 238 14
Primary syphilis
Yes 48 3 12 25
a
No 1629 97 223 14
Secondary or latent syphilis
Yes 295 18 53 18
a
No 1382 82 182 13
HSV2 infection
Incident 8 1 4 50
b
Recurrent 84 5 27 32
Chronic 597 35 131 22
No HSV 994 59 76 8
Chancroid
Yes 11 1 3 27
No 1660 99 232 14
Chlamydia urethritis
Yes 24 1 5 21
No 1647 99 231 14
Gonococcal urethritis
Yes 122 7 28 23
b
No 1543 93 208 13
Nongonococcal urethritis
Yes 135 8 15 11
No 1547 92 223 14
Condyloma acuminata
Yes 36 2 14 39
b
No 1647 98 224 14
Molluscum contagiosum
Yes 21 1 6 29
a
No 1662 99 232 14
LGV
Yes 5 0 2 40
No 1675 100 236 14
Any sexually transmitted infection
Yes 1018 60 201 20
b
No 665 40 37 6
*Fifty-eight of 1741 participants were missing HIV test results and
are excluded from this table. HIV human immunodeficiency virus;
HSV2 herpes simplex virus-2; LGV Lymphogranuloma vene-
reum.
Participants missing laboratory or clinical information for individual
STIs were excluded from relevant sections of the table.
a
P 0.05,
b
P 0.001.
Vol. 32
No. 11 687ALCOHOL USE IS A RISK FACTOR FOR STIs AND HIV
Page 3
reported vaginal sex, but 14% also had anal sex with an FSW
partner.
Being under the influence of alcohol while engaging in sex was
common: 66% and 57% of men reported this in their lifetime or in
the prior 3 months, respectively. Both SUI and inconsistent con-
dom use (lifetime and past 3 months) were significantly associated
with the presence of an STI or HIV infection.
Association of SUI with sexual risk behaviors
We evaluated the association of SUI to unprotected sex, anal
sex, and multiple sexual partners (Table 4). Using lifetime recall,
SUI was associated with unprotected sex (OR: 3.1; 95% CI,
2.3– 4.1); anal sex (OR: 1.5; 1.1–2.0); and more than 10 lifetime
FSW partners (OR: 2.2; 1.8 –2.7). SUI in the prior 3 months was
also associated with unprotected sex (OR: 2.1; 1.6, 2.8) and more
than 10 lifetime FSW partners (OR: 1.9; 1.5, 2.4).
Mediation Model of the Association of SUI and STI/HIV
Logistic regression analysis, in the context of the mediation
model, was used to explore whether unprotected sex, anal sex, and
more than 10 lifetime FSW partners might be mediating the
relationship between SUI to STI/HIV infection (Fig. 1). The bi-
variate OR of SUI to STI/HIV equaled 1.5 (95% CI, 1.2–1.9).
When unprotected sex, anal sex, and having more than 10 lifetime
FSW partners were included in a logistic model, the OR of SUI to
STI/HIV was reduced to 1.4 (95% CI, 1.2–1.8), a change that was
not statistically significant. This indicates that these behaviors
were not significant mediating variables. In addition to SUI, un-
protected sex (OR, 1.7; 1.2, 2.4) remained independently associ-
ated with STI/HIV. We evaluated the association between SUI and
risk behaviors with other partner types (regular and casual female
partners, wives, other men and transgenders), but found no signif-
icant associations with either SUI or STI/HIV.
Discussion
We found that Indian men who were under the influence of
alcohol while having sex with female sex workers, compared to
those who were sober at the time, were more likely to be infected
with HIV or to have an STI. To our knowledge, this is one of the
only studies from India to evaluate the relationship between alco-
hol use with sex and biologic markers of HIV risk. These results
suggest that prevention programs need to recognize that alcohol
may influence the ability to practice safer sex or be a marker for
clients who take greater risks.
Alcohol use with sex may be a prevalent problem in India: a
survey of male clients of female sex workers conducted by the
National AIDS Control Organization revealed that 19% consumed
alcohol regularly before sex.
