Impact of alcohol use on sexual behavior among men who have sex with men and transgender women in Lima, Peru

Highlights

• We describe AUDs among men who have sex with men and trans women in Lima, Peru.

• We examine the association between AUDs and high risk sexual behaviors and STIs.

• AUDs were not associated with either condomless anal intercourse or recent STI.

• Interventions to reduce potential harms of alcohol should be context-specific.

Abstract

Background

Alcohol use disorders (AUDs) may enhance the likelihood of risky sexual behaviors and the acquisition of sexually transmitted infections (STIs). Associations between AUDs with condomless anal intercourse (CAI) and STI/HIV prevalence were assessed among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru.

Methods

MSM and TW were eligible to participate based on a set of inclusion criteria which characterized them as high-risk. Participants completed a bio-behavioral survey. An AUDIT score ≥8 determined AUD presence. Recent STI diagnosis included rectal gonorrhea/chlamydia, syphilis, and/or new HIV infection within 6 months. Prevalence ratios (PR) were calculated using Poisson regression.

Results

Among 312 MSM and 89 TW, 45% (181/401) had an AUD. Among those with an AUD, 164 (91%) were hazardous/harmful drinkers, and 17 (9%) had alcohol dependence. Higher CAI was reported by participants with an AUD vs. without, (82% vs. 72% albeit not significant). Reporting anal sex in two or more risky venues was associated with screening AUD positive vs. not (24% vs. 15%, p = 0.001). There was no difference in recent STI/HIV prevalence by AUD status (32% overall). In multivariable analysis, screening AUD positive was not associated with CAI or recent STI/HIV infection.

Conclusions

In our sample AUDs were not associated with CAI or new HIV infection/recent STI. However higher prevalence of CAI, alcohol use at last sex, and anal sex in risky venues among those with AUDs suggests that interventions to reduce the harms of alcohol should be aimed toward specific contexts.

Introduction

Although the countries of Central and South America have a relatively low adult human immunodeficiency virus (HIV) infection prevalence among the general population, estimated to be 0.4% (UNAIDS, 2012), in Peru concentrated epidemics persist among gender and sexual minorities with the HIV prevalence among men who have sex with men (MSM) and transgender women (TW) estimated to be as high as 10% and 30%, respectively (Cáceres and Mendoza, 2009, Silva-Santisteban et al., 2012, Carcamo et al., 2003). HIV infection and other sexually transmitted infections (STIs) exist as “syndemics,” synergistically contributing to an excess disease burden in these key populations (CDC, 2002). Concurrent STIs such as syphilis, gonorrhea, and chlamydia have been proven to facilitate HIV transmission while HIV also complicates these infections (Fleming and Wasserheit, 1999). Myriad high-risk behaviors including condomless anal intercourse lead to HIV/STI acquisition. The predisposition to engage in sexual risk behaviors (Newcomb et al., 2010) is associated with psychosocial factors such as substance abuse (Koblin et al., 2006, Stall and Purcell, 2000), depression (Alvy et al., 2011), anxiety (Rosario et al., 2006), history of childhood sexual abuse (Paul et al., 2001), self-efficacy, prejudice, stigma and social inequality (Meyer et al., 2011).

A recent systematic review in Latin America, identified several studies in which alcohol consumption was significantly associated with high-risk sexual behavior across various populations (Vagenas et al., 2013). Yet regional prevention services neglect alcohol consumption as a modifiable risk factor meriting intervention. As a psychogenic substance, alcohol leads to disinhibition, decreased risk perception, impaired decision making, and diminished capacity to negotiate condom use (Rehm et al., 2012, Kalichman et al., 2007a, Gálvez-Buccollini et al., 2009). The need to address alcohol use to provide comprehensive HIV/STI preventive care is substantiated by the global literature, including support of an overall association between problematic alcohol consumption and both STIs and HIV incidence (Baliunas et al., 2010, Cook and Clark, 2005). A meta-analysis of African studies observed a significant relationship between alcohol and HIV wherein drinkers had a 70% greater chance of being HIV positive than non-drinkers (Fisher et al., 2007). However, there is a lack of prospective longitudinal studies that could demonstrate causality between alcohol use and HIV/STI incidence in Latin America. Project EXPLORE (Koblin et al., 2006), for example, longitudinally followed 4,000HIV-negative MSM in the United States, and found that the use of alcohol or drugs before sex and heavy alcohol use in the last 6 months were independent predictors of seroconversion accounting for 29% and 6% of new HIV infections, respectively.

The relationship between problem alcohol use and HIV/STI prevalence needs further study. According to the 2010 World Health Organization Global Status Report on Alcohol and Health, the prevalence of alcohol use disorders among males over the age of 15 years in Peru was 12.2% (WHO Country Profiles, 2014). Yet among samples of MSM and TW in Peru the prevalence of alcohol use disorders is 55–63% (Ludford et al., 2013, Vagenas et al., 2014). An event-level study in Peru found alcohol consumption prior to sex was associated with unprotected sex and at least one STI (Maguiña et al., 2013). While studies in Peru seem to agree that alcohol use is associated with condomless or risky sex, more global measures of problem alcohol use (such as the AUDIT and the CAGE questionnaire) have yielded inconsistent results with regard to the association between alcohol use and STI prevalence (Ludford et al., 2013, Deiss et al., 2013a). Therefore further information is needed to clarify the relationship between alcohol use and HIV/STI prevalence in this context.

Based on the known psychoactive effects alcohol has on judgment and reasoning in conjunction with the positive associations previously reported in international and Peruvian studies, we hypothesized that alcohol use disorders (AUDs) would be associated with higher baseline prevalence of both condomless anal intercourse in the last 3 months and new HIV infection/recent STI diagnosis.