Gender-based violence is a well-recognized risk factor for HIV infection among women. Alcohol use is associated with both gender-based violence and sexual risk behavior, but has not been examined as a correlate of both in a context of both high HIV risk and hazardous drinking. The purpose of this paper is to examine the association between recent abuse by a sex partner with alcohol and sexual risk behavior among female patrons of alcohol serving venues in South Africa. Specifically, the aim of this study is to determine whether sexual risk behaviors are associated with gender-based violence after controlling for levels of alcohol use. We surveyed 1,388 women attending informal drinking establishments in Cape Town, South Africa to assess recent history of gender-based violence, drinking, and sexual risk behaviors. Gender-based violence was associated with both drinking and sexual risk behaviors after controlling for demographics among the women. A hierarchical logistic regression analysis showed that after controlling for alcohol use sexual risk behavior remained significantly associated with gender-based violence, particularly with meeting a new sex partner at the bar, recent STI diagnosis, and engaging in transactional sex, but not protected intercourse or number of partners. In South Africa where heavy drinking is prevalent women may be at particular risk of physical abuse from intimate partners as well as higher sexual risk. Interventions that aim to reduce gender-based violence and sexual risk behaviors must directly work to reduce drinking behavior.
gender-based violence; intimate partner violence; alcohol; sexual risk; HIV risk
Evidence based, single-session, behavioral interventions that can be used in public health settings are urgently needed for preventing the spread of HIV and other sexually transmitted infections (STI). Brief interventions are particularly promising given the relatively low burden they place on financially limited service providers.
To estimate the efficacy of single-session, behavioral interventions for STI prevention.
MEDLINE (PubMed), PsycINFO, CINAHL, ERIC, Proquest, all international sub-databases in the WHO's Global Health Library were searched through May 2011.
Data from 29 single-session interventions (20 studies; N = 52,465) with an STI outcome were coded and analyzed.
The odds of participants being infected with an STI in the intervention group were reduced by 35% (OR = .65, 95% CI=.55–.77) relative to control group participants. Interventions were compared to active controls and follow-up periods averaged 58 weeks. As such, single-session interventions lead to considerable benefit in terms of disease prevention and create minimal burden for both the patient and the provider.
Single-session interventions were most often implemented during routine health care services by clinic staff. Use of these procedures make these interventions a reasonable option for currently existing health care infrastructure. Brief and effective STI prevention interventions are a valuable tool for disease prevention and can be readily adapted to bolster the benefits of partially effective biomedical STI/HIV prevention technologies.
Gender-based violence is a key determinant of HIV infection among women in South Africa as elsewhere. However, research has not examined potential mediating processes to explain the link between experiencing abuse and engaging in HIV sexual risk behavior. Previous studies suggest that alcohol use and mental health problems may explain how gender-based violence predicts sexual risk. In a prospective study, we examined whether lifetime history of gender-based violence indirectly affects future sexual risk behavior through alcohol use, depression and post-traumatic stress disorder (PTSD) in a high-risk socio-environmental context. We recruited a cohort of 560 women from alcohol drinking venues in a Cape Town, South African township. Participants completed computerized interviews at baseline and 4 months later. We tested prospective mediating associations between gender-based violence, alcohol use, depression, PTSD, and sexual risk behavior. There was a significant indirect effect of gender-based violence on sexual risk behavior through alcohol use, but not mental health problems. Women who were physically and sexually abused drank more, which in turn predicted more unprotected sex. We did not find a mediated relationship between alcohol use and sexual risk behavior through the experience of recent abuse or mental health problems. Alcohol use explains the link between gender-based violence and sexual risk behavior among women attending drinking venues in Cape Town, South Africa. Efforts to reduce HIV risk in South Africa by addressing gender-based violence must also address alcohol use.
South Africa; gender-based violence; HIV; HIV risk; sexual risk; alcohol use; mental health; mediation; women
Although pornography is widely available and frequently used among many adults in the US, little is known about the relationship between pornography and risk factors for HIV transmission among men who have sex with men.