26
In our study, alcohol was by far the
most commonly used substance before sex. Because our study was
not specifically designed to evaluate alcohol use, we do not have
information on the overall proportion of clients who drank or on
TABLE 2. Demographic Characteristics and History of
Frequenting Female Sex Workers: Association With Having
an STI or HIV Infection
Characteristic
STI/HIV
N (%) n (%)
All participants 1741 1105 64
Age
16–25 830 48 457 55**
26–35 567 33 406 72
36 340 20 245 72
Religion
Hindu 1172 67 768 66*
Muslim 428 25 252 59
Other 137 8 88 64
Marital status
Married 530 31 358 68*
Unmarried 1207 69 750 62
Education (years)
4 605 35 417 69**
4–9 773 44 475 61
10 358 21 215 60
Living situation
Flat/chawl 571 33 345 60*
Slum/footpath 1165 67 762 65
Birthplace
Mumbai 46 3 30 65
Maharastra 506 29 330 65
Another state 1185 68 748 63
Sex with an FSW, ever
Yes 1590 92 1021 64
No 144 8 87 60
Sex with an FSW, last
3mo
Yes 1215 70 762 63
No 517 30 344 67
FSW female sex worker; HIV human immunodeficiency virus;
STI sexually transmitted disease. *P 0.05. **P 0.001.
TABLE 3. The Relationship of Alcohol Use and Risky Sex With
STIs and HIV
Characteristic
STI/HIV
N (%) n (%) OR (95% CI)
Lifetime
Alcohol use during
sex with FSW
Yes 1040 (66) 703 (68)** 1.5 1.2–1.9
No 546 (34) 314 (56)
Unprotected sex
with FSW
Yes 1388 (87) 920 (66)** 1.9 1.4–2.6
No 200 (13) 101 (51)
Anal sex with FSW
Yes 226 (14) 141 (62) 0.9 0.7–1.2
No 1358 (86) 875 (64)
FSW partners, No.
1–10 861 (54) 535 (62)
11 729 (46) 486 (67) 1.2 1.0–1.5
Prior 3 months
Alcohol use during
sex with FSW
Yes 693 (57) 463 (67)** 2.1 1.6–2.8
No 521 (43) 296 (57)
Unprotected sex
with FSW
Yes 923 (76) 602 (65)** 1.6 1.2–2.1
No 292 (24) 160 (55)
FSW partners, So.
1 418 (23) 262 (63) 1.00
2–5 613 (34) 385 (63) 1.00 0.8–1.3
6–10 145 (8) 85 (59) 0.8 0.6–1.2
11 98 (5) 55 (56) 0.8 0.5–1.2
FSW female sex worker; HIV human immunodeficiency virus;
STI sexually transmitted disease. *P 0.05. **P 0.001.
688 Sexually Transmitted Diseases
November 2005MADHIVANAN ET AL
Page 4
the quantity, frequency, or types of alcohol consumed. More
detailed understanding about the prevalence of alcohol abuse, the
context in which drinking takes place, and expectations around
drinking (such as whether men drink because they hope it will
make them less sexually inhibited or because they feel less self-
conscious about going to see a sex worker), are important for
designing appropriate HIV prevention messages.
In this study, we tried to explore the means by which alcohol
resulted in greater STI/HIV acquisition. We postulated that men
who drank had more partners and were less likely to use condoms
and for these reasons would be at greater risk. We did find that
alcohol use was associated with sexual risk behaviors when ana-
lyzed independently and that these behaviors were in turn associ-
ated with HIV/STI. However, using statistical mediation analysis,
we could not demonstrate that these behaviors were mediating the
effects between alcohol use and STI/HIV acquisition. The reasons
for this are not entirely clear. We assume that alcohol use itself is
unlikely to result in a greater biologic susceptibility to STIs,
although research in this area is limited. It is possible that men
misreported or underreported their risk behaviors, particularly in
the context of alcohol. Alcohol use could also be associated with
other behaviors that were not well measured in our study, such as
receptive anal sex with high-risk men. Alternatively, men who
drink may be more likely to see sex workers who drink, and the
prevalence of HIV and STIs might be higher among these women.
Although we did not collect data to support this hypothesis, it is
conceivable that sex workers who use alcohol may have more
partners or more unprotected sex with clients overall or drink
because they are ill with HIV. Thus, if these women are more
likely to be HIV infected, unprotected sex with them would incur
more risk to the client than unprotected sex with other FSWs.
There are several possible explanations as to why alcohol use
may facilitate risk behavior. Alcohol use could make a man forget
to use a condom or make it difficult for him to use it properly, or
he may be disinclined to use one because it prevents him from
maintaining an erection when inebriated. Men may drink in social
situations with friends or in bars, settings in which peer pressure
could encourage seeing sex workers. On the other hand, drinking
could be a marker for men who have risk-taking personalities, and
thus having sex without a condom would be a type of sensation-
seeking behavior. In our study, men who drank were more likely
to have anal sex with FSWs, but this was not associated with HIV
or STIs. Anal sex has been shown to put a woman at greater risk
for HIV, but for a male partner it may be less risky than having
insertive vaginal sex.
