I am really surprised when I see absence of any discussion on the sexual behaviour influenced by alcohol consumption.
For instance: http://www.aidsmap.com/HIV-prevention-policy/cat/80322/
Article Risky behaviour and HIV prevalence among Zambian men
Hello, hello and how refreshing to see your remark. I agree with your concern that HIV prevention policies, in general, inadequately address the issue of substance abuse as a contributor to HIV seroconversion rates. Looking at subpopulation studies and my own clinical experience, there are certain programs that do a better job of this. For example, we have long been aware of the role of substance abuse on health-related behaviors and sexual risk behaviors in the lesbian, gay, bisexual and transgender populations. In the clinics I have worked in, mental health professionals had to help patients address internalized homophobia, fear of rejection, sexual identity issues and other psychosocial concerns that were found to lie at the root of the substance abuse problem. This component of treatment along with a substance abuse prevention component worked best when it came to attempts to prevent HIV seroconversion. Local governments and institutions implemented policies that required recipients of grant funding to include the mental health and substance abuse component of a treatment program for HIV prevention. (e.g., San Francisco County Dept. of Public Health, Ryan White funding, etc.)
One tremendously unfortunate reason for the issue you speak of is the lack of financial incentive to incorporate substance abuse prevention and treatment into HIV prevention. You would think with the number of substance abuse prevention and treatment providers there would be more utilization of their services and policies that require this component in HIV prevention. However, I think the financial incentive is not there in part due to the complexity of the issues. Further, we have seen little prevention success in the LGBT population despite all that we have come to learn. CDC (United States) continues to report increasing rates of HIV seroconversion in men who have sex with men. So we're left bewildered about the efficacy of prevention programming. And I only speak of the population I am most familiar with - although I imagine there must be some prevention programming success somewhere that would support the need for public health policies that address substance abuse and HIV risk.
Some studies have indicated that a treatment facility's ties to managed care payers and leadership in graduate education serve as potential leverage points for public policy. (For example, see Wells, Lemak and D'Auonno, 2006: http://www.substanceabusepolicy.com/content/1/1/21). What I gather from these studies is that we can begin with utilizing the clinical training experience component of graduate schools in the country. There certainly is a shortage of internships and fellowships for doctoral-level students in clinical psychology. The other component is getting third-party payors to better compensate treatment providers for prevention work. Unfortunately, cost control is a primary goal for managed care. And of course, it doesn't help that each year, fewer dollars are allocated for research in this area. Research that supports the efficacy of substance abuse prevention as a component would incentivize managed care, treatment facilities, and public policy think tanks. Yet, research is focused on pharmacological interventions - such as pre- and post-exposure prophylaxis. And we know that PrEP has proved moderately successful at preventing HIV seroconversion after potential exposure. And this is a huge incentive for managed care because of the costly nature of treating HIV infection.
This is a huge topic that cannot be adequately addressed in a forum but I am glad to see that you are starting the conversation about this issue.
This is an interesting topic indeed. Intuitively one would think surely there should be a link between alcohol consumption/ psychoactive drug use and HIV. However, to the best of my knowledge, this has remained a 'grey' area due to the lack of epidemiological evidence linking alcohol/ non-injection drug use directly to the acquisition of HIV. There is a lot of evidence linking alcohol to risky sexual behaviour (or the intention to have unprotected sex e.g. this systematic review DOI: 10.1111/j.1360-0443.2011.03621.x), but not to HIV acquisition for example; and lots of evidence also on injection drug use to hiv acquisition. Linking alcohol/ non-injection psychoactive drug use to HIV acquisition has remained an under developed area. Inturn, as most HIV prevention policies and practices are evidence driven/ evidence informed, this lack of scientific evidence results in lack of policies and practices addressing this.
However, the language has now changed and alcohol and other psychoactive substances are more and more being recognised as structural drivers of HIV. This has led to increased attention and interest in research in this area. STRIVE for example, an organization under the london school of hygiene and tropical medicine (http://strive.lshtm.ac.uk/drivers) has a research strand looking at this. Also there are now research fellowships to encourage researchers to look at this (e.g. the HIV and Drug Use Research Fellowship under the International AIDS Society). So as more and more evidence is accumulated in this area, we will hopefully begin to see prevention policies and practices addressing this issue.
I think one of the reasons that substance use isn't addressed in relation to HIV might be conservative funding policies. Harm reduction seems to be treated like a dirty word in Canada. Based on my experience of LGBTQ values, abstinence only approaches to substance use are not going to fly.
I think more has needs to be done to show a cause effect relationship, Many of the studies show an association but like Noreen highlighted, not a causal relationship. managing Alcohol and or substance abuse for HIV prevention would indeed mean managing structural issues. Currently, the big stuff is about combination prevention for HIV - biomedical, behavioural and structural. The bit that has continued to fall between the crack in National HIV prevention programmes in resource limited setting is the structural. And this is because structural changes are well beyond the capacity of donor fundings that focus on HIV programming: stuctural problems need to be tackled by the national government as it is an issue larger than HIV management in itself.
Those of us who have worked in the HIV community we are fully aware of the HIV, alcohol, and substance use cause and effect relationship. Many of the individuals I have worked with over the past 20 years discuss their use of alcohol and drugs and its role in their seroconversion. Furthermore, many individuals who test positive for HIV turn to alcohol and drugs to cope with their diagnosis and fears and also engage in unprotected sex with others. It is a vicious sad circle.
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