Perceived benefits and negative consequences of alcohol consumption in women living with HIV: a qualitative study

We obtained qualitative data using focus groups [23], and used a conventional content analysis approach for data analysis. Conventional content analysis is appropriate when investigators seek to obtain information without imposing preconceived themes [24].

We sought to include a range of women affected by alcohol and HIV infection in three locations where we were planning to conduct an alcohol intervention study. We first conducted two focus groups in Chicago in 2007. Focus group participants were recruited from the ongoing Women’s Interagency HIV Study (WIHS) [25], a cohort study of women living with HIV as well as women without HIV who had similar demographic and socioeconomic characteristics. At that time, we did not want to disclose our participants’ HIV status by their participation in focus groups limited to HIV-positive women, so we decided to include a few HIV-negative women within the focus groups to maintain anonymity. The two focus groups included a total of 14 women; all were African-American and 3 were HIV-negative. Neither the focus group interviewer nor the research coders could determine which participants were HIV-positive or negative. In 2009, we chose to conduct focus groups at two additional sites that would be part of a clinical trial, and the site leaders recommended separate groups for HIV-positive women only. In Washington DC, 4 HIV-positive women from the WIHS cohort who reported current drinking participated in one group, and in Jacksonville, FL, 6 HIV-positive women with current or past drinking were recruited from an academic medical center and from members of a local HIV research Community Advisory Board.

Prior to data collection, we received approval from Institutional Review Boards at the University of Florida (Jacksonville), Rush University (Chicago), and Georgetown University (Washington DC). Written informed consent was obtained at the Washington DC site, whereas verbal consent was obtained from participants in Jacksonville and Chicago. All participants were informed that the objective of the focus groups was to learn more about alcohol and HIV infection in women.

We created a list of semi-structured, open-ended questions to enhance discussion (Table 1). The questions sought to identify both benefits and harms related to drinking, reasons for drinking and reasons to stop drinking, consequences of drinking (including sexual consequences), and perceived benefits and harms of alcohol as it relates to HIV infection. By asking about both benefits and harms related to drinking, we sought to understand factors that may influence women’s “decisional balance” when contemplating a change in behavior such as alcohol consumption. After the initial focus groups were held in Chicago, and based on input from an HIV Community Advisory Board in Jacksonville, we added additional prompts to learn more about past drinking experiences, influences of friends and family, to probe more specifically about the connections between drinking, pain, and medication adherence, and to assess interest in an upcoming clinical trial related to drinking (Table 1).

Focus groups were conducted by a primary facilitator, who reviewed the consent document, answered questions, reaffirmed that participation was voluntary, and reminded persons not to make any statements that would identify themselves or another individual. In Chicago and Washington DC, information about participants’ demographic characteristics and drinking history was obtained from their most recent WIHS cohort data, whereas in Jacksonville we only had information about race and age. The focus groups were recorded and transcribed by a professional transcriptionist.

Data from four focus groups including 24 women were included for analysis. Two members of the research team conducted an initial coding analysis of the transcriptions, using an inductive, exploratory approach to identify themes related to reasons for drinking and consequences of drinking [24, 26]. Transcripts were color-coded independently, and the team met weekly to discuss emergent codes/categories and resolve discrepancies. A third researcher independently coded transcripts and identified themes using the same process. The three coders discussed their findings together, and also with an ongoing Qualitative Data Analysis Workgroup, an interdisciplinary team of researchers within and outside of the University of Florida. After this input, the themes were grouped within the context of the biopsychosocial model [21, 22] and exemplary quotes were identified for each theme. Although we could identify different persons’ responses in the transcripts, the focus groups were intended to be as anonymous as possible. Therefore, we did not prospectively plan to link individual participant information to the transcripts and did not maintain any code that would allow us to link specific statements to specific characteristics of individuals. Similarly, we did not attempt to compare themes according to geographic location due to the limited numbers of women from each location.

Biological reasons for drinking included addiction, positive physical sensations, and drinking to relieve pain. For example, several participants indicated that they could not stop drinking once they started. Some noted that they liked the way they felt when drinking. Drinking in response to pain was mentioned by multiple participants, and the pain could have represented true physical pain, emotional pain, or a combination.

The next day, I don’t feel good, my stomach acting up, and I’d say Lord, why I drink so much, but then I’d turn around and drink again. And I say Lord I got to stop drinking, but turn around and start drinking again. You know and that’s not a good feeling, you know, knowing that you’re killing yourself.

I like feeling drunk. I like feeling high. It’s like it wasn’t no feeling that made me feel any better but to drink. And nothing that nobody could say to me, oh just get over it and you’ll be ok. I didn’t want to hear that.

You drink to take the pain away.

Many women drank in order to feel control over their surroundings, and several noted the use of alcohol to help them feel more courageous. Women also frequently noted use of alcohol as a type of self-management of their mood, to cope with stress or life issues, and to cover up their low self-esteem.

You know addicts are control freaks even when we’re drunk, we are in control even if we control by not participating. Like for me, a long time ago, when I wanted to control, I would just withdraw, because that meant everybody in the room would be like, what’s wrong with her. Why she not, you know, so I had that sort of control.

It’s Dr. Jekyll and Mr. Hyde, that’s what I call it because when you’re not drinkin’ you timid, and then as soon as you start drinkin’, you get more vocal, and then you say the same thing over and over, you understand, you understand, you understand, you see what I mean. You say it over and over again, over and over again. And you know and also that alcohol gives you false courage, it gives you false courage. And then you crash.

