Reduce Alcohol Use and They Will Adhere to ART: Implementation Science Research for Vulnerable Women in South Africa

HIV persists as a public health emergency in South Africa, especially among women of childbearing age who use substances because of misinformation like the quote above.  Additionally, alcohol and other drug (AOD) use and exposure to gender-based violence (GBV) are syndemic issues with increased risk of HIV infection and reduced adherence to antiretroviral therapy (ART). Mounting evidence indicates that large-scale provision of ART is key to arresting the HIV epidemic, but ART adherence is essential. Since September 2016, when the government of South Africa rolled out the provision of Universal Test and Treat (UTT) policy where ART is provided to all people living with HIV, irrespective of CD4 cell count. To date, limited research has been conducted that estimates ART adherence rates for women who use substances in South Africa.

ART adherence means taking HIV medication at the right time (every day), in the right dose and in the right way (as prescribed). Adherence is key to sustaining healthy and longer lives.  Adherence to ART also reduces the risk of HIV transmission. Poor adherence to ART is associated with lower HIV viral suppression and also risk of treatment resistance to ART regimens and HIV treatment failure.

Ensuring access to ART is an important first step in reducing HIV incidence, especially among key populations such as women who use alcohol, especially heavy binge drinking. Woman-focused interventions targeting women who drink and use drugs have shown efficacy in reducing substance use and increasing uptake of HIV services. However, research of implementation of woman-focused interventions in local settings is essential for true sustainability of change[1].  This study proposed to assess the feasibility and acceptability of implementing the Women’s Health CoOp (WHC) intervention via a modified stepped-wedge design across four standard-of-care health clinics and four substance abuse rehabilitation centers in Cape Town, South Africa to reduce alcohol use and risk behavior and increase ART adherence among women who use substances.

[1] Wechsberg, W.M., van der Horst, C., Ndirangu, J. et al. Seek, test, treat: substance-using women in the HIV treatment cascade in South Africa. Addict Sci Clin Pract 12, 12 (2017). https://doi.org/10.1186/s13722-017-0077-x

Over the course of four implementation cycles, this Woman-focused ART adherence study reached 480 women living with HIV who used alcohol or other drugs. We completed field operations in 2018 after completion of final follow-ups and study activities in the fourth cycle, which had a 99% follow-up rate. Outcome data analysis revealed:

• Reduction of alcohol use is an important goal in improving HIV care and re-initiation and adherence.
• ART adherence is less likely in those with severe drinking and alcohol use disorder (AUD) without an intervention.
• Clinic staff found that WHC was well-aligned with goals to increase ART initiation and adherence and decrease substance use.
• There are real world challenges in clinic settings with staff shortages, frequent turnover and burnout, and missing laboratory test data—viral load.
• Conducting booster trainings of the WHC intervention for clinicians increases the likelihood of future sustainability.
• Intervention developers should consider the strengths and limitations of their anticipated implementation setting by engaging with key stakeholders before, during, and after the adaptation and implementation process when developing and attempting to scale-up interventions.

So it has actually paved a way...for women to talk about their issues and also for me as a therapist, an opportunity for me to actually recruit some new clients…in my [rehab] program.”
– WHC Facilitator

Future directions for improving ART adherence in South African women include current training of the WHC package for Cape Town health and Rehab Centres to continue implementation of the WHC and assessment of the continued implementation.  Ongoing training and quality assurance is occurring.

For more studies and information on topics like this one, visit RTI's Substance Use, Gender, and Applied Research Program.

• Wechsberg WM, Ndirangu JW, Speizer IS, Zule WA, Gumula W, Peasant C, Browne FA, Dunlap L. An implementation science protocol of the Women's Health CoOp in healthcare settings in Cape Town, South Africa: A stepped-wedge design. BMC Womens Health. 2017 Sep 18;17(1):85. doi: 10.1186/s12905-017-0433-8. PMID: 28923034; PMCID: PMC5604513.
• Howard, B.N., Van Dorn, R., Myers, B.J. et al. Barriers and facilitators to implementing an evidence-based woman-focused intervention in South African health services. BMC Health Serv Res 17, 746 (2017). https://doi.org/10.1186/s12913-017-2669-2
• Washio Y, Browne F, Ndirangu J, Kline T, Wechsberg W. (2021). Antiretroviral Therapy (ART) Adherence and Prenatal Alcohol Use among Women Who Are Pregnant with HIV in South Africa. International Journal of Environmental Research and Public Health, 18(14):7446.
• Wechsberg WM, Browne FA, Ndirangu J, Bonner CP, Kline TL, Gichane M, Zule WA. Outcomes of Implementing in the Real World the Women's Health CoOp Intervention in Cape Town, South Africa. AIDS Behav. 2021 Apr 23:1–14. doi: 10.1007/s10461-021-03251-7. Epub ahead of print. PMID: 33891233; PMCID: PMC8063777.
• Gichane MW, Wechsberg WM, Ndirangu J, Browne FA, Bonner CP, Grimwood A, Shaikh N, Howard B, Zule WA. Implementation science outcomes of a gender-focused HIV and alcohol risk-reduction intervention in usual-care settings in South Africa. Drug Alcohol Depend. 2020 Oct 1;215:108206. doi: 10.1016/j.drugalcdep.2020.108206. Epub 2020 Aug 1.
• Margaret W. Gichane, Wendee M. Wechsberg, Jacqueline Ndirangu, Brittni Howard, Courtney Peasant Bonner, Felicia A. Browne & William A. Zule (2021) Sustainability of a gender-focused HIV and alcohol risk-reduction intervention in usual care settings in South Africa: a mixed methods analysis, AIDS Care, DOI: 10.1080/09540121.2021.1966694