Indiana University Indiana University IU

Indiana Prevention Resource Center (IPRC)

Drug Abuse and HIV/AIDS: The Role of Alcohol

Drug abuse continues to be a major factor in the spread of HIV/AIDS. Despite receiving much attention since the beginning of the AIDS pandemic, injection drug use (IDU) is not the only way that drugs contribute to transmission. Other drugs, including alcohol, contribute to the spread of HIV by increasing the likelihood of high-risk sex with infected partners. Alcohol, more than tobacco or any illicit drug, is the most accessible, most commonly used and abused drug among youth in the United States. Alcohol is legal in most nations, with certain sale, consumption and age limits. In the United States, the minimum age for purchase and consumption is 21. According to the National Survey on Drug Use and Health (SAMHSA, 2011), in 2010 over half (51.8%) of Americans aged 12 or older were current drinkers of alcohol, 23.1% participated in binge drinking during the 30 days prior to the survey and 6.7% reported heavy drinking. Binge drinking is defined as the consumption of 4 or more drinks for women or 5 or more drinks for men at one sitting or within 2 hours. Heavy drinking is the consumption of more than 2 drinks per day for men or more than 1 drink per day for women on average. It may include binge drinking and can lead to dependence or addiction.

Alcohol abuse involves risky drinking patterns that are harmful to health, such as underage drinking, binge drinking and heavy drinking. Under-age drinking is where a person is below the legal age for drinking alcohol. Nationally, 26.3% of persons aged 12 to 20 reported being current drinkers, 17% were binge drinkers and 5.1% were heavy drinkers (SAMHSA, 2011).

The good news is that these rates have been on a steady decline in the recent past. Still, about 4 out of 5 (82.4%) of those who had used alcohol for the first time during the year prior to the survey were younger than 21.  In Indiana, current use among college students was reported at 70% overall and 63% for those underage during the 2011 Indiana college substance use survey (IPRC/ICAN, 2011).  Early initiation of alcohol consumption increases likelihood of alcohol-related problems and addiction later in life.

Binge drinking starts as early as 12 or 13 years (1%), rising to a high of 45.5% for 21-25 year-olds (SAMHSA, 2011). Over half of alcohol consumed by adults and 90% consumed by youth occur during binge drinking yet most Americans who binge drink are not dependent on alcohol (CDC, 2012). The relative low cost and easy availability of alcohol and the fact that binge drinking is frequently not addressed in clinical settings contribute to the acceptability of excessive alcohol use. According to the 2011 Indiana Youth Survey of Alcohol Tobacco and Other Drug (ATOD) use and high risk behaviors by Indiana 6th to 12th graders conducted by the Indiana Prevention Resource Center (IPRC), about 5.8% of Indiana youths are already binge drinking in 6th grade and rising to about 26.4%, which is higher than the national rate (23.2%), by 12th grade. (IPRC, 2011).  In the 2011 Indiana college substance use survey (ICSUS) also conducted by the IPRC through ICAN, 40% students reported binge drinking within the two weeks prior to the survey (IPRC/ICAN, 2011).

Consequences of Alcohol Abuse
Alcohol consumption has both direct and indirect consequences. Direct consequences relate to alcohol’s effect on one’s body, both physically and mentally. Alcohol impairs one’s judgment and lowers inhibitions, putting one at risk of serious health and social consequences. One may even black-out and not know where they were or what happened to them. Indirect consequences include behavioral changes arising from the impaired physical and mental state. The result is the inability to make rational decisions, leading one to take risks that one is less likely to take when sober, such as high-risk sexual behavior.

An example of high-risk sexual behavior is early initiation of sexual activity. Under-age drinkers are at particularly high risk because they are more likely to be sexually active at an earlier age, to have sexual intercourse more often and to lack the skill to negotiate safe sex especially where older partners are involved. Other high-risk sexual behaviors include unprotected sex, multiple sexual partners and sexual assault including by intimate partners. The risk of becoming a victim of sexual assault increases when one is drunk. According to the National Council on Alcoholism and Drug Dependence (NCADD), 37% of rapes and sexual assaults can be linked to alcohol use by the offender. Approximately 100,000 college students are victims of alcohol-related sexual assault or date rape (NCADD, 2011). During the 2011 Indiana College Substance Use Survey (ICSUS), 29% and 13% reported blacking out and engaging in risky sexual behavior, respectively, as a result of their drinking.

The Alcohol and HIV Link
Alcohol consumption leads to high-risk sexual behavior.   This behavior, in turn, is the link between alcohol abuse and HIV transmission. It is both a consequence of alcohol abuse and a likely cause of HIV transmission. Alcohol abuse can increase HIV risk by lowering inhibitions and promoting situations where opportunity for risky sex is increased, including gender-based violence and coercive sex. The CDCs 2009 National Youth Risk Behavior Survey (YRBS) identified early age at sexual initiation; unprotected sex and older sex partners as sexual risk factors (CDC, 2011). The YRBS also reported that 24.2% of youth are binge drinkers.  These findings, coupled with the early initiation of alcohol use, increase the risk of infection with HIV.

