HIV and AIDS

Few HIV prevention programs are addressing the link between alcohol consumption and sexual behaviors that put people at risk of HIV. ICRW is attempting to fill this gap with a new pilot project in Namibia.

Although a growing body of research shows a link between high alcohol use and a greater risk of HIV infection in developing countries, few prevention programs – save for a handful in sub-Saharan Africa and India – are addressing that association. It’s a complex connection to tackle, one in which gender and cultural norms must be considered, say experts from the International Center for Research on Women (ICRW).

Epidemiologists and social scientists have found a clear pattern of heavy drinking in countries with high rates of HIV – particularly in eastern and southern Africa. Studies show that drinking alcohol before sex or being intoxicated during sex is directly tied to contracting HIV; under the influence, people are more likely to engage in unprotected sex, sleep with more than one person and pay for sex.

“This link had not been recognized or acted on until recently, in the past decade,” said Katherine Fritz, who directs ICRW’s research on HIV and AIDS. “And because it’s still not clear exactly how to intervene – whether through policy or programs or both – the science behind preventing alcohol-related HIV is still emerging.”

“It’s sort of the elephant in the room, especially in sub-Saharan Africa, home to 60 percent of people living with AIDS worldwide,” Fritz said.

Kabila, part of Katutura, is a relatively new, informal settlement on the outskirts of Namibia’s capital city. Photo © Robyne Hayes/ICRW

ICRW is attempting to fill this gap by designing a 2½-year pilot project that will work with bar owners, servers and patrons to moderate drinking and curb the frequency of risky sex in Kabila, Namibia. The relatively new, informal settlement is part of Katutura, a low-income area on the outskirts of Namibia’s capital city, Windhoek, and a former township where black Namibians were forced to live during apartheid. Kabila is one of Katutura’s fastest-growing neighborhoods, largely due to migration from northern Namibia. Its exact population is not documented.

ICRW’s preliminary research aimed to better understand the lives and sexual behavior of men and women in Kabila as well as how the production, sale and consumption of alcohol fit into the social and economic fabric of the community. Experts found that the majority of families who settle in Kabila make a living by brewing beer or selling alcohol; it’s one of the few reliable sources of income. And opportunities to imbibe are abundant: ICRW found 265 bars in a 2.5-mile area, most of which operate out of people’s homes.

The informal, home-based bars – which also sell snack food, soap and other items – are primarily managed by men. Women often work as bartenders for little pay, or earn an income by selling fruit, meat and other perishable foods near the bars. Both men and women take part in what the bars have to offer; many told ICRW researchers that drinking helps them cope with boredom and the stresses of poverty.

Women often work as bartenders for little pay, or earn an income by selling fruit, meat and other perishable foods near the bars. Photo © Robyne Hayes/ICRW

ICRW will use its early findings to launch the pilot project this summer, with funding from the United States Agency for International Development’s (USAID) AIDSTAR-One program. ICRW will implement the Kabila effort in collaboration with the Society for Family Health in Namibia.

The project ultimately aims to help bar owners create an environment that promotes less high-risk sexual behavior among patrons. Experts suggest this will be possible through steps such as encouraging earlier closing hours and serving non-alcoholic beverages in addition to alcoholic ones. The program will also focus on mobilizing Kabila residents to examine how heavy drinking is affecting their community’s well-being and help them develop strategies to address it. In the end, experts hope that by altering the overall community environment, men and women will be more likely to make better decisions about their sexual behavior, and in turn, reduce their vulnerability to HIV.

“We’re testing a new approach; instead of targeting individuals, we’re engaging an entire community to address alcohol-related HIV risk,” said Amy Gregowski, an ICRW public health specialist who leads the Namibia project. “We’re analyzing HIV within the larger context of life in Kabila, and hoping to tackle people’s vulnerability to sexually transmitted infections in a more holistic way.”

Related blog: Environmental Influences

Gillian Gaynair is ICRW’s writer/editor.

It was early December, the day after World AIDS Day, 2010. I was back in Beijing for the first time in 23 years, standing outside the entrance to the Great Hall of the People on Tiananmen Square. I had an official invitation in hand to a high-level consultation on China’s national response to the AIDS epidemic, which is increasingly affecting women and girls.  

My mind toggled back to my last visit to China in 1987, when the government had just decreed mandatory AIDS testing for foreign residents. At that point in the epidemic, Chinese public health authorities said the source of the HIV threat was outside of China and they relied on China’s strong heteronormative culture to protect its citizens from sexual transmission of AIDS. The government figured they could contain the threat by focusing on foreigners and a very small number of gay Chinese men – a highly stigmatized group in China, as elsewhere. Back then, AIDS was viewed predominantly as a “gay man’s disease.”

Fast forward to December 2010. Reports released by the Chinese government and UNAIDS on World AIDS Day indicated that HIV and AIDS in China have evolved much like other epidemics in Asia, transforming from one concentrated among groups most at risk for HIV, such as injection drug users, to a broader epidemic among the general population. Sexual transmission is now the primary mode of HIV infection in China: As of 2009, heterosexual transmission accounted for 42 percent of new cases and homosexual transmission for 32 percent. And emerging data show that patterns of risk are becoming increasingly complex, in part due to the rapidly escalating diffusion of HIV among men who have sex with men as well as with women. At the Great Hall event, government officials acknowledged the need to understand and address the complexity of China’s national epidemic.

So where does China go from here? As Chinese public health experts develop their national AIDS strategy, they may want to pay close attention to two related elements: the evolving nature of women’s vulnerability to HIV and the impact of stigma and discrimination in complicating an already complex situation.

Focusing on women is essential. Recent data indicate that a growing proportion of Chinese women are being infected with HIV through sexual transmission, from 30 percent in 2000 to 74 percent in 2009. HIV transmission within marriage now poses a credible threat to many Chinese women, particularly those wedded to men most at risk for HIV, such as migrant workers, men who have sex with men and injection drug users. Public health authorities’ efforts will go farther if they understand the role of power relationships between women and men, and how that can contribute to women’s vulnerability to HIV. They may also want to consider that social dynamics and sexual practices are fluid from setting to setting, and interact differently under different environmental conditions. This creates a multitude of “local” epidemics within China’s national epidemic – each requiring a well-tailored response. 

This, I believe, includes working with civil society to reduce stigmatization of men who have sex with men and increase services available to them. As I talked with people leading AIDS programming for corporations, multi-laterals and foundations, it became apparent that very little is known about this community of men in China. Service providers are perplexed about how to reach this population and their sexual partners, both male and female, with information and services. We’ve studied HIV-related stigma extensively at ICRW, and our research in Cambodia and across the world may be useful in designing effective programs.

It’s critical that China’s next national AIDS plan, which is currently under development, lays the groundwork for an AIDS-free society. And I’m confident that the country has the ability to do so through policy, research and programs that tackle the underlying causes of women’s and men’s vulnerability to HIV.

Sarah Degnan Kambou is president of ICRW.