Alcohol use is inextricably linked to the HIV epidemic in fishing communities on Lake Victoria in Uganda, where HIV incidence among regular drinkers is 5 times higher than among non-drinkers. Heavy alcohol use is prevalent among male fisherfolk, and among individuals living with HIV leads to poor treatment outcomes and is associated with suboptimal antiretroviral (ART) adherence and engagement in care. Poverty and stressful work conditions paired with easy access to alcohol and to cash with no means of savings (i.e., access to banks, savings accounts) may be drivers of alcohol consumption among male fisherfolk. Moreover, frequent mobility and work responsibilities, a lack of social support, HIV stigma, and distance to the clinic have been shown to impede access to HIV care services among fisherfolk. Given the unique context of heavy alcohol use and challenges with engaging male fisherfolk in HIV care, a combination intervention, which addresses structural as well as behavioral factors may be needed for this population. We propose to develop and pilot a brief combination intervention which addresses the key drivers of alcohol use and barriers to HIV care engagement and ART adherence in this population. We address these multi-level factors in an intervention which combines a structural component of changing the mode of work payments from cash to mobile money, to reduce ?cash in the pocket,? and increase the accessibility of savings through mobile phone-based banking services, with behavioral components to change behavior. For the behavioral components, we will combine and adapt two efficacious Motivational Interviewing (MI)-based alcohol interventions to the cultural and situational context of this population: a brief intervention tested in Kenya and an intervention rooted in behavioral economics which focuses on increasing the extent to which individuals' behavior is motivated by and consistent with their long-term goals such as saving money for the future?in which will we will interweave the structural component of the intervention.
The aims of our project are to: 1) Combine a promising structural (e.g., reducing ?cash in the pocket?) and behavioral intervention to promote reductions in heavy alcohol use, engagement in HIV care, and ART adherence among HIV+ male fisherfolk. These interventions will be adapted and tailored to the population to create the proposed KISOBOKA (?It is possible!?) intervention. We will refine the combination intervention through qualitative research with HIV+ male fisherfolk and community stakeholders and an initial pilot test with 15 participants examining acceptability and feasibility; 2) Pilot the intervention, randomizing to the KISOBOKA intervention arm (n=80) or to the control arm (n=80, alcohol screening and referral). We will assess feasibility, acceptability, and preliminary estimates of the potential for the intervention, as compared to control, to decrease heavy drinking frequency and improve HIV care engagement and ART adherence through 6 month follow up among this key population.
Fisherfolk are a high risk population for HIV and are prioritized to receive antiretroviral treatment (ART) in Uganda, but risky alcohol use among fisherfolk is a barrier to HIV care engagement; multilevel factors influence alcohol use and poor access to HIV care in fishing villages, including a lack of motivation, social support, access to savings accounts, and access to HIV clinics. This project aims to address these barriers, and subsequently reduce heavy alcohol use and increase engagement in HIV care, through an intervention in which counselors provide individual and group counseling to increase motivation, while also addressing structural barriers to care through increased opportunities for savings and increased social support. This may be a feasible approach to help this hard-to-reach population reduce drinking and increase access care, which could ultimately reduce mortality rates, improve treatment outcomes, and through its effect on HIV viral load, decrease the likelihood of transmitting HIV to others.
