Share this article on:

Alcohol Use and Associations With Biological Markers and Self-Reported Indicators of Unprotected Sex in Human Immunodeficiency Virus-Positive Female Sex Workers in Mombasa, Kenya

White, Darcy MPH; Wilson, Kate S. MPH, PhD; Masese, Linnet N. MBChB, MPH, PhD; Wanje, George MPH; Jaoko, Walter PhD; Mandaliya, Kishorchandra MBChB, FRCP; Richardson, Barbra A. PhD; Kinuthia, John MPH; Simoni, Jane M. PhD; McClelland, R. Scott MD, MPH

doi: 10.1097/OLQ.0000000000000502
Original Studies

Background: Studies of alcohol use and sexual behavior in African populations have primarily been cross-sectional, used nonvalidated measures of alcohol use, or relied on self-reported sexual risk endpoints. Few have focused on human immunodeficiency virus (HIV)-positive women.

Methods: Longitudinal data were collected from a cohort of HIV-positive Kenyan female sex workers. At enrollment and annual visits, participants were asked about past-year alcohol use using the Alcohol Use Disorders Identification Test (AUDIT). The primary endpoint was detection of prostate-specific antigen (PSA) in vaginal secretions at quarterly examinations. Associations between hazardous/harmful alcohol use (AUDIT score ≥7), PSA detection, and secondary measures of sexual risk were evaluated using generalized estimating equations with a log binomial regression model.

Results: A total of 405 women contributed 2750 vaginal samples over 606 person-years of follow-up. Hazardous/harmful alcohol use was reported at 16.6% of AUDIT assessments and was associated with higher risk of PSA detection (relative risk 1.50; 95% confidence interval, 1.11–2.01) relative to no alcohol use. This association was attenuated and no longer statistically significant, after adjusting for age, work venue, intimate partner violence, depression, and partnership status (adjusted relative risk, 1.13; 95% confidence interval, 0.82–1.56). In exploratory analyses, alcohol use was associated with self-report of unprotected sex and with sexually transmitted infection acquisition.

Conclusions: Although hazardous/harmful alcohol use was not associated with detection of PSA in adjusted analysis, associations with secondary outcomes suggest that alcohol use is at least a marker of sexual risk behavior.

From the *Department of Epidemiology, †Department of Global Health, ‡Department of Medicine, University of Washington, Seattle, WA; §University of Washington-Kenya Non-Governmental Organization, Nairobi, Kenya; ¶Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya; ‖Department of Biostatistics, University of Washington, Seattle, WA; **Division of Public Health Sciences, ††Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Research Center, Seattle, WA; ‡‡Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya; §§Department of Psychology, University of Washington, Seattle, WA; ¶¶Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya

Acknowledgements: The authors wish to acknowledge the invaluable contributions of the clinical, laboratory, and administrative staff in Mombasa and Nairobi, Kenya, and Seattle, Washington, USA. The authors thank the participants in this study for their time and commitment to the research.

Conflicts of Interest and Sources of Funding.

R.S.M. currently receives research funding from Hologic Corporation, paid to the University of Washington, for a validation study of collection methods for cervical cancer screening. J.M.S. has received payment for lectures, travel, accommodations, and meeting expenses from the University of Wisconsin. B.A.R. holds consultancies as a Data Safety and Monitoring Board member with Theratechnologies, Inc. and Tobira Therpeutics, Inc. B.A.R. also provides expert testimony for Pepper Hamilton, LLC. D.W. held shares of stock in Bristol-Myers Squibb. For the remaining authors, no conflicts of interest were declared.

This research was funded by a grant from the National Institutes of Health (R01HD072617). Infrastructure and logistical support for the Mombasa research site was provided by the University of Washington’s Center for AIDS Research (CFAR), an NIH-funded program (P30 AI027757) which is supported by the following research centers: NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NCCAM. D.W. was supported by an NIH T32 grant (T32 AI07140). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Correspondence: Darcy White, MPH, Department of Epidemiology, University of Washington School of Public Health, Box 357236, Seattle, WA 98195. E-mail:

Received for publication April 1, 2016, and accepted June 12, 2016.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

© Copyright 2016 American Sexually Transmitted Diseases Association