Association between Levels of Alcohol Use, Perceived HIV Risk, and Untreated HIV Among Persons at Alcohol-Serving Venues in Kenya and Uganda

Alcohol-serving venues in East Africa are high-risk environments for HIV transmission but few studies in sub-Saharan Africa (SSA) have examined perceived HIV risk and sexual risk behaviors by alcohol use levels on a broader population of persons at alcohol-serving venues in the era of biomedical HIV prevention. We conducted a cross-sectional analysis of adults (≥ 18 years) at alcohol-serving venues in eight communities (~ 10,000 residents/community) in rural western Kenya and southwestern Uganda. We distributed recruitment cards to patrons and workers and invited them for free HIV screening at nearby health facilities, with same-day initiation of HIV pre- or post-exposure prophylaxis or antiretroviral therapy (ART) if eligible. Using generalized estimating equations with adjustment for age, sex, and country, we assessed whether increasing levels of alcohol use, as measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), categorized as no/low use (< 4 for men, < 3 for women), medium use (4-5 for men, 3-5 for women), high use (6-7), and very high use (≥ 8) were predictive of perceived HIV risk (current or anticipated in the next three months) and four HIV-risk factors (i.e., sex with a partner with HIV or unknown HIV status, multiple sexual partners, transactional sex, and sexually transmitted infections) among persons without HIV. We also evaluated the association between AUDIT-C levels and untreated HIV (defined as newly diagnosed or previously diagnosed but out of care for ≥ 6 months) among persons with HIV and between AUDIT-C levels and HIV-risk factors among persons with untreated HIV. We distributed 9,375 recruitment cards at 480 venues: 7,744 (83%) adults participated in screening at health facilities (median age 34 years; 38% women; 91% patrons). Overall, 4,107 (53%) reported unhealthy alcohol use: 26% medium, 11% high, 16% very high. Of 6,124 (79%) persons who tested HIV-negative, 2,285 (37%) reported perceived HIV risk. Increasing alcohol use was significantly associated with higher odds of perceived HIV risk (medium use: adjusted odds ratio (aOR) = 1.36, 95% CI: 1.17-1.58, p < 0.001; high: aOR = 2.06, 95%CI: 1.71-2.47, p < 0.001; and very high: aOR = 2.07, 95%CI: 1.74-2.47, p < 0.001; vs. no/low alcohol use) as well as sexual risk factors. Of 1,620 (21%) PWH, 219 (14%) had untreated HIV: 141 (9%) newly diagnosed; 78 (5%) previously diagnosed, not on ART. Increasing levels of alcohol use were not associated with untreated HIV. Our findings highlight the ongoing need for interventions to reduce alcohol use and improve engagement in biomedical HIV prevention and treatment among adults at alcohol-serving venues in East Africa.