Alcohol use and sexual risk behaviour among men and women in inner-city Johannesburg, South Africa

Alcohol misuse is frequently cited as being one of the key factors underlying the remarkable vulnerability to HIV infection in many parts of sub-Saharan Africa, especially in urban settings [1, 2]. Across the sub-continent, alcohol has been linked with HIV risk via unprotected sex [3], multiple sexual partnerships [4‐6], transactional sex [4], and physical and sexual violence [7, 8]. A meta-analysis of 20 African studies showed that both male and female drinkers were about 1.5 fold more likely to be HIV-infected than non-drinkers [9]. This is consistent with global findings [10].

Associations between drinking and sexual behaviour are biologically plausible. Alcohol has psychoactive effects which can result in poor judgement, dampened reasoning skills and a reduction in one’s sense of responsibility [11]. Alcohol alters the brain’s gamma-aminobutyric acid receptors and changes the body’s serotonin levels, resulting in disinhibition – reducing anxiety about the consequences of one’s actions [12]. Assertions about alcohol and sexual behaviour causality are strengthened by studies demonstrating links between drinking contexts and the likelihood of sexual risk behaviours [13]. Meta-analyses have noted that certain drinking contexts, such as bars and other public spaces, portend unprotected sex [14]. Importantly, associations between alcohol and unsafe sex have been demonstrated in event-level data, which assesses alcohol use at the time of specific sexual events [15‐17]. Taking all the evidence together, it is clear that associations between alcohol use and unsafe sexual behaviour (and consequent risk for HIV infection) are now well documented [18‐21]. Key questions remain unanswered, however. Firstly, a better understanding is needed of the mediating or confounding effects of personality factors such as sensation seeking and impulsivity on the alcohol and sex relationship [22‐24]. Secondly, additional evidence is needed across different settings to better elucidate which dimensions of alcohol use influence sexual behaviour, and the extent to which being male or female alters the relative effects of these different dimensions. These dimensions include total volume consumed, drinking patterns such as heavy episodic drinking, and alcohol abuse or dependence [25]. This knowledge will enable alcohol control strategies and specific interventions to reduce the harms of alcohol to be tailored to the particular aspects of alcohol use which are most harmful in each setting.

Levels of alcohol consumption and prevalence of HIV in South Africa rank among the highest in the world [26]. One-third of South Africans report heavy, episodic drinking [27] and rates are even higher in patients attending clinical services[28]. HIV prevalence in urban informal areas in the country is almost 20% [29]. HIV incidence is especially concerning among young migrants in urban and peri-urban settings [29], and alcohol problems pervade these communities, both historically and in more recent times [30‐34]. These populations also face challenges in accessing health services and other positive determinants of health including housing and employment [35]. Linkages between alcohol and sexual behaviours in these marginalized groups have, however, not been examined in sufficient detail.

We analysed data from a population-based study among men living in hostels and women inhabiting adjacent informal settlements in inner-city Johannesburg, South Africa, to determine the extent to which alcohol use influences sexual behaviours, and to identify which features of alcohol use have most impact in this population. Data on this population are especially important as the majority are internal migrants (from other parts of South Africa), a key group in the South African HIV epidemic [36, 37].

This study among men and women who are mostly internal migrants and at high risk for HIV [29], showed that alcohol use is associated with unsafe sexual behaviours in this population, though patterns of associations differ between genders. Being drunk in the past week was the strongest predictor of perpetrating sexual violence in men and of unsafe sexual behaviours more generally. On the whole, alcohol consumption was even more strongly associated with sexual risk behaviour among women than in men. Odds of the three unsafe sexual behaviours among females who currently drink were 3.2 to 5.9 fold higher than non-drinkers, while the corresponding odds were only 1.6 to 2.3 in their male peers. Clearly, this population, with notable levels of socio-economic vulnerability, is marked by very high levels of alcohol and sexual risk behaviours.

As in other studies in South Africa [46, 47], considerably fewer women than men drink, but women who do have especially harmful drinking patterns, which are often characterised by frequent heavy drinking episodes. Moreover, the high unemployment rate and considerably lower income among females may mean that those who drink have to depend on men for alcohol. Older men who had an income were much more likely to drink than younger unemployed men, and thus were probably able to purchase drinks for women and offer them transactional sex. The very strong association between transactional sex and alcohol use supports the assertion that alcohol is linked with sexual and other exchanges between men and women in this population [13, 48, 49]. In one study in Cape Town, South Africa, women with food insecurity had higher sexual risk behaviours than other women, with the associations between food and risky sex being fully mediated through women’s alcohol use [49]. Also, that drinking in females per se, rather than type of drinking as in men, was associated with sexual behaviour, suggests that being present in a drinking venue may be the key risk for women, rather than the degree to which they engage with alcohol [48]. In fact, few of the associations showed a dose-dependent relationship between alcohol use in men and sexual behaviour, though such associations have been demonstrated previously [50‐52].

The juxtaposition of single-sex male hostels and adjacent to informal settlements populated by impoverished women likely means that informal drinking venues in the areas (also called shebeens) play a key role in building social cohesion and cementing connections between these populations. Opportunities for drinking and for sexual encounters often co-exist in particular physical locations and the social dynamics that are generated in these locations [13, 53]. Patrons of drinking venues similar to those in the study site reported entering these places with an expectation of securing casual sex [3]. Sexual partners found at these drinking venues are more likely to have multiple sexual partners and to engage in unprotected sex than partners met elsewhere [54, 55]. These drinking venues are also often physically unsafe [38], perhaps accounting for the high levels of violence witnessed by drinkers in our study.

The linkages between alcohol use among men and using force to have sex, consistent with findings elsewhere [5, 56, 57], warrant discussion. Among males, both heavy alcohol use and sexual conquest may serve as markers of masculinity, which taken to their extremes can extend into sexual violence [58]. Drinking venues that encourage heavy alcohol consumption may thus propagate the social norms that underlie coercion and gender-based imbalances in sexual relationships [48]. Clearly, the links between alcohol and the perpetration of sexual violence, in itself, warrants stronger efforts to control alcohol use in South Africa.

The associations noted in the study between alcohol use and sexual behaviour may be accounted for by sex-related alcohol expectancies [59]. These are the anticipated effects of drinking alcohol, such as increased sexual pleasure and sexual riskiness, which then predict the likelihood of these consequences actually taking place [23, 60, 61]. Alcohol outcome expectancies were not studied in this population, but, potentially, the men and women who believed that alcohol would increase their sexual riskiness, may well have acted out those beliefs, which accounts for their high levels of concurrency and transactional sex. That we did not detect an association between alcohol and condom use might be due to the use of a weak indicator of condom use in the study, but also may reflect the mixed findings noted in other reports of associations between condom use and alcohol, with a few studies actually finding higher condom use among drinkers [51, 62]. Clearly, prospective data based on event–level indicators such as condom use while feeling drunk or after drinking are better suited to elucidating causal pathways between alcohol use and unsafe sex [63, 64].

Compared with the general population, the effects of alcohol on sexual behaviours are especially heightened among high-risk populations, such as sex workers and men who have sex with men [63]. This study suggests that these effects also hold true for high-risk male and female migrant groups in inner-city areas. More rigorous interventions, at both local and macro level, are needed to alleviate alcohol harms and to tackle the alcohol-HIV nexus, especially among already vulnerable groups. These should target the specific dimensions of alcohol use that are harmful (such as heavy episodic drinking in men), assist women who drink to do so in a safer manner and address the linkages between alcohol and sexual violence.