A significantly greater proportion of our study participants (pregnant and nonpregnant) recruited from the South African clinic were heavy/hazardous drinkers (35%) compared with women in Uganda (20%). This discrepancy is consistent with population-based data showing more prevalent heavy episodic drinking in South Africa (10.4%) compared with Uganda (3.4%).61 We did not explore the underpinnings of this finding; however, multifaceted cultural differences between countries, including social drinking norms, likely play a part.26,62 Future research should identify key factors associated with alcohol consumption in each country and, based on those data, develop alcohol reduction interventions tailored to local WLWH.
Depression was common and found in approximately 40% of all WLWH in the study. Depression was also significantly associated with alcohol use, such that WLWH with greater depressive symptoms were more likely to consume alcohol. These depression rates are consistent with the extant literature29,63 and suggestive of a pervasive problem among WLWH with potentially serious consequences. Indeed, a systematic review of the literature among persons living with HIV in sub-Saharan Africa showed that depressed patients were 55% less likely to demonstrate good adherence to ART compared to their nondepressed peers.64 Interventions that integrate depression treatment with alcohol-based counseling are needed. Furthermore, although pregnancy status was not a statistically significant effect modifier of the relationship between depression and alcohol use in our complete participant sample, we did find a significant association between incremental increases in depression and alcohol use among pregnant women only; it is possible that our relatively small sample size may have limited statistical power to detect a significant result in the full participant pool. Further research should attempt to confirm these findings in a larger sample.
Some methodological limitations to our study should be noted. First, PEth biomarker data reflect only sustained alcohol intake up to 3 weeks before blood draws,65 whereas the self-report measure captures alcohol use from the preceding 3 months. This mismatch may have affected the accuracy of our findings by underestimating the rate of under-reporting. Thus, our estimate of under-reporting in this sample of WLWH is likely a conservative one. Second, our findings may have differed had we prospectively measured alcohol intake in the months following ART initiation (ie, after study enrollment). Research suggests that individuals starting HIV treatment are often driven to reduce alcohol intake in the short-term; however, alcohol reduction efforts may wane over time, possibly in the absence of HIV- or ART-related physical symptoms.37 Indeed, an analysis of data from men and WLWH recruited for our parent study showed heavier alcohol use among individuals with higher CD4 levels in Uganda.66 Third, it is possible that PEth results among pregnant WLWH in our study were skewed because of intake of traditional fermented food and beverages with low, but detectable, alcohol content, and that are believed to render health benefits during pregnancy.14 Fourth, our participant sample had significantly higher (ie, better) CD4 levels and lower reported stigma compared with individuals from the parent study not included in these analyses. It is possible, therefore, that our data would not generalize to all persons living with HIV in the geographic regions sampled. Fifth, it is worth noting that some pregnant participants meeting criteria for perinatal alcohol consumption may have done so only before learning of their pregnancy. In other words, women who drank during pregnancy may not have been aware of their pregnancy. Those who have stopped drinking since learning they are pregnant may need counseling to avoid pregnancy during times of heavy alcohol use in the future, but may not need counseling during the current pregnancy. To maximize the efficacy of alcohol use interventions for pregnant WLWH, women should be asked about the timing of their drinking behaviors in relation to pregnancy recognition. Finally, the generalizability of our findings may be limited by the exclusion of individuals with intermediate stage disease, and the short average duration of time since HIV diagnosis (1.2 months) in our sample. The latter may have altered our results in a number of ways, namely inflating depression scores, and potentially decreasing alcohol use.37
Finally, although some data support the use of PEth to distinguish levels of drinking (eg, none versus heavy) among pregnant women,36,71 more studies are needed to confirm the validity of this method in the context of pregnancy (and the physiological changes associated with pregnancy, such as increased blood volume, which could affect test results).
Principal Investigators: Dr. J.E.H., Dr. Catherine Orrell, Dr. Norma Ware, Dr. Mwebesa Bosco Bwana, Dr. S.A., Dr. G.A., Hon. Dr. Elioda Tumwesigye, Dr. David Bangsberg.
Co-Investigators: Dr. Alexander C. Tsai, Dr. Mark Siedner, Dr. L.T.M., Dr. Ingrid Katz, Monique Wyatt.
Research Assistants: Nomakhaya April (RN), Alienah Mpahleni, Vivie Situlo, Speech Mzamo, Nomsa Ngwenya, Khosi Tshangela Regina Panda, Teboho Linda, Christine Atwiine, Sheila Moonight, Edna Tindimwebwa, Nicholas Mugisha, Peace Atwogeire, Dr. Vian Namana, Catherine Kyampaire, Gabriel Nuwagaba
Program Managers: Annet Kembabazi, Stephen Mugisha, Victoria Nanfuka, A.C., Nicky Kelly, Daphne Moralie, Kate Bell.
