DOI: 10.31038/AWHC.2019221

In spite of recent scientific advances, HIV continues to exact a significant toll on morbidity, mortality and societal resources in many parts of the world, including the United States (U.S.). In the US, between 2010–2014, 207, 120 new HIV cases were diagnosed [1]. HIV prevalence increased by 9.1% during this period, and by 2014 there were 1.1 million persons living with HIV (PLWHA) [1]. Despite the availability of rapid diagnostic tests, 17.1% of PLWHA remain unaware of their infection [1]. However, HIV is not uniformly distributed among U.S. populations. Minority women bear a disproportionate burden of the epidemic, with 24.9/100,000 Black women and 5.0/100,000 Latinas being diagnosed with HIV in 2017, as opposed to 1.7/100,000 White women [2]. Heterosexual contact accounted for 85.5% of all new HIV diagnoses among women in 2017 [2].

As is well established in the literature, while risk factors, singly, may increase risk of HIV acquisition, these risk factors often occur in clusters, further amplifying woman’s HIV risk, and reflect multi-level social determinants of health among minority women. A socio-ecological framework that includes individual, interpersonal, neighborhood and societal-level factors provides a lens for identifying and, more importantly for a public health perspective, understanding the mechanisms through which these social determinants create disparities in HIV infections and related health outcomes [3]. For example, epidemiologic data at the individual level suggests that risky sexual practices, such as number of lifetime sexual partners and noncondom use by male partners, early sexual debut, and substance use, increase risk for HIV and other sexually transmitted infections (STIs) [4]. Conversely, efficacy in negotiating male partner’s condom use, assertive communication skills, intention to use condoms, and stronger ethnic identification have been observed to be protective factors for sexual risk-taking among Latina and Black female adolescents [5–9]. However, while informative, individual-level predictors do not fully account for marked inequities observed in HIV and STI rates [10, 11]. At the interpersonal level, unprotected sex with risky, mainly primary, sex partners, such as those with existing HIV or STI infections, place minority women at elevated risk [11, 12]. A study found that Black female adolescents were at 5-fold risk for STIs, relative to White peers; the observed risk disparity was largely attributable to male sex partner characteristics [4]. Conversely, a systematic review of sexual health among Latinas found that partner communication about birth-control methods predicted contraceptive use and that woman’s power in the relationship was associated with lower risk of pregnancy [8]. Attitudes and expectancies with regards to sexual behavior informed by gender norms underlie some of the observed disparities in sexual and reproductive health risk; [4, 13] for instance, overall, more equitable relationships are associated with sexual health [14]. At the broader structural level, neighborhood overcrowding and economic deprivation have been associated with higher rates of chlamydia, gonorrhea and HIV infection [15, 16]. Discrimination based on race/ethnicity coupled with socioeconomic disadvantage is associated with segregated high-risk sexual networks; networks with a high prevalence of HIV and other STIs, which limit minority women’s male partner choice [10, 17, 18].

Within this socio-ecological framework, alcohol use interacts with sexual behaviors and HIV risk and disease progression at all levels. Alcohol is by far the most common psychoactive drug consumed in the U.S. According to the 2015 National Survey on Drug Use and Health (NSDUH), 78.3% of women in the U.S. ever drank alcohol; and almost half (47.4%) did so in the last month [19]. In 2015, 1 in 5 adult women (20.5%) engaged in heavy episodic drinking [20]. Over the past 10 years, there has been a significant increase in alcohol use (0.3% per year) and binge drinking (0.7% per year) in the U.S., particularly among women [21]. On average, an estimated 26,000 women die annually from alcohol-related causes [22], making alcohol the third leading preventable cause of death in the U.S. Globally, alcohol consumption is the leading cause of death among 15–49 year-old women [23]. The costs of excessive alcohol consumption in the U.S. is estimated at $223.5 billion, or $746 per person, 76.4% attributable to binge drinking [24].

