This project aims to conduct the formative research to develop and pilot test a combined economic and relationship-strengthening intervention for HIV-affected couples with a heavy alcohol user, with the goal of reducing heavy alcohol use and improving adherence to antiretroviral therapy. After conducting the formative work to adapt and integrate two evidence-based interventions and to develop the study protocol and procedures, we will conduct a pilot study to evaluate the feasibility and acceptability of the combined intervention. The combined intervention will be compared to an enhanced standard of care control, consisting of regular HIV clinical care plus brief unstructured advice on alcohol use.
Heavy alcohol use has deleterious effects on antiretroviral therapy (ART) adherence and HIV clinical outcomes, and indirectly affects health by damaging the couple relationships needed for social support, economic survival, and well-being. Our recent mixed-methods study with HIV-affected couples in Malawi found that 50% of alcohol drinkers met criteria for heavy alcohol use. Male peer pressure, desires for friendship, and coping with poverty were common barriers to reducing consumption. Men expressed the need for an economic or peer-based intervention to reduce alcohol use, and women were very concerned with how alcohol drains family financial resources and causes conflict in the couple. Yet, there are currently no interventions that have jointly addressed the economic and relationship context of drinking in sub-Saharan Africa. In other populations, standalone relationship-strengthening and economic-strengthening interventions have been effective at addressing alcohol use, engagement in HIV care, adherence to ART, household economics, and mental health. However, such interventions have not been designed for HIV-positive couples who use alcohol, nor have they been combined into a single intervention with potentially synergistic effects. We propose to develop and pilot test a combined economic and relationship-strengthening intervention to redirect funds spent on alcohol into financial investments (e.g., education, income-generating business) and to improve couple relationships and adherence to ART. We posit that engaging couples to work together on alcohol use and financial goals—equipped with financial, communication, and problem-solving skills—will decrease alcohol use, and improve relationship dynamics and adherence to ART. The specific aims are: (1) to adapt and integrate two proven interventions, Suubi and Uthando Lwethu, into a combined intervention for HIV-affected couples with a heavy alcohol user (to be called Malambe); (2) to develop and pilot test the study procedures to evaluate Malambe; and (3) to assess the feasibility and acceptability of Malambe through a pilot study. Using the ADAPT-ITT method, we will develop a draft of the intervention manual and conduct five focus group discussions with couples and key stakeholders to obtain input on the intervention. For the pilot study, we will enroll 80 HIV-affected couples with a heavy alcohol user and randomize the couples to either Malambe or the comparison arm (regular HIV care plus brief advice on alcohol use). We will conduct qualitative interviews with a subset of 20 couples to contextualize feasibility and acceptability data, and then will analyze the mixed- methods feasibility and acceptability data to refine intervention and procedures for a future trial. Alcohol interventions for PLHIV in limited-resource settings may register large impacts by targeting the dyadic and economic context of heavy alcohol use. Our long-term goal is to produce a culturally-grounded, sustainable, and evidence-based intervention to reduce heavy alcohol use and its harms on couple relationships, household poverty, and HIV health outcomes.