Baseline assessments from a behavioral intervention trial for at-risk men who have sex with men were conducted in Atlanta, GA in 2009. Univariate and multivariate generalized linear models were used to assess the relationships between known risk factors for HIV infection, time spent viewing pornography, and sex behaviors.
One hundred forty nine men reporting HIV-negative status and two or more unprotected anal sex partners in the past six months were enrolled in an intervention trial and completed survey assessments. Time spent viewing pornography was significantly associated with having more male sexual partners (B=.45, SE=.04, p<.001) and unprotected insertive anal sex acts (B=.28, SE=.04, p<.001). Moreover, increased substance use (drug use, B=.61, SE=.14, p<.001; alcohol use, B=.03, SE=.01, p<.01) and decreased perception of risk for HIV infection (B=-.09, SE=.04, p<.05) were found to be significantly associated with greater time spent viewing pornography.
This exploratory study is novel in that it sheds light on the associations between viewing pornography and sexual risk taking for HIV infection. Future studies in this area should focus on understanding how the content of pornography, in particular the viewing of unprotected and protected sex acts, may affect sexual risk taking behavior.
AIDS-related stigma as a barrier to HIV testing has not been examined within the context of high at-risk environments such as drinking venues. Of particular importance is whether AIDS-related stigma is associated with HIV transmission risks among people who have never been tested for HIV.
We examined: 1) AIDS-related stigma as a barrier to testing, controlling for other potential barriers, and 2) whether stigma is associated with HIV risks among HIV-untested individuals.
We surveyed 2,572 individuals attending informal drinking establishments in Cape Town, South Africa to assess HIV testing status, AIDS-related stigma endorsement, and HIV transmission sexual risk behavior.
Endorsement of AIDS-related stigma was negatively associated with HIV lifetime testing. In addition, stigma endorsement was associated with higher HIV transmission risks.
AIDS-related stigma must be addressed in HIV prevention campaigns across South Africa. Anti-stigma messages should be integrated with risk reduction counseling and testing.
HIV/AIDS-related stigma; HIV testing; HIV risk behavior; alcohol; substance use
The highest rates of fetal alcohol syndrome worldwide can be found in South Africa. Particularly in impoverished townships in the Western Cape, pregnant women live in environments where alcohol intake during pregnancy has become normalized and interpersonal violence (IPV) is reported at high rates. For the current study we sought to examine how pregnancy, for both men and women, is related to alcohol use behaviors and IPV.
We surveyed 2,120 men and women attending drinking establishments in a township located in the Western Cape of South Africa.
Among women 13% reported being pregnant, and among men 12.2% reported their partner pregnant. For pregnant women, 61% reported attending the bar that evening to drink alcohol and 26% reported both alcohol use and currently experiencing IPV. Daily or almost daily binge drinking was reported twice as often among pregnant women than non-pregnant women (8.4% vs. 4.2%). Men with pregnant partners reported the highest rates of hitting sex partners, forcing a partner to have sex, and being forced to have sex. High rates of alcohol frequency, consumption, binge drinking, and problematic drinking were reported across the entire sample. In general, experiencing and perpetrating IPV were associated with alcohol use among all participants except for men with pregnant partners.
Alcohol use among pregnant women attending shebeens is alarmingly high. Moreover, alcohol use appears to be an important factor in understanding the relationship between IPV and pregnancy. Intensive, targeted, and effective interventions for both men and women are urgently needed to address high rates of drinking alcohol among pregnant women who attend drinking establishments.
Advances in HIV treatment and opportunistic illness prophylaxis have significantly extended the life expectancy of people living with HIV/AIDS. Increased HIV/AIDS longevity is also marked by changes in HIV transmission risk behaviors. Here we review the literature on HIV transmission risk behaviors as they change in relation to stages of HIV disease among persons who are infected with HIV/AIDS. Studies confirm that the time period immediately preceding testing HIV positive is characterized by high risk behaviors indicating the potential for rapid spread of HIV during acute infection. For many people, reductions in risk behavior are seen immediately following HIV diagnosis. However, these changes in risk taking are not universal and great variability exists in terms of how HIV diagnosis influences risk behaviors. Chronic periods of asymptomatic HIV infection are generally associated with some degree of reverting to high risk behaviors. Also, a CD4 count below 200 cells/mm3 resulting in a formal diagnosis of AIDS, is associated with decreased sexual and drug-related risk behaviors. HIV risk reduction interventions that target men and women living with HIV/AIDS therefore require tailoring to stages of HIV disease. Additional research on risk behaviors of long term HIV positive persons is needed.