HIV, the virus that causes Acquired Immunodeficiency Syndrome (AIDS), is highly transmissible, incurable but preventable. Sexual intercourse is the main mode of HIV transmission for both heterosexual and same sex partners. Unprotected, unintended and unwanted sex, sometimes with multiple partners can result in HIV infection and other sexually transmitted infections (STIs) which further increase risk of HIV infection. The most common high-risk sexual behavior is unprotected sex which may be vaginal or anal. Unprotected anal intercourse presents increased risk because of greater chance of mucosal disruption (damage to protective mucous membrane) and trauma of the more fragile lining of the rectum. Being drunk makes one more vulnerable to unprotected sex because one may not be in the state of mind to make rational decisions or may even have passed-out. One study of high-risk heterosexual women found that 98% of those who had unprotected anal intercourse also had unprotected vaginal intercourse and were more likely to binge drink (Jenness et. al., 2011).

Having multiple sex partners increases the risk of acquiring or transmitting the virus. This is true within a network of sexual partners, exposing even those who are faithful to a single partner.  Also, the incidence of crimes of sexual assault increase when people are under the influence. The risk of becoming a victim of rape increases when one is drunk and possibly even passed out. This may be in the form of date rape, rape within marriage, or worse still -- gang rape! Both victim and assailant are at risk of acquiring HIV in such circumstances.

Behavioral interventions for HIV prevention should discuss the link between drug use and HIV/STD by addressing the high-risk sexual behaviors which are consequences of drug use, most commonly alcohol consumption. The focus for HIV prevention has been on effective interventions such as condom use, testing and counseling, pre- and post-exposure prophylaxis (preventive medicine), male circumcision and harm reduction through offering needle exchange services to reduce needle sharing that may lead to HIV transmission for injecting drug users. However, there is need to pay more attention now to preventing and treating non-injectable drug use including alcohol, which can interfere with these efforts, impairing people’s judgment and making them less likely to use protection during sex. Preventing and treating alcohol abuse can reduce the incidence of alcohol-induced high-risk sexual behaviors and subsequently reduce HIV transmission.

Action is required at both individual and community level for effective behavior change.

As individuals:

  • If under 21, do not drink alcohol.
  • If 21 or older, drink responsibly (in moderation)
  • Be a good role model
  • Seek help to quit

Primary service providers:

  • Identify alcohol abuse problems early through regular screening on contact, brief intervention and referral to further treatment if needed. The IPRC is currently providing leadership in a five-year grant project to integrate drug and alcohol screening, brief intervention and referral to treatment (SBIRT) services into the routine standard of care at community health centers (CHCs) and community mental health centers (CMHCs) throughout the State of Indiana. The grant was awarded in response to target identified failure by health care providers to routinely ask patients about their alcohol and drug use.
  • Provide a conducive environment, listen and look out for cues from clients

The community:

  • Monitor youth activities
  • Reduce access to alcohol
  • Create environments that empower young people not to drink.
  • Educate youth and adults about the risks of alcohol abuse
  • Support implementation and enforcement of alcohol policies.

The link between alcohol and HIV transmission is a serious issue where HIV prevalence is already high. However, the consequences can be equally devastating, spreading fast in low prevalence areas if high-risk behavior such as unprotected sex with multiple partners is not curtailed. It takes just one infected person in a sexual network of 3 or more partners to infect all. Preventing or treating alcohol abuse can reduce high-risk sexual behavior and prevent HIV transmission!

Selected Bibliography

CDC (2012). Binge Drinking: Nationwide Problem, Local Solutions. Accessed April 14, 2012 at

Centers for Disease Control and Prevention. HIV among Youth: Fast Facts. Published December 2011. Accessed April 14, 2012 at http://www.cdc.gov/hiv/youth/index.htm  

IPRC (2011). Alcohol, Tobacco, and Other Drug (ATOD) Use by Indiana Children and Adolescents Survey. Accessed April 15, 2012 at http://www.drugs.indiana.edu/publications/survey/indianaSurvey_2011_high.pdf

IPRC/ICAN (2011). Indiana College Substance Use Survey 2011. Accessed April 14, 2012 at http://www.drugs.indiana.edu/publications/icsus/ICSUS_Survey_2011.pdf

Jenness et al. (2011) Unprotected Anal Intercourse and Sexually Transmitted Diseases in High-Risk Heterosexual Women. American Journal of Public Health, 101(4), 745-750. doi:10.2105/AJPH.2009.181883

NCADD. “NCADD Fact Sheet On Underage Drinking

SAMHSA (2011).  Results from the 2010 National Survey on Drug Use and Health (NSDUH): Summary of National Findings. Accessed April 14, 2012 at http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf

Indiana College Substance Use Survey 2011 was small with only nine institutions of higher learning in the State participating.

By Susan Nyawade, 5/3/2012