Hazardous Alcohol Use, Sexual Behavior, and Incident HIV across 11 Eastern and Southern African Countries

Objectives: Quantify hazardous alcohol consumption prevalence among individuals at risk of acquiring HIV infection and its association with high-risk sexual behaviors and incident HIV in 11 Eastern and Southern African countries. Design: Secondary analysis of 16 nationally-representative household surveys (2015-2023). Methods: The study included sexually active individuals aged [≥]15 years. Alcohol use patterns were classified using the AUDIT-C (non-drinkers/low-risk drinkers/hazardous non-binge drinkers/hazardous binge drinkers). Outcomes included high-risk sexual behaviors, recent HIV infection, and undiagnosed HIV infection. Survey-weighted alcohol use prevalence and logistic regression were estimated by gender, adjusting for sociodemographic covariates. Model outputs were used to estimate change in incident infections when removing excess risks associated with alcohol use patterns. Results: Analyses included 251,931 participants. Across countries, 5.8%-21.1% reported hazardous binge drinking, and 3.7%-15.7% reported hazardous non-binge drinking, with large gender differences. Sexual risk behaviors increased with drinking severity among men and women. Compared with non-drinkers, alcohol use was associated with higher odds of undiagnosed HIV infection; adjusted odds ratios ranged from 1.32 (1.16-1.50) for low-risk drinkers to 1.52 (1.34-1.72) for hazardous binge drinkers among men, and 1.28 (1.13-1.46) to 1.55 (1.31-1.82) among women. Simulated removal of alcohol-associated excess risk reduced undiagnosed HIV by 15.1% (10.9%-19.4%) among men and 5.8% (4.0%-7.9%) among women. Estimates for recent HIV infection followed a similar pattern but with larger uncertainty. Conclusions: Hazardous alcohol use was associated with sexual risk and HIV infection in Eastern and Southern Africa. Reaching individuals who use alcohol with effective HIV prevention may reduce HIV acquisition risk across the region.