Women in South Africa are at particularly high-risk for HIV infection and are dependent on their male partners' use of condoms for sexual risk reduction. However, many women are afraid to discuss condoms with male partners, placing them at higher risk of HIV infection.
To examine the association between fear of condom negotiation with HIV testing and transmission risk behaviors, including alcohol use and sexual risks among South African women.
Women (N = 1333) residing in a primarily Xhosa-speaking African township in Cape Town and attending informal alcohol-serving venues (shebeens) completed anonymous surveys. Logistic regression was used to test the hypothesis that fear of condom negotiation would be associated with increased risk for HIV.
Compared to women who did not fear condom negotiation, those who did were significantly less likely to have been tested for HIV, were more likely to have experienced relationship abuse, and to report more alcohol use and more unprotected sex.
For women in South Africa, fear of condom negotiation is related to higher risk of HIV. HIV prevention efforts, including targeted HIV counseling and testing, must directly address gender issues.
Affordable and effective antiretroviral therapy (ART) adherence interventions are needed for many patients to promote positive treatment outcomes and prevent viral resistance. We conducted a two-arm randomized trial (n = 40 men and women receiving and less than 95% adherent to ART) to test a single office session followed by four biweekly cell phone counseling sessions that were grounded in behavioral self-management model of medication adherence using data from phone-based unannounced pill counts to provide feedback-guided adherence strategies. The control condition received usual care and matched office and cell phone/pill count contacts. Participants were baseline assessed and followed with biweekly unannounced pill counts and 4-month from baseline computerized interviews (39/40 retained). Results showed that the self-regulation counseling delivered by cell phone demonstrated significant improvements in adherence compared to the control condition; adherence improved from 87% of pills taken at baseline to 94% adherence 4 months after baseline, p < 0.01. The observed effect sizes ranged from moderate (d = 0.45) to large (d = 0.80). Gains in adherence were paralleled with increased self-efficacy (p < 0.05) and use of behavioral strategies for ART adherence (p < 0.05). We conclude that the outcomes from this test of concept trial warrant further research on cell phone-delivered self-regulation counseling in a larger and more rigorous trial.
Sexually transmitted infections (STI) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STI in a community sample of 490 HIV positive men and women.
Confidential computerized interviews were collected in a community research setting.
14% of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a six month period. Individuals with a new STI had significantly more sex partners in that time period, including non-HIV positive partners. Participants who had contracted an STI were significantly more likely to have detectable viral loads and were less likely to know their viral load than participants who did not contract an STI. Multivariate analysis showed that believing an undetectable viral load leads to lower infectiousness was associated with contracting a new STI.
Individuals who believe having an undetectable viral load reduces HIV transmission risks were more likely infectious because of STI co-infection. Programs that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STI among people living with HIV/AIDS.
HIV/AIDS prevention; HIV/AIDS treatment; Sexually Transmitted Infections
The purpose of the current study was to assess whether or not men who have sex with men who limit their unprotected anal sexual partners to those who are of the same HIV status (serosort) differ in their risk for HIV transmission than MSM who do not serosort.
Cross-sectional surveys administered at a large gay pride festival (80% response rate) were collected from MSM. Univariate and multivariate logistic regressions were used to identify predictors of serosorting.
Participants were self-identified as HIV negative MSM (N=628), about one third of whom engaged in serosorting (n=229). Men who serosort were more likely to believe that serosorting offered protection against HIV transmission, perceived themselves as being at no relatively higher risk for HIV transmission, and had more unprotected anal intercourse partners. Over half the sample reported their frequency of HIV testing as yearly or less frequently; this finding did not differ between serosorters and non-serosorters.
Men who identify as HIV negative and serosort are no more likely to know their HIV status than men who do not serosort and are at higher risk for exposure to HIV. Interventions targeting MSM must address the limitations of serosorting.
