By Arvinder S Sood
3rd Year medical student, Imperial College London
Despite repeated health warnings from doctors and health ministers, the global health burden of alcohol consumption has shown no signs of slowing. The economic and health implications posed by alcohol are often overlooked in favour of its social benefits, and it is precisely this fact that makes alcohol such a dangerous commodity. The prevalence of alcohol-related chronic diseases and injury are well documented. Between 1999 and 2005 there was a 41% increase in alcohol-related mortality and in the last 30 years, mortality has risen over 450% in the UK1.With this in mind, society cannot underestimate the social complexity of alcohol as a strong risk factor for disease transmission, such as HIV/AIDS, especially in the context of global health.
Recent studies have highlighted the correlation between alcohol consumption and HIV sero-positivity2. A multi-dimensional approach is needed to explain how alcohol acts as a risk factor. However, we must first understand the interdependent relationship between alcohol consumption and HIV transmission. Those who consume excessive amounts of alcohol are more likely than the general population to contract HIV. Equally, those who are HIV-positive are more likely to misuse alcohol during their lifetime3. HIV can be transmitted via several routes, but arguably the two most important ones are high-risk sexual behaviour and injecting drugs, both of which are augmented by alcohol use. Research has proven that a history of heavy alcohol use increases the tendency for a particular individual to engage in high-risk sexual activities, including multiple sex partners, unprotected intercourse, sex with high-risk partners (e.g. injection drug users, prostitutes) and the exchange of sex for money or drugs4, 5-7. The effects of alcohol are known to have profound effects on the mental state, such as impairment of judgement and consciousness. More specifically, alcohol is said to act directly on the brain to reduce inhibitions and reduce risk awareness8. Excessive alcohol use can therefore put the individual in a very vulnerable position – a position of irrational thinking and poor decision-making.
This begs the question as to why alcohol is so commonly abused. The reasoning is not so simple. In many societies, alcohol-use is deep-rooted in social and cultural beliefs – it is recognised as a symbol of masculinity and often viewed as a way of life. According to some critics, the media should be held responsible for promoting advertisements that glamorise alcohol. Furthermore, there are certain privileges attached to alcohol, for instance the pardoning of socially unacceptable behaviour if proven to be under the influence of alcohol. McKirnan and colleagues suggested this practice may be especially common among homosexual men21. Observations have been made that men who drink prior to or during homosexual contact are more likely to part-take in high-risk sexual behaviour than heterosexuals5, 9-11.
To further our discussion, reliable studies have shown that people who strongly believe that alcohol increases sexual arousal and performance are more likely to engage in risky sex after drinking12-15. This is one of several pieces of evidence suggesting that alcohol is a strong risk factor in increasing HIV transmission. What is not yet clear, however, is the definitive science underpinning this association. Preliminary investigations have provided an insight into how alcohol affects the course of HIV transmission. One theory put forward is that alcohol decreases the immune response to HIV infection, allowing the virus to overcome the host’s defence mechanisms. Emerging laboratory evidence suggests that alcohol may alter cellular structures to increase both the HIV infectivity and vulnerability of cells22. In addition, increased viral replication and progression of AIDS related illness are enhanced by alcohol consumption20.
The burden of alcohol is exacerbated by its impact on the medical aspects of AIDS. Evidence has revealed that alcohol increases the susceptibility and severity of opportunistic infections that are more prevalent in people with AIDS16. Infections common to both alcohol and AIDS include tuberculosis, pneumonia caused by the bacterium Streptococcus pneumoniae, and viral hepatitis C which is the principal cause of death amongst the HIV-positive population16-17. Advances in medicine have led to the development of highly active antiretroviral therapy (HAART), a collection of powerful antiviral medications, which is the first line of treatment to slow the progression of HIV and the associated AIDS-related infections. Results for HIV-positive people receiving HAART have been very encouraging with many patients now enjoying a longer and better quality of life. It has been suggested that alcohol hinders antiretroviral therapy and certain evidence has highlighted the troublesome effects of alcohol during this treatment regime. Firstly, alcoholism results in reduced self control due to associated medical and psychiatric complications, which leads to a delay in seeking treatment. Secondly, alcohol can cause gastrointestinal irritation, resulting in a failure to comply with the complex medication schedule18. Moreover, alcohol itself weakens the response of the body to HIV therapy by increasing viral replication and drug resistance, restricting nutrition, and impairing liver function with subsequent poor drug metabolism23.