Data Managers: Dolphina Cogill, Justus Ashaba, Zoleka Xapa, Mathias Orimwesiga, Elly Tuhanamagyezi, Catherine Kyampaire
2. Kekwaletswe C, Morojele N, Nkosi S. Depression, Alcohol
Use and Adherence to Antiretroviral Therapy (ART). Poster presented at the: 6th International AIDS Society Conference on HIV
Pathogenesis and Treatment; July 17–20, 2011; Rome, Italy.
3. Myer L, Smit J, Le Roux L, et al. Common mental disorders among HIV
-infected individuals in South Africa
: prevalence, predictors, and validation of brief psychiatric rating scales. AIDS Patient Care STDS. 2008;22:147–158.
4. Nakimuli-Mpungu E, Munyaneza G. Depression, alcohol
abuse, and disclosure of HIV
serostatus among rural HIV
-positive individuals in western Uganda
. Neurobehav HIV
5. Olley BO, Seedat S, Stein DJ. Persistence of psychiatric disorders in a cohort of HIV
/AIDS patients in South Africa
: a 6-month follow-up study. J Psychosom Res. 2006;61:479–484.
6. Williams EC, Hahn JA, Saitz R, et al. Alcohol
use and human immunodeficiency virus (HIV
) infection: current knowledge, implications, and future directions. Alcohol
Clin Exp Res. 2016;40:2056–2072.
7. Donald KAM, Fernandez A, Claborn K, et al. The developmental effects of HIV
: a comparison of gestational outcomes among babies from South African communities with high prevalence of HIV
use. AIDS Res Ther. 2017;14:28.
8. May PA, Blankenship J, Marais AS, et al. Approaching the prevalence of the full spectrum of fetal alcohol
spectrum disorders in a South African population-based study. Alcohol
Clin Exp Res. 2013;37:818–830.
9. Russell B, Eaton L, Petersen-Williams P. Intersecting epidemics among pregnant women: alcohol
use, interpersonal violence, and HIV
infection in South Africa
. Curr HIVAIDS Rep. 2013;10:103–110.
10. Slyker JA, Patterson J, Ambler G, et al. Correlates and outcomes of preterm birth, low birth weight, and small for gestational age in HIV
-exposed uninfected infants. BMC Pregnancy
11. Turner AN, Tabbah S, Mwapasa V, et al. Severity of maternal HIV
-1 disease is associated with adverse birth outcomes in Malawian women: a cohort study. J Acquir Immune Defic Syndr. 2013;64:392–399.
12. Zash R, Jacobson DL, Diseko M, et al. Comparative safety of antiretroviral treatment regimens in pregnancy
. JAMA Pediatr. 2017;171:e172222.
13. Croxford J, Viljoen D. Alcohol
consumption by pregnant women in the Western Cape. S Afr Med J. 1999;89:962–965.
14. Namagembe I, Jackson LW, Zullo MD, et al. Consumption of alcoholic beverages among pregnant urban Ugandan women. Matern Child Health J. 2010;14:492–500.
15. Vythilingum B, Roos A, Faure SC, et al. Risk factors for substance use in pregnant women in South Africa
. S Afr Med J. 2012;102:851–854.
16. Desmond K, Milburn N, Richter L, et al. Alcohol
consumption among HIV
-positive pregnant women in KwaZulu-Natal, South Africa
: prevalence and correlates. Drug Alcohol
17. Brittain K, Remien RH, Phillips T, et al. Factors associated with alcohol
use prior to and during pregnancy
-infected pregnant women in Cape Town, South Africa
. Drug Alcohol
18. Sania A, Brittain K, Phillips TK, et al. Effect of alcohol
consumption and psychosocial stressors on preterm and small-for-gestational-age births in HIV
-infected women in South Africa
: a cohort study. BMJ Open. 2017;7:e014293.
19. Hahn JA, Bwana MB, Javors MA, et al. Biomarker testing to estimate under-reported heavy alcohol
consumption by persons with HIV
initiating ART in Uganda
. AIDS Behav. 2010;14:1265–1268.
20. Francis JM, Grosskurth H, Kapiga SH, et al. Ethanol concentration of traditional alcoholic beverages in northern Tanzania. J Stud Alcohol
21. Papas R, Gakinya B, Baliddawa J, et al. Ethical issues in a stage 1 cognitive-behavioral therapy feasibility study and trial to reduce alcohol
use among HIV
-infected outpatients in western Kenya. J Empir Res Hum Res Ethics. 2012;7:29–37.