Individual, interpersonal, and social level factors are linked to alcohol consumption and poor sexual health. A study among Latinas found that heavy episodic drinking was associated with higher odds of having more lifetime partners, regretting sexual initiation after alcohol use, and noncondom use [25]. Even at non abuse levels, alcohol consumption predicts STI acquisition and noncondom use with casual partners among Black females [26]. Another study revealed that female Black adolescents with high alcohol consumption were more likely than those with lower alcohol consumption to test positive for STIs, use condoms inconsistently, report multiple male sexual partners, and engage in anal sex [27]. Among PLWHA, alcohol use is associated with poorer antiretroviral treatment (ART) adherence and could hinder ART effectiveness, by interfering with drug metabolism [28]. In a Brazilian study, PLWHA who were alcohol dependent were nine times (p<0.01) more likely to have CD4 cell count ≤200/mm, independent of ART adherence [29]. Several reviews have identified any level of alcohol consumption to be associated with unprotected sex among PLWHA [28, 30]. Unfortunately, despite the observed health risks of alcohol use, few woman are engaged in alcohol treatment. For instance, one study found that only 19% of HIV+ women with alcohol use disorders utilized any alcohol treatment [31]. Gender-based violence is also associated with both woman’s and male partner’s alcohol consumption. In the context of abusive relationships, often fueled and intensified by male partner’s alcohol abuse, women are less likely to initiate sexual negotiation and engage in safe sex [14, 32]. A study of HIV+ Russian women found that non condom use was not significantly associated with the woman’s alcohol consumption, but with male partner’s alcohol consumption [33]. At the environmental level, higher concentrations of alcohol outlets have been associated with lower ART adherence and increased alcohol consumption among PLWHA [34]. Substantial evidence links exposure to alcohol marketing with earlier initiation of alcohol use and engagement in heavy episodic drinking [35, 36]. A study found that in high-income countries higher quantities of drinking among youth were mediated by liking alcohol ads [37]. A South Africa study identified pathways by which access to alcohol contributes to women’s poor health at multiple levels; [38] increased access to alcohol and exposure to alcohol advertisements was associated with negative pregnancy outcomes, intimate partner violence, heavy episodic drinking among partners, and community-level hazardous drinking [38].

There is growing evidence to support no safe threshold for alcohol consumption [39]. However, the alcohol industry continues to invest substantial sums of fiscal resources in lobbying and advertisement in the U.S. and abroad [40]. In 2015, the alcohol sector spent 13.2 million USD lobbying in state legislatures, and donated 27 million USD to Congressional representatives in 2016 alone [41]. In 2011, the 14 major alcohol beverage companies invested 3.45 billion USD on marketing activities [41, 42]. In spite of evidence that exposure to alcohol advertisement is positively associated with number of drinks consumed, and that young people consume more in markets with more expenditure in ads [35, 43], alcohol marketing is ubiquitous. In New York City, for example, 90% of retail-dense blocks have some type of stationary alcohol advertisement [44] and, before the ban, over half (53.1%) of subway stations with any advertisement displayed at least one alcohol advertisement [45]. Since then, in 2017, New York City’s Metropolitan Transit Authority has followed the lead of other large urban centers, such as Los Angeles, San Francisco, Detroit, Seattle, San Diego, and Baltimore, and banned alcohol advertisement [46].

Curtailing availability, increasing prices and restricting marketing have been found to be cost-effective policies for regulating alcohol consumption [37, 47]. Restrictions on alcohol outlet density and age and time of sale, alcohol taxes, self-screening and commercial liability are CDC recommended strategies to curtail excessive drinking [48]. The most cost-effective public health strategies for reducing drinking have been raising the price of alcohol and banning advertising [49]. Based on this evidence, the World Health Organization recommends the establishment of a global framework, with clear monitoring and enforcement mechanisms, to regulate marketing of alcohol [43].