HIV transmission may be prevented by effectively suppressing viral replication with antiretroviral therapy (ART). However, adherence is essential to the success of ART, including for reducing HIV transmission risk behaviors. This study examined the association of nonadherence versus adherence with HIV transmission risks. Men (n = 226) living with HIV/AIDS and receiving ART completed confidential computerized interviews and telephone-based unannounced pill counts for ART adherence monitoring. Data were collected between January 2008 and June 2009. Results showed that nonadherence to ART was associated with greater number of sex partners and engaging in unprotected and protected anal intercourse. These associations were not moderated by substance use. The belief that having an undetectable viral load leads to lower infectiousness was associated with greater number of partners, including nonpositive partners, and less condom use. Men who had an undetectable viral load and believed that having an undetectable viral load reduces their infectiousness, were significantly more likely to have contracted a recent STI. Programs aimed at testing and treating people living with HIV/AIDS for prevention require attention to adherence and sexual behaviors.
HIV continues to disproportionately affect men who have sex with men (MSM). As a result of the impact of HIV among MSM, multiple strategies for reducing HIV risks have emerged from within the gay community. One common HIV risk reduction strategy is to limit unprotected sex partners to those who are of the same HIV status, or to serosort. Although serosorting is commonly practiced for risk reduction, it is closely linked to HIV transmission because of infrequent HIV testing, lack of HIV status disclosure, sexually transmitted infections, and acute HIV infection.
The current study tested a novel, brief, one-on-one, peer counselor-delivered intervention based on informed decision making, to address the limitations of serosorting. One hundred forty nine at-risk men were recruited and randomly assigned to an intervention condition addressing serosorting or a standard-of-care control.
Men in the serosorting intervention reported fewer sexual partners (Wald X2=8.79,p=<.01) at study follow-ups.
Addressing risks associated with serosorting in a feasible, low -cost intervention has the potential to significantly impact the HIV epidemic.
People living with HIV can be reinfected with a new viral strain resulting in potential treatment resistant recombinant virus known as HIV super-infection. Individual’s beliefs about the risks for HIV super-infection may have significant effects on the sexual behaviors of people living with HIV/AIDS.
To examine HIV super-infection beliefs and sexual behaviors among people living with HIV/AIDS.
Three hundred and twenty men, 137 women, and 33 transgender persons completed confidential surveys in a community research setting.
A majority of participants were aware of HIV super-infection and most believed it was harmful to their health. Hierarchical multiple regressions predicting protected anal/vaginal intercourse with same HIV status (seroconcordant) partners showed that older age and less alcohol use were associated with greater protected sex. In addition, HIV super-infection beliefs predicted protected sexual behavior over and above participant age and alcohol use.
Beliefs about HIV super-infection exert significant influence on sexual behaviors of people living with HIV/AIDS and should be targeted in HIV prevention messages for HIV infected persons.
AIDS denialists offer false hope to people living with HIV/AIDS by claiming that HIV is harmless and that AIDS can be cured with natural remedies. The current study examined the prevalence of AIDS denialism beliefs and their association to health-related outcomes among people living with HIV/AIDS. Confidential surveys and unannounced pill counts were collected from a predominantly middle aged and African American convenience sample of 266 men and 77 women living with HIV/AIDS. One in five participants stated that there is no proof that HIV causes AIDS and that HIV treatments do more harm than good. AIDS denialism beliefs were more often endorsed by people who more frequently used the internet after controlling for confounds. Believing that there is a debate among scientists about whether HIV causes AIDS was related to refusing HIV treatments and poorer health outcomes. AIDS denialism beliefs may be common among people living with HIV/AIDS and such beliefs are associated with poor health outcomes.