Even though our sample was recruited from STI clinics, only
60% of men had a confirmed sexually transmitted disease. This is
because some men complained of symptoms that were determined
on examination not to be due to an STI. Men without symptoms
could also be enrolled in the study if they were requesting an HIV
test or admitted to having sex without a condom in the last 3
months. HSV2 infection was the most prevalent STI, with incident
and recurrent disease strongly associated with HIV. These results
are similar to a recent study from Pune that also evaluated the
relationship of HSV2 infection to HIV.
27
The adjusted hazard ratio
for acquiring HIV-1 infection from prevalent HSV2 infection was
1.67; recent incident HSV2 infection was 3.8. These data lend
support for the concept, now in clinical trials, that prophylaxis for
HSV2 may reduce HIV transmission.
Currently, only limited prevention efforts targeting STD patients
exist in Mumbai, and few if any of these include information about
the risk of alcohol use with sexual partners. This information could
easily be incorporated into HIV test counseling or clinic visits. It
is particularly important for men to be aware of the relationship of
TABLE 4. Relationship of SUI With an FSW With Sexual Risk Behaviors, Over a Lifetime and in the Last 3 mo
Characteristic, N (%)
Unprotected Sex Anal Sex 10 FSW Partners
n (%) OR (95% CI) n (%) OR (95% CI) n (%) OR (95% CI)
Lifetime
SUI with FSW
Yes 1040 (66) 954 (92) 3.06
b
2.3–4.1 164 (16) 1.5
a
1.1–1.9 546 (53) 2.2
b
1.8–2.7
No 546 (34) 430 (79) 62 (11) 182 (33)
Prior 3 months
SUI with FSW
Yes 693 (57) 567 (82) 2.1
b
1.6–2.8 —* 403 (58) 1.9
b
1.5–2.4
No 521 (43) 354 (68) 218 (42)
*Anal sex with FSW was not measured in the prior 3 months.
a
P 0.05.
b
P 0.001. FSW female sex worker; SUI sex while under the
influence of alcohol.
STI/HIV
SUI
Unprotected sex
Anal sex
> 10 FSW partners
a, a’
b
c
d
e’
f’
g’
Fig. 1. Mediation model of the association of sex under the
influence of alcohol (SUI) with an FSW and STI/HIV. Note: a, b, c, d
are the unadjusted odds ratios for SUI, with FSW predicting STI/HIV,
unprotected sex, anal sex, and 10 partners, respectively. The
adjusted odds ratios of SUI conditional on all the 3 risk behaviors
is shown as a. The rest of the adjusted odds ratios e,f,g are
showing the relationship of each of the risk behavior, unprotected
sex, anal sex, and 10 partners, respectively, predicting STI/HIV
conditional on SUI. The unadjusted and adjusted odds ratio and
95% CI for each of these relations are: OR (95% confidence inter-
val), a, 1.5 (1.2–1.9); a, 1.4 (1.2–1.8); b, 3.1 (2.3–4.1); c, 1.5 (1.1–
2.0); d, 2.2 (1.7–2.7); e, 1.7 (1.2–2.4); f, 0.8 (0.6 –1.2); g, 1.1
(0.9 –1.4).
Vol. 32
No. 11 689ALCOHOL USE IS A RISK FACTOR FOR STIs AND HIV
Page 5
alcohol use and HIV risk, as sex workers may find it difficult to
insist that inebriated clients use a condom.
28
Overall, this study
demonstrates the need for future evaluation of the extent of alcohol
use and the mechanisms by which it affects sexual behavior and
STI/HIV risk in India.