With the global health burden of alcohol becoming an increasing problem, we must find solutions to tackle this crisis. According to the World Health Organisation (WHO), the harmful use of alcohol causes about 2.3 million premature deaths per year worldwide (3.7% of global mortality) and is responsible for 4.4% of the global disease burden24. Perhaps, the most encouraging aspect of alcohol use is that it is modifiable through community and individual-based interventions. Basic tools such as public campaigns to increase awareness of alcohol-related harms, dispelling certain myths and misconception about alcohol and cognitive counselling are available. Time is also of an essence with regards to effective HIV treatment and prevention. Early detection of HIV infection facilitates the prompt beginning of behavioural changes aimed at reducing transmission25. To compound this further, many people who test HIV-positive fail to seek medical care until the disease has reached an advanced stage26. Having facilities whereby patients seeking treatment for their alcohol and drug-use are also routinely screened for HIV may go some way to alleviate this problem. Furthermore, we must now realise that alcohol-abuse treatment be considered primary HIV prevention. Research has shown that reducing alcohol use among HIV patients not only decreases the medical and psychiatric complications associated with alcohol use, but also reduces other drug use and HIV transmission18. Avins and colleagues found a 58% reduction in injection drug use among heterosexual patients one year after treatment for alcohol abuse27.
Our efforts should be diverted towards focusing on screening and prevention for HIV risk actors on those with severe alcohol dependence. Of a particular concern, however, is prevention of alcoholism amongst the youth population. AIDS is a leading cause of death among people aged 15 to 24 in urban, inner-city North America7, and new injection users usually become infected with HIV or viral hepatitis with two years of starting19. Therefore, sensible policies would suggest that HIV prevention programmes for youths should target alcohol consumption, in addition to injecting drug use and sexual risk reduction.
The problems associated with alcohol are very much common within the public domain. With research ongoing society is now starting to learn about other alcohol-related diseases, such as HIV/AIDS, which were previously discarded. A review of health policies and restructuring of health-care delivery is just a starting point in this journey to tackle the global health burden created by alcohol abuse.
1. Calling time: The nation’s drinking as a major health issue, Academy of Medical Sciences, 2004/The human cost of alcohol misuse BMA 2009
2. Mbulaiteye SM, Ruberantwari A, Nakiyingi JS, Carpenter LM, Kamali A, Whitworth JA. Alcohol and HIV: a study among sexually active adults in rural southwest Uganda. Int J Epidemiol. 2000 Oct;29(5):911-5.
1. Petry, N.M. Alcohol use in HIV patients: What we don’t know may hurt us. International Journal of STD and AIDS 10(9):561-570, 1999.
2. Windle, M. The trading of sex for money or drugs, sexually transmitted diseases (STDs), and HIV-related risk behaviors among multisubstance using alcoholic inpatients. Drug and Alcohol Dependence 49(1):33-38, 1997.
3. Avins, A.L.; Woods, W.J.; Lindan, C.P.; et al. HIV infection and risk behaviors among heterosexuals in alcohol treatment programs. JAMA 271(7):515-518, 1994.
4. Boscarino, J.A.; Avins, A.L.; Woods, W.J.; et al. Alcohol-related risk factors associated with HIV infection among patients entering alcoholism treatment: Implications for prevention. Journal of Studies on Alcohol 56(6):642-653, 1995.
5. Malow, R.M.; Dévieux, J.G.; Jennings, T.; et al. Substance-abusing adolescents at varying levels of HIV risk: Psychosocial characteristics, drug use, and sexual behavior. Journal of Substance Abuse 13:103-117, 2001.
6. MacDonald, T.K.; MacDonald, G.; Zanna, M.P.; and Fong, G.T. Alcohol, sexual arousal, and intentions to use condoms in young men: Applying alcohol myopia theory to risky sexual behavior. Health Psychology 19(3):290-298, 2000.
