Effects of sex and alcohol use on antiretroviral therapy outcomes in Botswana: a cohort study

Aims: To determine alcohol use effect on HIV treatment success and whether alcohol use mediates the relation between male sex and treatment failure.

Design: Longitudinal cohort study.

Setting: Eight HIV clinics in and near Gaborone, Botswana.

Participants: A total of 938 HIV-infected treatment-naive adults initiating regimens containing the antiretroviral medication efavirenz between June 2009 and February 2013, including 478 (51%) males, median age 38 years, and plasma HIV RNA 4.9 log₁₀ copies/ml.

Measurements: Primary outcome was a composite of treatment failure over 6 months including death, lost to care or plasma HIV RNA > 25 copies/ml. Exposures included alcohol use and gender.

Findings: Failure in 339 (36%) participants included 40 (4%) deaths, 194 (21%) lost to care and 105 (11%) with HIV RNA > 25 copies/ml. Both hazardous alcohol use in the past year [adjusted odds ratio (aOR) = 1.4, 95% confidence interval (CI) = 1.0, 1.9] and male sex (aOR = 2.1, 95% CI = 1.5, 2.9) were associated with failure. Hazardous alcohol use in the year prior to enrollment was more common in men (57%) than women (24%), P < 0.001. There was no difference in alcohol use effect on failure between sexes (P for interaction > 0.5). Controlling for hazardous alcohol use did not change the relation between sex and failure.

Conclusion: Alcohol use among HIV-infected adults in Botswana appears to worsen HIV treatment outcomes. Alcohol use does not appear to have either a mediating or a moderating effect on the relation between gender and HIV treatment outcome failure.