Assessing the role of alcohol and intimate partner violence on HIV care and viral suppression in Uganda

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Project Summary Human immunodeficiency virus (HIV) infection, alcohol use and intimate partner violence (IPV) are critical interrelated public health issues in Rakai district, Uganda. In Rakai, HIV prevalence is three times the national average (19.7% versus 6.2%). Alcohol use is also common among persons living with HIV (PLWH); recently collected data form Rakai found that the majority (57%) of PLWH consume alcohol with heavy drinking common amongst those who drink. There is a growing evidence base that suggests that alcohol use adversely impacts engagement and retention in care throughout the HIV care continuum. Findings regarding the effects of alcohol use on viral suppression have been less conclusive and in resource constrained settings like Uganda, are largely informed by immunologic monitoring (CD4 count) which is less sensitive to treatment failure than virologic monitoring. Similarly, experiencing IPV is also associated with delayed and decreased engagement throughout the HIV care continuum, although most of the research on this topic has been conducted in high income countries. Although IPV often occurs in the context of alcohol use, the combined effects of these two exposures on care and treatment outcome has not been explored. The proposed study aims to address these gaps by assessing how alcohol use (aim 1), IPV (aim 2) and co-occurring alcohol use and IPV (aim 3) are associated with engagement in HIV care, use of antiretroviral therapy and achievement of viral suppression among PLWH participating in the Rakai Community Cohort Study (RCCS), one of the oldest and most established community-based HIV surveillance cohorts in the world. Secondary data analysis on the two most recent rounds of collected RCCS data will facilitate the achievement of the specific research aims. Aims 2 and 3 will focus on experiences of IPV among women living with HIV because the overwhelming majority of IPV is experienced by women and perpetrated by men. The rationale of the proposed work, is that once the effects of alcohol use alone, IPV alone and IPV and co-occurring alcohol use on engagement and retention in care and HIV disease progression are better understood, it will be known if (i) research is needed to assess if there is a dose response relationship between these variables and HIV disease progression and (ii) if intervening on alcohol use and IPV among PLWH should be a public health priority in this setting. Furthermore, if co-occurring IPV and alcohol use has an additive effect on engagement and retention in HIV care and treatment and disease progression, this will inform whether IPV should be addressed in alcohol use interventions targeting PLWH in this setting. The opportunities afforded through this F31 mechanism (protected time to pursue advanced training in subject areas identified by the applicant and her sponsor as critical to professional advancement and a successful research career) will significantly contribute to the applicant’s advancement towards her long term goal of being an independent, academic public health researcher who specializes in applying advanced quantitative methods to understand the relationship between substance use, HIV and other common co-morbidities in high- risk populations such as persons living with HIV.