Selecting sex partners of the same HIV status or serosorting is a sexual risk reduction strategy used by many men who have sex with men. However, the effectiveness of serosorting for protection against HIV is potentially limited. We sought to examine how men perceive the protective benefits of factors related to serosorting including beliefs about engaging in serosorting, sexual communication, and perceptions of risk for HIV. Participants were 94 HIV negative seroconcordant (same HIV status) couples, 20 HIV serodiscordant (discrepant HIV status) couples, and 13 HIV positive seroconcordant (same HIV status) couples recruited from a large gay pride festival in the southeastern US. To account for nonindependence found in the couple-level data, we used multilevel modeling which includes dyad in the analysis. Findings demonstrated that participants in seroconcordant relationships were more likely to believe that serosorting reduces concerns for condom use. HIV negative participants in seroconcordant relationships viewed themselves at relatively low risk for HIV transmission even though monogamy within relationships and HIV testing were infrequent. Dyadic analyses demonstrated that partners have a substantial effect on an individual’s beliefs and number of unprotected sex partners. We conclude that relationship partners are an important source of influence and, thus, intervening with partners is necessary to reduce HIV transmission risks.
HIV; serosorting; MSM; dyad; multilevel modeling
A common HIV/AIDS risk reduction strategy among men who have sex with men (MSM) is to limit their unprotected sex partners to those who are of the same HIV status, a practice referred to as serosorting. Decisions to serosort for HIV risk reduction are based on personal impressions and beliefs, and there is limited guidance offered on this community derived strategy from public health services. This paper reviews research on serosorting for HIV risk reduction and offers an evidence-based approach to serosorting guidance. Following a comprehensive electronic and manual literature search, we reviewed 51 studies relating to the implications of serosorting. Studies showed that HIV negative MSM who select partners based on HIV status are inadvertently placing themselves at risk for HIV. Infrequent HIV testing, lack of HIV status disclosure, co-occurring STIs, and acute HIV infection impede the potential protective benefits of serosorting. Public health messages should continue to encourage reductions in numbers of sexual partners and increases in condom use. Risk reduction messages should also highlight the limitations of relying on one’s own and partner’s HIV status in making sexual risk decisions.
serosorting; acute infection; HIV testing; prevention messages
Studies investigating the effects of biological HIV prevention technologies have been reported with promising results for slowing the spread of HIV. Although prevention technologies can reduce the rate of HIV transmission at varying levels of efficaciousness, it is vital to anticipate the impact of HIV prevention technologies on subsequent sexual behaviors. Risk homeostasis theory posits that decreases in perceived risk, which will occur with access to HIV prevention technologies, will correspond with increases in risk taking behavior. Here we review the literature on risk compensation in response to HIV vaccines, topical microbicides, antiretroviral medications, and male circumcision. Behavioral risk compensation is evident in response to prevention technologies that are used in advance of HIV exposure and at minimal personal cost. We conclude that behavioral risk compensation be addressed by implementing adjunct behavioral risk reduction interventions to avoid negating the preventive benefits of biomedical HIV prevention technologies.
In the US, black men who have sex with men (BMSM) are diagnosed with HIV at a rate far exceeding other men. However, many studies report no substantial increase in risk behavior among BMSM. Here we examine a partner selection strategy as a potential risk factor for HIV among BMSM and white MSM (WMSM).
Cross-sectional surveys were collected from self-reported HIV negative BMSM and WMSM attending a gay pride festival in Atlanta, GA.
HIV negative WMSM were more likely to report having unprotected anal intercourse with HIV negative men, and HIV negative BMSM were more likely to report unprotected anal intercourse with HIV status unknown partners. Furthermore, WMSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than BMSM.
WMSM appear to be using risk reduction strategies to reduce the likelihood of HIV infection more so than BMSM. Partner selection strategies have serious limitations; however they may explain in part the disproportionate number of HIV infections among BMSM.
ethnicity; men who have sex with men; risk behavior; perceptions of risk
Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.
Although demonstrated valid for monitoring medication adherence, unannounced pill counts conducted in patients’ homes are costly and logistically challenging. Telephone-based unannounced pill counts offer a promising adaptation that resolves most of the limitations of home-based pill counting.
We tested the reliability and validity of a telephone-based unannounced pill count assessment of antiretroviral adherence.
HIV positive men and women (N = 89) in Atlanta GA completed a telephone-based unannounced pill count and provided contemporaneous blood specimens to obtain viral loads; 68 participants also received an immediate second pill count conducted during an unannounced home visit.
