Recent reviews of the literature indicate that alcohol is "adding fuel to the fire" of the HIV epidemic in sub- Saharan Africa due to its association with higher frequency of unprotected sex, lower adherence to antiretroviral treatment (ART), and consequently increased cumulative risk of onward transmission among HIV- positives. Uganda has one of the highest levels of per capita alcohol consumption in the world combined with a generalized HIV epidemic that affects approximately 6.5% of the adult population. The research proposed in this application examines the co-occurrence of alcohol use and unprotected sex among HIV+ Ugandan adults in order to develop a behavioral HIV prevention intervention targeting alcohol use that has the potential to ameliorate these co-occurring public health burdens.
Alcohol consumption in sub-Saharan Africa is a major public health concern that has received insufficient attention. The World Health Organization (WHO) estimates that although 70% of adults in sub- Saharan Africa are self-reported abstainers, the 30% who report consuming alcohol have among the highest levels of per capita consumption in the world. The heavy, episodic pattern of consumption that characterizes alcohol use in this region is associated with many negative HIV-related consequences including an increased likelihood of engaging in high risk behavior and a higher cumulative risk of onward transmission among sero-discordant partnerships. The intersection of these two epidemics underscores the urgency of increased research attention and intervention development. Research aimed at understanding how, and in what contexts, alcohol is most likely to result in high risk behavior in sub-Saharan Africa has been dominated by cross-sectional study designs that fail to capture the temporal relationship between alcohol consumption and its subsequent effect on risky behavior. The overall objective of this K01 Career Development Award is to achieve a better understanding of the relationship between event-level alcohol use and high risk behavior among HIV-positive (HIV+) African adults using cell- phone based, daily data collection techniques. The long-term goal of this application is to develop a behavioral HIV prevention intervention targeting alcohol use that can be implemented with HIV+ adults in sub-Saharan Africa and to provide the principal investigator, Dr. Woolf-King, with the skills and training necessary to successfully develop and test the efficacy of this intervention. Dr. Woolf-King is trained as a clinical psychologist with expertise in the use of laboratory-based, alcohol administration studies for determining the causal effect of event-level alcohol intoxication on the behavior of high risk men, college students, and African American adults. Dr. Woolf-King's long-term goal is to become a successful NIH-funded behavioral scientist with international expertise in alcohol's relationship to HIV. She has proposed a combination of didactic and applied research activities, under the mentorship of experts in the field, to provide her with the following skills necessary to accomplish this goal: (1) the design and analysis of longitudinal event-level research, (2) the use of biological data to estimate the accuracy of self-reported behavior, and (3) the development of behavioral HIV prevention intervention development. The proposed research consists of three specific aims and will be conducted in conjunction with Dr. Judy Hahn's ongoing NIH/NIAAA-funded (R01 and U01) cohorts of ART-naive, HIV+ African adults. Aim 1: Enhance our understanding of the event-level association between alcohol consumption and high risk behavior among HIV+ adults in Africa. We will accomplish this aim by: (a) conducting a prospective, event-level study with 100 HIV+ men (n= 50) and women (n =50) who report consuming alcohol in the last three months, (b) assessing the situational and relationship-level aspects of high risk events over a six- week period using interactive voice response (IVR) technology, and (c) using a theory-guided conceptual framework and advanced multilevel modeling to determine the extent to which individual, situational, and relationship-leve variables work together to explain the association between alcohol use and risky behavior. Aim 2: Estimate the accuracy of self-reported high risk behavior using biological data.. We will accomplish this aim by: (a) using a qualitative test for Prostate Specific Antigen (PSA), an indicator of recent (i.e., last 24 hours) semen exposure that can be reliably recovered from self-administered vaginal swabs, (b) comparing these PSA tests to self-report of risky behavior in the last 24 hours, and (c) using women with positive PSA tests to estimate self-report bias. Aim 3: Develop a plan for an intervention targeting alcohol use and high risk behavior that incorporates event-level data collected with IVR. We will accomplish this aim by: (a) conducting brief qualitative exit interviews with a sub-group of participants in the event-level study to assess the feasibility and acceptability of IVR as a self-monitoring device, (b) using an existing alcohol use risk reduction intervention to guide us in translating these self-monitoring data into personalized feedback that highlights the within-person variability in alcohol's relationship to risky behavior and (c) ultimately developing a new brief, patient-centered HIV risk-reduction intervention for high risk, alcohol consuming HIV+ adults in Africa. These research activities will culminate in the submission of an R34 as part of NIAAA's Behavioral and Integrative Treatment Development Program, during the 4th year of the K-award period, to further develop and pilot test the intervention that emerges from these specific aims. This will lead directly to the submission of an R01 to conduct a full Randomized Controlled Trial (RCT) of the intervention to determine its efficacy. The career development and research activities proposed in this K01 application will lay the foundation for Dr. Woolf-King's career as successful, independent, NIH-funded behavioral scientist with the skills to conduct a wide-range of research on alcohol's relationship to the HIV epidemic, both domestically and internationally.