 It will be challenging to prevent the harmful effects of alcohol consumption for as long as it is socially acceptable [50]. Similar to tobacco control, continuing to restrict alcohol availability and marketing, while increasing access to treatment to those with an alcohol use disorder coupled with public health messaging about harm reduction, is necessary to make alcohol less socially acceptable [40]. While reducing public acceptability of alcohol, it is also critical to implement and scale up multi-level interventions to reduce alcohol consumption targeted specifically to women [51], their partners and their communities. These interventions should be targeted to prevent adverse sexual and reproductive health outcomes for HIV+ women [52]. Linking the women most affected by alcohol, including PLWHA, with prevention programs that address alcohol use in the context of sexual behavior are needed, and these interventions may be more effective if they engage male partners to promote gender equitable relationships.

Improving woman’s sexual and reproductive health requires a coordinated and concerted multi-sectoral effort. Without addressing key drivers of woman’s risk for HIV, other STIs, and unintended pregnancy, programs are not likely to be optimally effective. And, importantly, strategies need to address multiple risk factors, across ecological domains. The resolve of governments, academia, and private sector agencies, to implement and sustain these health promotion programs will be critical for enhancing woman’s sexual and reproductive health.

References

1. Satcher Johnson A, Song R, Hall HI (2017) Estimated HIV Incidence, Prevalence, and Undiagnosed Infections in US States and Washington, DC, 2010–2014.  J Acquir Immune Defic Syndr 76: 116–122. [crossref]
2. Centers for Disease Control and Prevention (2017) HIV Surveillance Report, 2016. Atlanta, GA: CDC.
3. Scribner R, Theall KP, Simonsen N, Robinson W (2010) HIV risk and the alcohol environment: advancing an ecological epidemiology for HIV/AIDS. Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism 33: 179–183. [crossref]
4. Pflieger J, Cook E, Niccolai L, Connell C (2013) Racial/Ethnic Differences in Patterns of Sexual Risk Behavior and Rates of Sexually Transmitted Infections Among Female Young Adults. Am J Public Health 103: 903–909. [crossref]
5. Widman L, Choukas-Bradley S, Helms SW, Golin CE, Prinstein MJ (2013) Sexual Communication Between Early Adolescents and Their Dating Partners, Parents, and Best Friends. The Journal of Sex Research 51:731–741. [crossref]
6. Widman L, Golin CE, Noar SM (2013) When do condom use intentions lead to actions? Examining the role of sexual communication on safer sexual behavior among people living with HIV. J Health Psychol 18: 507–517. [crossref]
7. Noar SM, Carlyle K, Cole C (2006) Why communication is crucial: meta-analysis of the relationship between safer sexual communication and condom use. J Health Commun 11: 365–390. [crossref]
8. Morales-Aleman MM, Scarinci IC (2016) Correlates and predictors of sexual health among adolescent Latinas in the United States: A systematic review of the literature, 2004–2015. Prev Med 87: 183–193. [crossref]
9. Belgrave FZ, Van Oss Marin B, Chambers DB (2000) Culture, contextual, and intrapersonal predictors of risky sexual attitudes among urban African American girls in early adolescence. Cultural Diversity & Ethnic Minority Psychology 6: 309–322. [crossref]
10. Crawford ND, Galea S, Ford CL, Latkin C, Link BG, et al. (2014) The relationship between discrimination and high-risk social ties by race/ethnicity: examining social pathways of HIV risk. J Urban Health 91: 151–161. [crossref]
11. Graves SK, Little SJ, Hoenigl M (2017) Risk profile and HIV testing outcomes of women undergoing community-based testing in San Diego 2008–2014. Scientific Reports 7: 42183. [crossref]
12. Conley TD, Matsick JL, Moors AC, Ziegler A, Rubin JD (2015) Re-examining the effectiveness of monogamy as an STI-preventive strategy. Preventive medicine78: 23–28. [crossref]
