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      Population attributable fraction of incident HIV infections associated with alcohol consumption in fishing communities around Lake Victoria, Uganda

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          Abstract

          Background

          Although the association between alcohol consumption and HIV risk is well documented, few studies have examined the magnitude of new HIV infections that could be prevented by controlling alcohol use. We report the population attributable fraction (PAF) of incident HIV infections due to alcohol consumption among the HIV high-risk population of fishing communities along Lake Victoria, Uganda.

          Methods

          In a community-based cohort study, 1607 HIV sero-negative participants aged 18–49 years were enrolled from eight fishing communities along Lake Victoria, Uganda. At follow up 12 months later, 1288 (80.1%) were seen and interviewed. At baseline and follow-up visits, participants completed interviewer-administered questionnaires on alcohol consumption, demographics, and sexual risk behavior, and were tested for HIV infection. HIV incidence and adjusted incident rate ratios (adjusted IRRs) were estimated using Poisson regression models; the crude and adjusted PAFs of incident HIV infections associated with alcohol consumption were calculated using the Greenland and Drescher method for cohort studies.

          Results

          Among the 1288 participants seen at follow up, 53.5% reported drinking alcohol of whom 24.4% drank occasionally (2 days a week or less) and 29.1% drank regularly (3–7 days a week). Forty eight incident HIV infections occurred giving an incidence rate of 3.39/100 person years at-risk (pyar) (95% CI, 2.55–4.49). Compared to non-drinkers, the adjusted IRR of HIV was 3.09 (1.13–8.46) among occasional drinkers and 5.34 (2.04–13.97) among regular drinkers. The overall adjusted PAF of incident HIV infections due alcohol was 64.1 (95% CI; 23.5–83.1); ranging from 52.3 (11.9–74.2) among Muslims to 71.2 (32.6–87.7) for participants who reported ≥ 2 sexual partners in the past 12 months.

          Conclusion

          In fishing communities along Lake Victoria, Uganda, 64% of new HIV infections can be attributed to drinking alcohol. Interventions to reduce alcohol consumption should be integrated in HIV/AIDS prevention activities for populations in whom both HIV and alcohol consumption are highly prevalent.

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          Most cited references48

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          Maximum likelihood estimation of the attributable fraction from logistic models.

          Bruzzi et al. (1985, American Journal of Epidemiology 122, 904-914) provided a general logistic-model-based estimator of the attributable fraction for case-control data, and Benichou and Gail (1990, Biometrics 46, 991-1003) gave an implicit-delta-method variance formula for this estimator. The Bruzzi et al. estimator is not, however, the maximum likelihood estimator (MLE) based on the model, as it uses the model only to construct the relative risk estimates, and not the covariate-distribution estimate. We here provide maximum likelihood estimators for the attributable fraction in cohort and case-control studies, and their asymptotic variances. The case-control estimator generalizes the estimator of Drescher and Schill (1991, Biometrics 47, 1247-1256). We also present a limited simulation study which confirms earlier work that better small-sample performance is obtained when the confidence interval is centered on the log-transformed point estimator rather than the original point estimator.
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            Alcohol use and risky sexual behavior among college students and youth: evaluating the evidence.

            To evaluate the empirical associations between alcohol use and risky sex at two levels of analysis. Global associations test whether individuals who engage in one behavior are more likely to engage in the other, whereas event-specific associations test whether the likelihood of engaging in one behavior on a given occasion varies as a function of engaging in the other on that same occasion. Studies examining the association between drinking and risky sex in samples of college students and youth were reviewed. Those published in the past 10 years and using event-level methodology or random sampling were emphasized. Findings were generally consistent across levels of analysis, but differed across types of risky behaviors. Drinking was strongly related to the decision to have sex and to indiscriminate forms of risky sex (e.g., having multiple or casual sex partners), but was inconsistently related to protective behaviors (e.g., condom use). Moreover, the links among alcohol use, the decision to have sex and indiscriminate behaviors were found in both between-persons and within-persons analyses, suggesting that these relationships cannot be adequately explained by stable individual differences between people who do and do not drink. Analysis of event characteristics showed that drinking was more strongly associated with decreased protective behaviors among younger individuals, on first intercourse experiences and for events that occurred on average longer ago. Future efforts aimed at reducing alcohol use in potentially sexual situations may decrease some forms of risky sex, but are less likely to affect protective behaviors directly.
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              The association between HIV infection and alcohol use: a systematic review and meta-analysis of African studies.