22. Asiimwe SB, Fatch R, Emenyonu NI, et al. Comparison of traditional and novel self-report measures to an alcohol
biomarker for quantifying alcohol
consumption among HIV
-infected adults in sub-Saharan Africa. Alcohol
Clin Exp Res. 2015;39:1518–1527.
23. Muyindike W, Lloyd-Travaglini C, Fatch R, et al. Phosphatidylethanol
use among ART-naïve HIV
-infected persons who denied consumption in rural Uganda
. AIDS Care. 2017;29:1442–1447.
24. Bajunirwe F, Haberer JE, Boum Y II, et al. Comparison of self-reported alcohol
consumption to phosphatidylethanol
measurement among HIV
-infected patients initiating antiretroviral treatment in southwestern Uganda
. PLoS One. 2014;9:e113152.
26. Watt MH, Eaton LA, Choi KW, et al. “It's better for me to drink, at least the stress is going away”: perspectives on alcohol
use during pregnancy
among South African women attending drinking establishments. Soc Sci Med. 2014;116:119–125.
27. Sandelowski M, Barroso J. Motherhood in the context of maternal HIV
infection. Res Nurs Health. 2003;26:470–482.
28. Bernatsky S, Souza R, De Jong K. Mental health in HIV
-positive pregnant women: results from Angola. AIDS Care. 2007;19:674–676.
29. Kaida A, Matthews LT, Ashaba S, et al. Depression during pregnancy
and the postpartum among HIV
-infected women on antiretroviral therapy in Uganda
. J Acquir Immune Defic Syndr. 2014;67(suppl 4):S179–S187.
30. Ashaba S, Kaida A, Coleman JN, et al. Psychosocial challenges facing women living with HIV
during the perinatal period in rural Uganda
. PLoS One. 2017;12:e0176256.
31. Haberer JE, Bwana BM, Orrell C, et al. ART adherence and viral suppression are high among most non-pregnant individuals with early-stage, asymptomatic HIV
infection: An observational study from Uganda
and South Africa
. J Int AIDS Soc. 2019;22:e25232.
32. Bradley K, Bush K, Epler A, et al. Two brief alcohol
-screening tests from the alcohol
use disorders identification test (AUDIT): validation in a female veterans affairs patient population. Arch Intern Med. 2003;163:821–829.
33. Hahn JA, Anton RF, Javors MA. The formation, elimination, interpretation, and future research needs of phosphatidylethanol
for research studies and clinical practice. Alcohol
Clin Exp Res. 2016;40:2292–2295.
34. Jones J, Jones M, Plate C, et al. The detection of 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphoethanol in human dried blood spots. Anal Methods. 2011;3:1101–1106.
35. Hahn JA, Dobkin LM, Mayanja B, et al. Phosphatidylethanol
(PEth) as a biomarker of alcohol
consumption in HIV
positives in sub-Saharan Africa. Alcohol
Clin Exp Res. 2012;36:854–862.
36. Kwak H, Han J, Choi J, et al. Characterization of phosphatidylethanol
blood concentrations for screening alcohol
consumption in early pregnancy
. Clin Toxicol Phila. 2014;52:24–31.
37. Hahn J, Emenyonu N, Fatch R, et al. Declining and rebounding unhealthy alcohol
consumption during the first year of HIV
care in rural Uganda
, using phosphatidylethanol
to augment self-report. Addiction. 2016;111:272–279.
38. Derogatis LR, Lipman RS, Rickels K, et al. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19:1–15.
39. Martinez P, Andia I, Emenyonu N, et al. Alcohol
use, depressive symptoms and the receipt of antiretroviral therapy in southwest Uganda
. AIDS Behav. 2008;12:605–612.
40. Kalichman SC, Sikkema KJ, Somlai A. Assessing persons with human immunodeficiency virus (HIV
) infection using the Beck Depression Inventory: disease processes and other potential confounds. J Assess. 1995;64:86–100.
41. Kalichman SC, Rompa D, Cage M. Distinguishing between overlapping somatic symptoms of depression and HIV
disease in people living with HIV
-AIDS. J Nerv Ment Dis. 2000;188:662–670.
42. Bolton P, Wilk CM, Ndogoni L. Assessment of depression prevalence in rural Uganda
using symptom and function criteria. Soc Psychiatry Psychiatr Epidemiol. 2004;39:442–447.
43. Tsai AC, Scott JA, Hung KJ, et al. Reliability and validity of instruments for assessing perinatal depression in African settings: systematic review and meta-analysis. PLoS One. 2013;8:e82521.