13. Wingood GM, DiClemente RJ (2000) Application of the Theory of Gender and Power to Examine HIV-Related Exposures, Risk Factors, and Effective Interventions for Women. Health Education & Behavior 27: 539–565. [crossref]
14. Wingood GM, DiClemente RJ (1998) Partner influences and gender-related factors associated with noncondom use among young adult African American women. Am J Community Psychol 26: 29–51. [crossref]
15. Krieger N, Waterman PD, Chen JT, Soobader M-J, Subramanian S (2003) Monitoring Socioeconomic Inequalities in Sexually Transmitted Infections, Tuberculosis, and Violence: Geocoding and Choice of Area-Based Socioeconomic Measures—The Public Health Disparities Geocoding Project (US). Public Health Reports 118: 240–260. [crossref]
16. Zierler S, Krieger N, Tang Y, Coady W, Siegfried E, et al. (2000) Economic deprivation and AIDS incidence in Massachusetts. Am J Public Health 90: 1064–1073. [crossref]
17. Adimora AA, Schoenbach VJ (2005) Social Context, Sexual Networks, and Racial Disparities in Rates of Sexually Transmitted Infections. The Journal of Infectious Diseases 191: 115–122. [crossref]
18. Adimora AA, Schoenbach VJ, Taylor AM, Khan MR, Schwartz RJ (2011) Concurrent Partnerships, Nonmonogamous Partners, and Substance Use Among Women in the United States. Am J Public Health 101: 128–136. [crossref]
19. Substance Abuse and Mental Health Services Administration (SAMHSA) (2016) 2015 National Survey on Drug Use and Health (NSDUH). Table 2.41B—Alcohol Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older, by Demographic Characteristics: Percentages, 2014 and 2015. Rockville, MD: SAMHSA, Center for Behavioral Health Statistics and Quality. Rockville, Maryland 20857, USA.
20. Zhai Y, Santibanez TA, Kahn KE, Srivastav A (2017) Parental-Reported Full Influenza Vaccination Coverage of Children in the U.S. Am J Prev Med 52: e103-103e113. [crossref]
21. Grucza RA, Sher KJ, Kerr WC, Krauss MJ, Lui CK, et al. (2018) Trends in Adult Alcohol Use and Binge Drinking in the Early 21st-Century United States: A Meta-Analysis of 6 National Survey Series. Alcohol Clin Exp Res 42: 1939–1950. [crossref]
22. Centers for Disease Control and Prevention (2011) Alcohol and Public Health: Alcohol-Related Disease Impact (ARDI). Average for United States 2006–2010 Alcohol-Attributable Deaths Due to Excessive Alcohol Use.
23. GBD 2016 Alcohol Collaborators (2018) Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 392: 1015–1035. [crossref]
24. Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD (2011) Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med 41: 516–524. [crossref]
25. Hahm H, Lee J (2010) Acculturation and sexual risk behaviors among Latina adolescents transitioning to young adulthood. Journal of Youth and Adolescence 39: 414–427. [crossref]
26. Seth P, Wingood GM, DiClemente RJ, Robinson LS (2011) Alcohol use as a marker for risky sexual behaviors and biologically confirmed sexually transmitted infections among young adult African-American women. Women Health Iss 21: 130–135. [crossref]
27. Seth P, Sales JM, DiClemente RJ, Wingood GM, Rose E, et al. (2011) Longitudinal examination of alcohol use: a predictor of risky sexual behavior and Trichomonas vaginalis among African-American female adolescents. Sex Transm Dis 38: 96–101. [crossref]
28. Hahn JA, Samet JH (2010) Alcohol and HIV disease progression: weighing the evidence. Curr HIV/AIDS Rep 7: 226–233. [crossref]
29. Malbergier A, Amaral RA, Cardoso LD (2015) Alcohol dependence and CD4 cell count: is there a relationship? AIDS Care 27: 54–58. [crossref]
30. Scott-Sheldon LA, Walstrom P, Carey KB, Johnson BT, Carey MP, et al. (2013) Alcohol use and sexual risk behaviors among individuals infected with HIV: a systematic review and meta-analysis 2012 to early 2013. Curr HIV/AIDS Rep 10: 314–323. [crossref]
31. Hu X, Harman J, Winterstein AG, Zhong Y, Wheeler AL, et al. (2016) Utilization of Alcohol Treatment Among HIV-Positive Women with Hazardous Drinking. J Subst Abuse Treat 64: 55–61. [crossref]