              To summarize the association between alcohol use and human immunodeficiency virus (HIV) infection based on studies conducted in Africa, EMBASE and PubMed were searched for African studies that related alcohol use to HIV infection. Meta-analyses were conducted to obtain pooled univariate and multivariate relative risk estimates. Subgroup analyses were performed for studies having different sample types: males or females and population-based or high-risk, and ones that differentiated between problem and asymptomatic drinkers. Alcohol drinkers were more apt to be HIV+ than nondrinkers. The pooled unadjusted odds ratio (OR) from 20 studies was 1.70 (95% confidence interval, CI = 1.45-1.99). Results from 11 studies that adjusted for other risk factors produced a pooled risk estimate of 1.57 (95% CI = 1.42-1.72). Males and females had similar risk estimates, while studies involving high-risk samples tended to report larger pooled odds ratios than studies of the general population. When compared with nondrinkers, the pooled estimates of HIV risk were 1.57 (95% CI = 1.33-1.86) for non-problem drinkers versus 2.04 (95% CI = 1.61-2.58) for problem drinkers, a statistically significant difference (z = 2.08, P <0.04). Alcohol use was associated with HIV infection in Africa and alcohol-related interventions might help reduce further expansion of the epidemic.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                16 February 2017
                2017
                : 12
                : 2
                : e0171200
                Affiliations
                [1 ]Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
                [2 ]Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
                [3 ]Department of Medical Microbiology, School of Biomedical Sciences, Makerere University, Kampala, Uganda
                [4 ]International AIDS Vaccine Initiative (IAVI), New York, New York, United States of America
                [5 ]Medical Research Council/Uganda Virus Research Insitute, Uganda Research Unit on AIDS, Entebbe, Uganda
                [6 ]Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [7 ]Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California, United States of America
                [8 ]Makerere University College of Health Sciences, School of Medicine, Clinical Epidemiology Unit, Kampala, Uganda
                University of Toronto Dalla Lana School of Public Health, CANADA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: NK AS NKS.

                • Data curation: NK IS AS AN AB PKK BSB PK.

                • Formal analysis: NK AN JS CL JH NKS.

                • Funding acquisition: NK PK NKS.

                • Investigation: NK IS AS AN AB PKK BSB.

                • Methodology: NK AS IS AN.

                • Project administration: NK AS AB.

                • Resources: NK PKK BSB.

                • Software: NK JS AN.

                • Supervision: NK AS IS AN.

                • Validation: NK IS AS NA JS PKK BSB.

                • Visualization: NK AB AS CL JH NKS PK.

                • Writing – original draft: NK AS NA AB BSB.

                • Writing – review & editing: NK BSB JH CL NKS.

                Article
                PONE-D-16-18152
                10.1371/journal.pone.0171200
                5313154
                28207844
                0a939b2d-fa98-45b3-b2cc-3689095c26d6
                © 2017 Kiwanuka et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 12 May 2016
                : 18 January 2017
                Page count
                Figures: 0, Tables: 4, Pages: 14
                Funding
                Funded by: Canada-Africa Prevention Trials Network
                Award ID: 1063357-001
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award ID: 087540/Z/08/Z
                Award Recipient :
                This work was supported by Training Health Researchers into Vocational Excellence in East Africa Project (THRiVE), grant number 087540/Z/08/Z funded by the Wellcome Trust, and the Canada-Africa Prevention Trials Network (CAPTN) grant number 1063357-001. We greatly appreciated the support given by the International AIDS Vaccine Initiative (IAVI) through the UVRI-IAVI HIV Vaccine Program in form of clinical research sites where study coordination activities were carried out. We also thank the study participants and the UVRI-IAVI Community Advisory Board. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the supporting offices. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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