44. Chorwe-Sungani G, Chipps J. Validity and utility of instruments for screening of depression in women attending antenatal clinics in Blantyre district in Malawi. Afr Fam Pr. 2018;60:114–120.
45. Kaaya S, Smith Fawzi M, Mbwambo J, et al. Validity of the Hopkins symptom checklist-25 amongst HIV
-positive pregnant women in Tanzania. Acta Psychiatr Scand. 2002;106:9–19.
46. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry. 1987;150:782–786.
47. Kakyo T, Muliira J, Mbalinda S, et al. Factors associated with depressive symptoms among postpartum mothers in a rural district in Uganda
. Midwifery. 2011;28:374–379.
48. Leung SS, Leung C, Lam TH, et al. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health (Oxf). 2011;33:292–301.
49. Ongeri L, Wanga V, Otieno P, et al. Demographic, psychosocial and clinical factors associated with postpartum depression in Kenyan women. BMC Psychiatry. 2018;18:318.
50. Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV
: psychometric assessment of the HIV
stigma scale. Res Nurs Health. 2001;24:518–529.
51. English L, Mugyenyi G, Nightingale I, et al. Prevalence of ethanol use among pregnant women in southwestern Uganda
. Matern Child Health J. 2016;20:2209–2215.
52. Behnke M, Smith VC. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics. 2013;131:e1009–e1024.
53. Jones KL. The effects of alcohol
on fetal development. Birth Defects Res C Embryo Today. 2011;93:3–11.
54. Polańska K, Jurewicz J, Hanke W. Smoking and alcohol
drinking during pregnancy
as the risk factors for poor child neurodevelopment—a review of epidemiological studies. Int J Occup Med Env Health. 2015;28:419–443.
55. Uthman OA, Nachega JB, Anderson J, et al. Timing of initiation of antiretroviral therapy and adverse pregnancy
outcomes: a systematic review and meta-analysis. Lancet HIV
56. Choi KW, Abler LA, Watt MH, et al. Drinking before and after pregnancy
recognition among South African women: the moderating role of traumatic experiences. BMC Pregnancy
57. Milligan K, Niccols A, Sword W, et al. Maternal substance use and integrated treatment programs for women with substance abuse issues and their children: a meta-analysis. Subst Abuse Treat Prev Pol. 2010;5:21.
58. Niccols A, Milligan K, Sword W, et al. Integrated programs for mothers with substance abuse issues: a systematic review of studies reporting on parenting outcomes. Harm Reduct J. 2012;9:14.
59. Sweeney PJ, Schwartz RM, Mattis NG, et al. The effect of integrating substance abuse treatment with prenatal care on birth outcome. J Perinatol. 2000;20:219–224.
60. Del Boca FK, Darkes J. The validity of self-reports of alcohol
consumption: state of the science and challenges for research. Addiction. 2003;98(suppl 2):1–12.
63. Yeji F, Klipstein-Grobusch K, Newell M, et al. Are social support and HIV
coping strategies associated with lower depression in adults on antiretroviral treatment? Evidence from rural KwaZulu-Natal, South Africa
. AIDS Care. 2014;26:1482–1489.
64. Nakimuli-Mpungu E, Bass JK, Alexandre P, et al. Depression, alcohol
use and adherence to antiretroviral therapy in Sub-Saharan Africa: a systematic review. AIDS Behav. 2012;16:2101–2118.
65. Wurst FM, Thon N, Yegles M, et al. Ethanol metabolites: their role in the assessment of alcohol
Clin Exp Res. 2015;39:2060–2072.
66. Magidson J, Fatch R, Orrell C, et al. Biomarker-measured unhealthy alcohol
use in relation to CD4 count among individuals starting ART in sub-Saharan Africa. AIDS Behav. 2019;23:1656–1667.
67. Pitpitan EV, Kalichman SC, Eaton LA, et al. Co-occurring psychosocial problems and HIV
risk among women attending drinking venues in a South African township: a syndemic approach. Ann Behav Med. 2013;45:153–162.
68. Wong M, Myer L, Zerbe A, et al. Depression, alcohol
use, and stigma in younger versus older HIV
-infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa
. Arch Womens Ment Health. 2017;20:149–159.
69. Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthr Q. 2003;17:423–441.
70. Rotheram-Borus MJ, le Roux IM, Tomlinson M, et al. Philani Plus (+): a mentor mother community health worker home visiting program to improve maternal and infants' outcomes. Prev Sci. 2011;12:372–388.
71. Bracero LA, Maxwell S, Nyanin A, et al. Improving screening for alcohol
consumption during pregnancy
. Reprod Toxicol. 2017;74:104–107.