32. Stockman JK, Lucea MB, Campbell JC (2013) Forced sexual initiation, sexual intimate partner violence and HIV risk in women: a global review of the literature. AIDS Behav 17: 832–847. [crossref]
33. Brown JL, DiClemente RJ, Sales JM, et al. (2016) Alcohol Use, Partner Characteristics, and Condom Use Among HIV-Infected Russian Women: An Event-Level Study. J Stud Alcohol Drugs 77: 968–973. [crossref]
34. Theall KP, Felker-Kantor E, Wallace M, Zhang X, Morrison CN, et al. (2018) Considering high alcohol and violence neighborhood context using daily diaries and GPS: A pilot study among people living with HIV. Drug Alcohol Depend 187: 236–241. [crossref]
35. Jernigan D, Noel J, Landon J, Thornton N, Lobstein T (2017) Alcohol marketing and youth alcohol consumption: a systematic review of longitudinal studies published since 2008. Addiction 112: 7–20. [crossref]
36. Smith LA, Foxcroft DR (2009) The effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: systematic review of prospective cohort studies. BMC Public Health 9: 51. [crossref]
37. Casswell S, Huckle T, Wall M, Parker K, Chaiyasong S, et al. (2018) Policy-relevant behaviours predict heavier drinking and mediate the relationship with age, gender and education status: Analysis from the International Alcohol Control Study. Drug Alcohol Rev37: S86-S95. [crossref]
38. Amanuel H, Morojele N, London L (2018) The Health and Social Impacts of Easy Access to Alcohol and Exposure to Alcohol Advertisements Among Women of Childbearing Age in Urban and Rural South Africa. Journal of Studies on Alcohol and Drugs 79: 302–308. [crossref]
39. Wood AM, Kaptoge S, Butterworth AS, et al. (2018) Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599?912 current drinkers in 83 prospective studies. The Lancet 391: 1513–1523.
40. Hawkins B, Holden C, Eckhardt J, Lee K (2018) Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries. Glob Public Health 13: 1–19. [crossref]
41. Jernigan D (2017) Alcohol marketing: Overview of the landscape. Dartmouth University, Hanover, USA.
42. Federal Trade Commission (2014) Self-Regulation in the Alcohol Industry: Report of the Federal Trade Commission, Washington, DC 20580, USA.
43. World Health Organization (2018) Global status report on alcohol and health 2018. Geneva, Switzerland: WHO.
44. Thihalolipavan S, Goranson C, Heller D (2011) Alcohol advertising visible at the street level in retail-dense areas of NYC. New York City Department of Health and Mental Hygiene, New York.
45. Fullwood M (2018) Transit Advertising with Alcohol and Violent Content on Public Platforms: A Descriptive Study of Advertisements within the New York City Subway System. New York, NY, Teachers College, Columbia University.
46. Schultz EJ (2017) As Alcohol Ads Sprawl Elsewhere, New York Buses and Trains Go Dry. October 26.
47. World Health Organization (2011) From Burden to “Best Buys”: Reducing the Economic Impact of Non-Communicable Diseases in Low and Middle-Income Countries. Geneva, Switzerland: WHO.
48. Centers for Disease Control and Prevention (2018) The Community Guide: CPSTF Findings for Excessive Alcohol Consumption. https://www.thecommunityguide.org/content/task-force-findings-excessive-alcohol-consumption.
49. Anderson P, Chisholm D, Fuhr DC (2009) Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 373: 2234–2246. [crossref]
50. Pechey R, Burge P, Mentzakis E, Suhrcke M, Marteau TM (2014) Public acceptability of population-level interventions to reduce alcohol consumption: a discrete choice experiment. Soc Sci Med 113: 104–109. [crossref]
51. Fitzgerald N, Angus K, Emslie C, Shipton D, Bauld L (2016) Gender differences in the impact of population-level alcohol policy interventions: evidence synthesis of systematic reviews. Addiction 111: 1735–1747. [crossref]
52. Myers JE, Braunstein SL, Xia Q, Scanlin K, Edelstein Z, et al. (2018) Redefining Prevention and Care: A Status-Neutral Approach to HIV. Open Forum Infect Dis 5: ofy097. [crossref]