We found that physical violence, sexual violence and difficulties conceiving were associated with alcohol abuse. Furthermore, alcohol abuse was directly associated with STIs symptoms, and indirectly associated with testing positive for STIs through its association with multiple sexual partners. This is one of the first population-based studies in sub-Saharan Africa designed at assessing problem drinking in women with regards to STIs-associated risks. Most studies have looked at STIs in association with alcohol use prior to sex10
; we did not investigate alcohol use prior to sex.
About 15% of the study participants were considered to be alcohol abusers using the CAGE score. This finding is consistent with previous reports from the sub-region 7, 9, 28
. Seventy six percent of the alcohol abusers had only pre-secondary education. Are these women using alcohol as self-medication for an underlying problem? The affirmative answer to this question could be deduced based on the significant association between alcohol abuse and a history of intimate partner violence (physical and sexual violence) and having multiple partners. Moreover, women with difficulties conceiving were more likely to resort to alcohol abuse (p=0.04) in adjusted models ().
In most sub-Saharan African countries, women are accorded a subordinate status and this may affect their abilities to negotiate sexual decisions and behaviors and their risk of STIs 29, 30
. Women are expected to be faithful and even condone their partners engagement in multiple partnerships and sexual risk behaviors 30
. It is plausible that societal expectations and pressures put upon women by their partners result in alcohol use and abuse as an escape. Alcohol use may reduce women’s inhibition and the use of alcohol may help women refrain from protesting and condone with the sexual risk behaviors of their partners. The findings in this study are consistent with earlier studies that found significant associations between sexual risk behaviors and alcohol consumption in female partners 9, 28
and contrast a study in Uganda where no relation was established 31
. In sum, male perpetrators of intimate partner violence may engage in sexual risk behaviors putting their female partners at greater risk of acquiring an STI/HIV, especially those who resort to alcohol use.
Alcohol abuse had a direct association with having STIs symptoms and was indirectly associated with testing positive for an STI through its association with multiple sexual partners. This finding suggests that multiple sexual partners may be in the pathway of alcohol abuse and STIs. This finding is consistent with the association between alcohol use and STI/HIV previously reported 10
. Although the association between alcohol and HIV is not clear, it has been suggested that alcohol enhances in vitro
susceptibility of human peripheral mononuclear cells to HIV infection and the replication of virus in HIV-infected individuals 32, 33
. Furthermore, reduced inhibition from alcohol use may result in sexual risk-taking behaviors associated with STIs 8, 34
. Hence, screening for alcohol use in women in sub-Saharan African may be a useful surrogate for predicting intimate partner violence (physical and sexual violence) and an individual’s risk of acquiring STIs/HIV.
Alcohol abuse was significantly associated with number of sexual partners. Stable and monogamous relationships were associated with a reduced risk of alcohol abuse, although the association was not significant. This finding is consistent with previous studies from the sub-region 9, 35
. We found no significant association between alcohol use and ethnicity, religion or education. The most prevalent STIs among study participants were HSV-2 reaching 45.8% followed by the infection rates of 11.6% for HIV and 10.8% for trichomonas, while the remaining STIs studied had prevalence rates below 5.0%. The STIs prevalence rates found in the study population are high and consistent with other studies in the region 36, 37
. Most STIs prevalence data are based on selected populations attending gynecological and family planning clinics. The similarity between the population based rates in this study and rates in high risk groups, such as bar and hotel workers, is of concern.
HSV-2 and other STIs, particularly those causing genital ulcerations, are known to facilitate HIV acquisition and transmission. The high prevalence rate (45.8%) of HSV-2 is of concern as it can further fuel the HIV epidemic. Moreover, we observed a rather low prevalence of condom use in the last 12 months among study participants. At the time of the study HIV awareness and prevalence in the community were low and that may partly explain the rather low condom use. Preferably, the study should have analyzed data about life time use of condoms, but that information was not collected. There is a need for comprehensive community-based STIs prevention programs in Moshi, as well as throughout sub-Saharan Africa.
This study has several strengths compared to previous studies. It has a large sample size. Moreover, the data on STIs come from both biological samples and self-reports. However, it has inherent limitations associated with population-based studies. First, only women who provided information on alcohol use and STIs were included in the analysis. Analysis of the complete cases ignores the possible systematic difference between the women who provided information on these variables (alcohol use, number of sexual partners and symptoms of STIs) and those who did not. Thus, inferences from complete cases can be biased if there were a systematic difference between cases with observed data and those with unobserved data. For example, if subjects who provided urine samples were more likely to report symptoms consistent with STIs, this might have led to overestimation of the population prevalence. The reported sexual behaviors might have been affected by social desirability bias. For instance, in most sub-Saharan African cultures women are not permitted to have multiple partners; the number of partners reported by study participants could be an underestimation. Moreover, the analysis is based on a cross-sectional data, which limits the conclusions that can be drawn with regards to causality between alcohol abuse, sexual risk factors and STIs.
In conclusion, we found an association between physical violence, sexual violence, difficulties conceiving and alcohol abuse. There was a direct relationship between alcohol abuse, number of sexual partners and STIs symptoms and an indirect relationship between alcohol abuse and testing positive for an STI. These findings have significant public health implications. In sub-Saharan Africa, where women are disproportionately affected by the HIV epidemic, screening for alcohol use should be part of comprehensive STIs and HIV prevention programs.