Schneider et al.  devote their editorial to the under-recognized association between alcohol consumption/hazardous drinking and HIV prevention or HIV outcomes. They also highlight the missed opportunities for combined prevention and co-treatment of HIV and alcohol-related problems, especially in countries where this association is striking. Despite the ever-increasing body of evidence showing connections between excessive drinking and both HIV-related risky sexual behaviours and HIV treatment adherence, these connections have not been taken into account in major public health policy and HIV prevention plans.
Sexuality and alcohol are often linked, especially in the most vulnerable groups. In HIV-infected patients, alcohol use is associated with both impaired antiretroviral therapy (ART) adherence and unprotected sex, and therefore a higher ‘susceptibility’ of sexually transmitting the virus exists in HIV-infected individuals with excessive alcohol use. Although the declaration ‘ART is prevention’ is helping to promote access to ART in countries where HIV is driven by sexual risk behaviours, the effectiveness of ART as a preventive tool can be seriously compromised by hazardous drinking in HIV-infected populations. Interestingly, in drug users, hazardous drinking is a more important risk factor for non-adherence than active drug injection .
To explore these issues, we used data from a representative sample of individuals living with HIV in France, where the prevalence of hazardous drinking is high .
In a previous study , conducted on a representative sample of 2340 HIV-infected patients in 102 French hospital departments delivering HIV care, 27% were found to have a hazardous level of alcohol consumption [based on the Alcohol Use Disorders Identification Test (AUDIT-C) >4 for women and >5 for men]. Drinking at this level was associated with both non-adherence to ARV and unsafe sexual behaviours with HIV-negative or unknown HIV serostatus partners [odds ratio (OR): 1.8, 95% confidence interval (CI) 1.5–2.1 and OR: 1.4, 95% CI: 1.1–1.8, respectively]; but as stated by Schneider et al., the variables associated with hazardous drinking and HIV infection are somewhat complex. With regard to alcohol use, the consequences of alcohol consumption/excessive drinking may differ depending on the pattern and context of drinking. Binge drinking is of particular concern due to the loss of behavioural control, high-risk behaviours and violence in the general population [5, 6], but such behaviours are seldom assessed in HIV-infected patients, especially those on ART. In the same study group we estimated that 9.4% were regular binge drinkers (6 or more alcohol units drunk consecutively at least twice a month) and that after adjustment for known confounders, this practice was associated strongly not only with unprotected sex (OR: 1.64, 95% CI: 1.13–2.38), but also with non-adherence (OR: 2.16, 95% CI: 1.60–2.90) and lack of virological response (OR: 1.40, 95% CI: 1.01–1.94). In other words, it was associated with a higher susceptibility to sexually transmit the virus.
We do not believe that additional studies are needed to show this association in countries with a high prevalence of hazardous drinking and HIV. Schneider and colleagues remind us that combining interventions for alcohol-related problems and HIV prevention is a strategy which policy makers have neglected for too long. It is time to switch from research to action to make ART scale-up a tool for optimized prevention even in countries where HIV transmission is also driven by alcohol.
Declarations of interest
This study was supported by the French National Agency of AIDS and Hepatitis Research (ANRS, France). Special thanks are due to the members of the VESPA Group. The authors would like to thank Lionel Fugon for the statistical analysis and Jude Sweeney for the English revision and editing of the manuscript.