You can be in denial and can’t face what’s going on, you just want to erase it. You don’t want to think about it. And the bottle just feels like it’s your friend, that’s what you’re coping with. That’s your friend. You don’t want to face reality; you just want to be somewhere else.

There are quite a few ladies that I have talked to that stay drunk so I don’t have to deal with this issue and you see them day after day because they have not come to grip with what’s going on about their HIV, or whatever problem it is that they’re going through.

I was, there wasn’t much to like about myself. I didn’t like, do you want me to be specific? I didn’t like the circumstances I was in, I didn’t like my living conditions, I didn’t like how I was carrying myself on as a female, I didn’t like, I didn’t like nothing about my existence. My total existence was fairly displeasing to me. And sometimes it (alcohol) can bring me out of my shell sometimes; you know, compensating for all those feelings of inferiority that were pretty much inherent.

Many women reported drinking for social reasons, such as being in the company of someone drinking, having fun, or being in places where people were drinking. Family and peer influences were also commonly cited, and some women noted how they started drinking at an early age or adolescence due to family exposures or peer influences.

We go to bars or at each others’ house to start. Same places; just different scenarios. Just want to party and have fun.

Before I started hanging out with my friends, yes. Because I was very anti-drinking. They would drink, and I knew that they drank, but I had martial arts and, I had martial arts 6 days a week, so I was always busy. And sometimes on Sunday I had a tournament, so I wasn’t partying with them, but I had gotten hurt in martial arts, so for about 2 or 3 months I stopped and started to socialize with my friends a little bit more, and went to a party and that’s where I started the drinking.

My mom considered herself to be a functioning alcoholic. And I’ve never really seen her too many days when she wasn’t drunk or high, you know, that’s what she did every day. She woke up, she didn’t have a water, she drunk beer like that was what she had. So it was normal for me, I guess, my everyday life.

Participants identified several biological consequences of drinking, including some more immediate consequences (e.g. black-outs, hangovers, physical assaults). Several women noted that they did not take good care of themselves when drinking. Many women recalled severe consequences of drinking from their past. When discussing how their drinking impacted their health, the participants focused on broad issues rather than HIV-specific issues, unless they were specifically asked about HIV infection.

Alcohol interferes with their HAART medication and that could be really damaging, it could make them become resistant to medication, it’s not good, it’s not good to gamble.

I had drunk so much at one time that I had a pancreatic ulcer I didn’t care about that ulcer I had. I was tripping, I was so sick. It was like, I walked like a square block, each square that I walked past on the block, it seemed like I was gagging and throwing up. I went to the hospital, and the doctor did like that and I about jumped off the bed. He said, you got ulcers, no more drinking for you. And people don’t realize that, it can eat up your liver you know, you just don’t know.

You’re really not going to take care of yourself, you know. I mean they’re incompatible and an alcoholic doesn’t take care, of course they can drink and like, you know have a drink once a year. Even a person with HIV can do that, but that person with a problem drinking, problem drug use, if I’m using drugs, everything else is completely out the window. I mean my health, my medication, any responsibility that I have, I don’t even eat. I’m doing good to keep myself hydrated at all. Everything goes.

If you have HIV and you drink, don’t drink if you love life, continue to take your medicine. Because that’s double jeopardy, the medicine and the alcohol on your liver, that’s double jeopardy.

Women noted several psychological consequences of drinking, including effects on emotions, decisions, and behaviors. Specific psychological consequences included out of control behavior, criminal activity, bad choices, and risky sexual behavior. Some women noted that they had different consequences from different types of alcoholic beverages, with liquor having a different effect than beer, for example.

Because you know you get drunk and you want to go do Sally husband, and Sally don’t play.

I stopped for like a year and I started back gradually drinking beer and everything. Now I like to drink a lot of beer, I would drink liquor if somebody pissed me off, but I try to give people fair warning, if I start drinking you ain’t going to like me, that keep people back off me. Let me go ahead and do my thing. Now really, like I said, I just drink beer, that’s every day, every night.

I woke up and didn’t know where I was and I was in the bed with a guy that I didn’t know.

Women identified numerous social consequences of drinking. For example, some women discussed how drinking aversely affected their relationships with their family or their friends, or how they were later embarrassed about things they had done or said. Also, several women identified social consequences related to breaking the law or societal rules.

Your job, you neglect your family, you can have your children taken away from you, and all kinds of things.

Yes, because it was causing more problems at the time. I lost everything. I lost a job, relationship, respect, respect from family, I lost everything, and at the time, yes, certainly, I would have done it. And even when I went to AA, I’m sitting around people where I’m like, wow, my life isn’t that bad, but even realizing it, it was, I had hit bottom, and that’s where I sat.

When I drink, I break out in handcuffs. That’s what happens when I drink…(When you say ‘break out in handcuffs’ what do you mean?) I mean I’m pretty much going to do something stupid, and I’m going to end up in jail. I just lose complete control of myself. It’s going to be either other drugs and then I’m going to be in real trouble.

But socially, I will drink a lot when I’m you know, like I said, I’ve gotten a couple DWIs, blew a .12 and really I didn’t feel like I was drunk, you know… I almost got a third one, one time, and that time I really was drunk because I was sick, and they didn’t give me a DWI, thank God that time.