A high degree of concordance was observed between the number of pills counted on the telephone and in the home (Intraclass Correlation, ICC, = .981, p < .001) and percent of pills taken (ICC = .987, p < .001). Adherence obtained by the telephone count and home count reached 92% agreement, Kappa coefficient = .94. Adherence determined by telephone-based pill counts also corresponded with patient viral load, providing evidence for criterion-related validity.
Unannounced telephone-based pill counts offer a feasible objective method for monitoring medication adherence.
HIV//AIDS Treatment; Medication Adherence; Pill Counts; Adherence Assessment; Medication Monitoring
Alcohol use is a barrier to medication adherence. Beyond the cognitive effects of intoxication, people living with HIV/AIDS who believe that alcohol should not be mixed with their medications may temporarily stop taking medications when drinking. To examine the effects of alcohol-treatment beliefs on HIV treatment adherence. People living with HIV/AIDS who were receiving treatment (n = 145) were recruited from community and clinical services during the period between January 2006 and May 2008 to complete measures of substance use and alcohol-antiretroviral (ARV) interactive toxicity beliefs (e.g., alcohol breaks down HIV medications so they will not work). Medication adherence was monitored using unannounced telephone-based pill counts. Forty percent of participants were currently using alcohol and nearly one in four drinkers reported stopping their medications when drinking. Beliefs that mixing alcohol and medications is toxic were common among drinkers and nondrinkers, with most beliefs endorsed more frequently by non-drinkers. Hierarchical regression analysis showed that stopping ARVs when drinking was associated with treatment nonadherence over and above quantity/frequency of alcohol use and problem drinking. Beliefs that alcohol and ARVs should not be mixed and that treatments should be interrupted when drinking are common among people living with HIV/AIDS. Clinicians should educate patients about the necessity of continuing to take ARV medications without interruption even if they are drinking alcohol.
Unannounced pill counts conducted in patients’ homes is a valid objective method for monitoring medication adherence that is unfortunately costly and often impractical. Conducting unannounced pill counts by telephone may be a viable alternative for objectively assessing medication adherence.
To test an unannounced pill count assessment of adherence conducted by telephone.
HIV-positive men and women (N = 77) in Atlanta GA completed an unannounced telephone-based pill count immediately followed by a pill count conducted in an unannounced home visit.
A high degree of concordance was observed between phone and home-based number of pills counted (Intraclass correlation, ICC = .997, 95% CI .995–.998, P < .001) and percent of pills taken (ICC = .990, 95% CI .986–.992, P < .001). Concordance between adherence above/below 90% and phone/home counts was 95%, Kappa coefficient = .995. Concordance between pill counts was not influenced by participant education or health literacy and was maintained when the data were censored to remove higher levels of adherence. Analyses of discordant pill counts found the most common source of error resulted from overcounted doses in pillboxes on the telephone.
Unannounced phone-based pill counts offer an economically and logistically feasible objective method for monitoring medication adherence.
HIV//AIDS treatment; medication adherence; pill counts; adherence assessment; medication monitoring
Concurrent sexual relationships facilitate the spread of HIV infection, and sex with non-primary partners may pose particularly high risks for HIV transmission to primary partners.
We examined the sexual and alcohol-related risks associated with sex partners outside of primary relationships among South African men and women in informal drinking establishments.
Men (n=4959) and women (n=2367) with primary sex partners residing in a Xhosa-speaking South African township completed anonymous surveys. Logistic regressions tested associations between having outside partners and risks for sexually transmitted infections (STI)/HIV.
Forty-four percent of men and 26% women with primary sex partners reported also having outside sex partners in the previous month. Condom use with outside partners was inconsistent for men and women; only 19% of men and 12% of women used condoms consistently with outside sex partners. Multivariable regressions for men and women showed that having outside partners was significantly associated with having been diagnosed with an STI, consuming alcohol in greater frequency and quantity, alcohol use during sex, meeting sex partners in alcohol-serving venues, and higher rates of unprotected sex.
Having outside sex partners was associated with multiple risk factors for HIV infection among South African shebeen patrons. Social and structural interventions that encourage condom use are needed for men and women with outside partners who patronise alcohol-serving venues.
Substance Misuse; Africa; Sexual Behaviour