7. Stall, R.; McKusick, L.; Wiley, J.; et al. Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: The AIDS Behavioral Research Project. Health Education Quarterly 13(4):359-371, 1986.
8. Purcell, D.W.; Parsons, J.T.; Halkitis, P.N.; et al. Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men. Journal of Substance Abuse 13(1-2):185-200, 2001.
9. Maslow, C.B.; Friedman, S.R.; Perlis, T.E.; et al. Changes in HIV seroprevalence and related behaviors among male injection drug users who do and do not have sex with men: New York City, 1990-1999. American Journal of Public Health 92(3):382-384, 2002.
10. Cooper, M.L. Alcohol use and risky sexual behavior among college students and youth: Evaluating the evidence. Journal of Studies on Alcohol (Suppl. 14):101-117, 2002.
11. Dermen, K.H.; Cooper, M.L.; and Agocha, V.B. Sex-related alcohol expectancies as moderators of the relationship between alcohol use and risky sex in adolescents. Journal of Studies on Alcohol 59(1):71-77, 1998.
12. George, W.H.; Stoner, S.A.; Norris, J.; et al. Alcohol expectancies and sexuality: A self-fulfilling prophecy analysis of dyadic perceptions and behavior. Journal of Studies on Alcohol 61(1):168-176, 2000.
13. Dermen, K.H., and Cooper, M.L. Inhibition conflict and alcohol expectancy as moderators of alcohol’s relationship to condom use. Experimental and Clinical Psychopharmacology 8(2):198-206, 2000.
14. Fauci, A.S., and Lane, H.C. Human immunodeficiency virus (HIV) disease: AIDS and related disorders. In: Braunwald, E.; Fauci, A.S.; Kasper, D.L.; et al. Harrison’s Principles of Internal Medicine, 15th Edition. New York: McGraw-Hill, 2001. pp. 1852-1913.
15. Cook, R.T. Alcohol abuse, alcoholism, and damage to the immune system: A review. Alcoholism: Clinical and Experimental Research 22(9):1927-1942, 1998.
16. Lucas, G.M.; Gebo, K.A.; Chaisson, R.E.; and Moore, R.D. Longitudinal assessment of the effects of drug and alcohol abuse on HIV-1 treatment outcomes in an urban clinic. AIDS 16(5):767-774, 2002.
17. Fuller, C.M.; Vlahov, D.; Ompad, D.C.; et al. High-risk behaviors associated with transition from illicit non-injection drug use among adolescent and young adult drug users: A case-control study. Drug and Alcohol Dependence 66(2):189-198, 2002.
18. Marianna K. Baum, Carlin Rafie, Shenghan Lai, Sabrina Sales, John Bryan Page, Adriana Campa. AIDS Research and Human Retroviruses. May 2010, 26(5): 511-518. doi:10.1089/aid.2009.0211.
19. McKirnan, D.J.; Vanable, P.A.; Ostrow, D.G.; and Hope, B. Expectancies of sexual “escape” and sexual risk among drug and alcohol-involved gay and bisexual men. Journal of Substance Abuse 13(1-2):137-154, 2001.
20. Bagby Gregory J, Barve Shirisj, (2006) Alcohol abuse may increase susceptibility to HIV infection, Alcoholism: Clinical & Experimental Research
21. Centers for Disease Control and Prevention (CDC). Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. MMWR-Morbidity and Mortality Weekly Report 47(RR-5):42-82, 1998.
22. Alcohol misuse needs a global response: The Lancet, Volume 373, Issue 9662, Page 433, 7 February 2009. Doi:10.1016/S0140-6736(09)60146-X
23. Samet, J.H.; Mulvey, K.P.; Zaremba, N.; and Plough, A. HIV testing in substance abusers. American Journal of Drug and Alcohol Abuse 25(2):269-280, 1999.
24. Samet, J.H.; Freedberg, K.A.; Stein, M.D.; et al. Trillion virion delay: Time from testing positive for HIV to presentation for primary care. Archives of Internal Medicine 158(7):734-740, 1998.
25. Avins, A.L.; Lindan, C.P.; Woods, W.J.; et al. Changes in HIV-related behaviors among heterosexual alcoholics following addiction treatment. Drug and Alcohol Dependence 44(1):47-55, 1997.