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November 2005MADHIVANAN ET AL
Page 6
  • Source
    • "Alcohol use is a major contributor to unprotected, coerced sex (Go et al., 2004; Schensul et al., 2006) and thus HIV risk. Although the intersection between alcohol use, unprotected sexual behavior, and HIV transmission/ acquisition is well established (Madhivanan et al., 2005; Schensul et al., 2006), it is unclear whether husbands curb their alcohol use after an HIV diagnosis or whether wives avoid or refuse sex when their husbands are intoxicated . These behavioral dynamics are important to explore among HIV serodiscordant couples. "
    [Show abstract] [Hide abstract] ABSTRACT: This study examined factors that mitigate or heighten HIV risk among HIV-negative wives in serodiscordant relationships in Gujarat, India. Grounded theory was used to analyze 46 interviews (23 couples) where husbands were HIV-positive and wives were HIV-negative. A conceptual framework emerged from analysis from which we identified five pathways and four key behaviors: (a) safer sex, (b) no sex, (c) coercive sex, and (d) unprotected sex. Most couples either practiced safe sex or abstained from sex. Factors such as wives' assertiveness, a wife's fear of acquiring HIV, mutual understanding, positive sex communication, and a husband's desire to protect wife influenced safe sex/sexual abstinence. Factors such as desire for children, a husband's alcohol use, and intimate partner violence influenced coercive and unprotected sex. Counseling topics on sex communication, verbal and non-verbal safer sex strategies, as well as addressing intimate partner violence and alcohol use may be important in preventing risk to HIV-negative wives.
    Full-text · Article · Feb 2016 · Qualitative Health Research
  • Source
    • "Alcohol use has a well-established association with sexual risk-taking that can lead to HIV acquisition and transmission [2] . Research has repeatedly shown that alcohol use is related to sexual risk-taking behavior, including increased number of sexual partners, inconsistent condom use, and increased incidence of sexually transmitted infections (STIs)345678910. Alcohol use can reduce the ability to learn and to perform sexual risk-reduction strategies [11]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Namibia's HIV prevalence is 13.3 %. Alcohol is associated with sexual risk-taking, leading to increased HIV risk. Baseline sexual behaviors, HIV and alcohol knowledge, and self-perceived HIV risk were examined among men reporting high-risk drinking in Katutura, Namibia. Methods: HIV negative men, ≥ 18 years, were screened for harmful or hazardous levels of drinking and >1 recent sex partner prior to randomization into control or intervention arm. SAS 9.3 and R 3.01 were used for descriptive baseline cohort analyses. Results: A total of 501 participants who met criteria were included in analysis (mean Alcohol Use Disorders Identification Test [AUDIT] =12.4). HIV and alcohol knowledge were high with the majority (>85 and 89.8-98 %, respectively) of respondents correctly answering assessment questions. Despite high knowledge levels, 66.7 % of men felt they were at some or high risk of HIV acquisition. Among those respondents, 56.5 % stated often wanting to have sex after drinking and 40.3 % stated sex was better when drunk. Among respondents with non-steady partners [n = 188], 44.1 % of last sexual encounters occurred while the participant was drunk and condoms were not used 32.5 % of those times. Among persons who were not drunk condoms were not used 13.3 % of those times. Conclusions: Sex with casual partners was high. Inconsistent condom use and alcohol use before sex were frequently reported. Increased emphasis on alcohol risk-reduction strategies, including drinking due to peer pressure and unsafe sexual behaviors, is needed.
    Full-text · Article · Nov 2015 · BMC Public Health
  • Source
    • "Alcohol use and its association with HIV-related sexual risk is well documented by studies in other countries [4–7], including studies on MSM [8–11]. Studies in India have found alcohol use to be associated with HIV-related sexual risk across a range of male populations—married men [12], male migrant workers [13], men from low income communities [14], male clients of female sex workers (FSWs) [15], and male patrons of wine shops [16]. However, little information is available on alcohol use among Indian MSM and its association with HIV-related sexual risk. "
    [Show abstract] [Hide abstract] ABSTRACT: This paper examines the association between alcohol use and HIV-related sexual risk behaviors among men who have sex with men (MSM). A cross-sectional bio-behavioral survey was conducted among 3,880 MSM, recruited using time-location cluster sampling from cruising sites in three Indian states. Nearly three-fifths of the participants reported alcohol use. Among frequent users (40 % of the sample), defined as those who consumed alcohol daily or at least once a week, 66 % were aged 25 years and above, 53 % self-identified as kothi (feminine/receptive), and 63 % consistently used condoms with male paying partners. Multivariate logistic regression demonstrated that frequent users were more likely to be aged 25 years and above, less likely to self-identify as kothi, and less likely to consistently use condoms with male paying (AOR = 0.7; 95 % CI 0.5-0.9) and male regular (AOR = 0.7; 95 % CI 0.6-0.9) partners. HIV prevention interventions for MSM need to provide tailored information on alcohol use-related sexual risk, especially for MSM in sex work and MSM with male regular partners.
    Full-text · Article · Jan 2014 · AIDS and Behavior
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