National AIDS Control Organisation of India estimated that 2.39 million people live with AIDS in India. (2008–09)
11 percent of Indians were binge drinkers, against the global average of 16 percent.(WHO)
Alcohol and HIV have an overwhelming impact on morbidity and mortality in the world’s populations both separately and together. They rank among the top 10 leading causes of death. Their dynamic interaction increases the risk for HIV infection and complicates their treatment. How this combined epidemic is expressed for individuals, their families, and their cultural contexts and the wider institutions that serve them is explored in a publication by National Center for Biotechnology Information
It helps to arrive at a more complete understanding of the role that drinking plays in the lives of individuals and communities. There are many questions that arise in context of alcohol drinking in India that this case study aids to shed light on such as-
- Where does drinking take place?
- What types of alcohol are drunk?
- Are youth who begin drinking at an earlier age at greater risk, and if so, of what?
- What are the variations in HIV and other risks related to alcohol use?
- Are there gender differences in men and women’s perception and use of alcohol?
- How this repertoire of individual and group behaviors is linked to HIV risk, particularly sexual risk under the influence of alcohol
During AIDS epidemic in India, international and domestic alcohol manufacturers were seeing it as an opportunity for their products to expand in Indian middle and upper middle class communities with resources to spend on leisure time activities. Alcohol production and use has a long history in India. Recently, however, the sale and consumption of new forms of alcohol containing more pure alcohol content such as “strong beers”, and associated with higher status and prestige such as “English liquors” including whiskey, scotch and brandy, has began to replace traditional beverages with lower alcohol content and more nutritional components such as tadi madi (date wine), fenny (distilled coconut or cashew wine) and toddy (palm liquor).
In 2000, two new WHO publications highlighted the growing significance of alcohol with respect to HIV risk. The WHO Eight Country Study on alcohol and HIV (2000) included a chapter on alcohol and HIV in India, followed by an historical review of secondary data sources on the history of alcohol and its association with HIV risk in India.
Important discoveries found in the NCBI’s case study:
- According to research done on mobile female sex workers and male mobile workers who are clients of these FSW in 14 districts of India, alcohol consumption is common in both, females and males prior to sex, and is linked to inconsistent condom use. In some cases men who pay for sex with women outside of brothels are much more likely to avoid condom use or to use condoms inconsistently. These results suggest the importance of focusing interventions on reducing risks associated with paid sex and informal sexual transactions that take place outside of the brothel environment.
- HIV positive patients who consume alcohol exacerbates gaps in medication adherence, and acts as a facilitator of sexual risk behavior. This population is highly understudied in the India context and as more people become seropositive, reducing alcohol risk and unprotected sex among PLWA is increasingly important, both to reduce transmission and improve health and related outcomes.
- Central India showed that alcohol used before sex was a significant predictor of HIV seropositivity in married men 30–39, but not in single men who were probably younger
- On the other hand, in a study of HIV risk among clients of wine shops in Chennai reported that 89% of respondents interviewed drank before having sex and that non-protection was significantly more common among unmarried men who drank before having sex. These studies have led scholars such to conclude that one viable option for HIV prevention in the Indian context is reducing alcohol consumption prior to sex in both married and unmarried men
- Resource poor communities in Mumbai shows conclusively that daily drinking is associated with extramarital sex, higher level drinkers have more non spousal sexual partners and use protection less with them. It suggests that moderate level drinkers also may be at risk of exposure to STI and HIV and that interventions should be tailored, with cessation the goal in the case of regular daily drinkers and reduction of frequency and amount of consumption among moderate and lower level drinkers to reduce sexual risk.
- Poor mental health and hazardous drinking is associated with both violence and HIV risk among men.
- Violence associated with alcohol use has been shown to have an effect on HIV and STI risk exposure, primarily through forced, “rough” or painful sex between men and vulnerable or unwilling women including spouses. The evidence is accumulating to suggest that alcohol, when linked with gender norms, disinhibits men, and focuses them on meeting their perceived sexual and other needs in marriage through the use of violence or abuse
- Venues where alcohol is sold and consumed including wine shops, addas and bars and restaurants clearly influence, endorse, support and enable risky sexual behavior.
What can be done?
- In India, it is unlikely that “single sector” approaches alone will be effective in combating the gender based violence, risky sexual behaviors and other consequences of pervasive alcohol use. Sensitive community-based, community-controlled approaches to mediating alcohol use and its relationship to unprotected sex and violence should be undertaken with communities, including men, women, and families affected by alcohol, community organizations, distributors, media and providers.
- Reinforce the importance of HIV risk reduction programs for men in the general population as well as other vulnerable populations such as sex workers, truckers and injection drug users, including de-addiction of alcohol as a focus of HIV risk reduction.
- HIV prevention interventions that involve discussion of sex are not very widely supported in India. Such interventions should be altered accordingly so that they can be successfully implemented, sustained and disseminated in all locations of India as a model for much needed educational and workplace approaches to prevention.
What do you think? Does HIV risk grows due to alcohol?