Psychometric assessment of the Runyankole-translated Marlowe-Crowne Social Desirability Scale among persons with HIV in Uganda.

BACKGROUND: Social desirability can negatively affect the validity of self-reported measures, including underreporting of stigmatized behaviors like alcohol consumption. The Marlowe-Crowne Social Desirability Scale (SDS) is widely implemented and comprised of Denial and Attribution Domains (i.e., tendencies to deny undesirable traits or attribute socially desirable traits to oneself, respectively). Yet, limited psychometric research has been conducted in sub-Saharan Africa, where the prevalence of unhealthy alcohol consumption is high as well as religiosity and hierarchical social norms. To address this gap, we (a) conducted an exploratory study assessing certain psychometric properties of the 28-item SDS (Runyankole-translated) among persons with HIV (PWH) in Uganda, and (b) examined the relationship between social desirability and self-reported alcohol use. METHODS: We pooled baseline data (N = 1153) from three studies of PWH engaged in alcohol use from 2017 to 2021. We assessed the translated scales construct validity (via confirmatory factor analysis), internal consistency, item performance, differential item functioning by gender, concurrent validity with the DUREL religiosity index domains, and the association between social desirability and self-reported alcohol use. RESULTS: Participants had a mean age of 40.42 years, 63% were men, and 91% had an undetectable HIV viral load. The 28-item SDS had satisfactory construct validity (Model fit indices: RMSEA = 0.07, CFI = 0.84, TLI = 0.82) and internal consistency (Denial Domain ΩTotal = 0.82, Attribution Domain ΩTotal = 0.69). We excluded Item 14 (I never hesitate to help someone in trouble) from the Attribution Domain, which mitigated differential measurement error by gender and slightly improved the construct validity (Model fit indices: RMSEA = 0.06, CFI = 0.86, TLI = 0.85) and reliability (Attribution Domain ΩTotal = 0.72) of the 27-item modified SDS. Using the 27-item SDS, we found that social desirability was weakly correlated with religiosity and inversely associated with self-reported alcohol use after adjusting for biomarker-measured alcohol use and other confounders (β = -0.05, 95% confidence interval: -0.09 to -0.01, p-value = 0.03). CONCLUSIONS: We detected and mitigated measurement error in the 28-item Runyankole-translated SDS, and found that the modified 27-item scale had satisfactory construct validity and internal consistency in our sample. Future studies should continue to evaluate the psychometric properties of the Runyankole-translated SDS, including retranslating Item 14 and reevaluating its performance

Phosphatidylethanol confirmed alcohol use among ART-naïve HIV-infected persons who denied consumption in rural Uganda

Under-reporting of alcohol use by HIV-infected patients could adversely impact clinical care. This study examined factors associated with under-reporting of alcohol consumption by patients who denied alcohol use in clinical and research settings using an alcohol biomarker. We enrolled ART-naïve, HIV-infected adults at Mbarara Hospital HIV clinic in Uganda. We conducted baseline interviews on alcohol use, demographics, Spirituality and Religiosity Index (SRI), health and functional status; and tested for breath alcohol content and collected blood for phosphatidylethanol (PEth), a sensitive and specific biomarker of alcohol use. We determined PEth status among participants who denied alcohol consumption to clinic counselors (Group 1, n = 104), and those who denied alcohol use on their research interview (Group 2, n = 198). A positive PEth was defined as ≥8 ng/ml. Multiple logistic regression models were used to examine whether testing PEth-positive varied by demographics, literacy, spirituality, socially desirable reporting and physical health status. Results showed that, among the 104 participants in Group 1, 28.8% were PEth-positive. The odds of being PEth-positive were higher for those reporting prior unhealthy drinking (adjusted odds ratio (AOR): 4.7, 95% confidence interval (CI): 1.8, 12.5). No other factors were statistically significant. Among the 198 participants in Group 2, 13.1% were PEth-positive. The odds of being PEth-positive were higher for those reporting past unhealthy drinking (AOR: 4.6, 95% CI: 1.8, 12.2), the Catholics (AOR: 3.8, 95% CI: 1.3, 11.0) compared to Protestants and lower for the literate participants (AOR: 0.3, 95% CI: 0.1, 0.8). We concluded that under-reporting of alcohol use to HIV clinic staff was substantial, but it was lower in a research setting that conducted testing for breath alcohol and PEth. A report of past unhealthy drinking may highlight current alcohol use among deniers. Strategies to improve alcohol self-report are needed within HIV care settings in Uganda

Cell Phone Availability and Usage for mHealth and Intervention Delivery to Persons Living With HIV in a Low-Resource Setting: Cross-sectional Study.

BackgroundHIV/AIDS is now a manageable chronic illness owing to effective antiretroviral therapy (ART), which involves routine follow-up care, including regular physical visits to the clinic. In the recent past, and in wake of the COVID-19 pandemic, there has been increased need for virtual care and intervention delivery, a modality known as mobile health (mHealth), which includes cell phone-delivered services for medical and public health practice.ObjectiveHere we describe cell phone use and its relationship with alcohol use in a cohort of persons living with HIV and latent tuberculosis (TB).MethodsWe performed a cross-sectional analysis of baseline data from a cohort of persons living with HIV and latent TB in HIV care in southwestern Uganda. We estimated proportions of cell phone and text message use and evaluated their associations with alcohol use-a common modifiable behavior among persons living with HIV. Cell phone use (primary outcome) was defined as owning a cell phone that is turned on at least half of the day. Any alcohol use was defined as any self-reported alcohol use in the prior 3 months or a phosphatidylethanol (an alcohol biomarker) level of ≥8 ng/mL.ResultsA total of 300 participants (median age 40 years; n=146, 48.7% male) were included in the analysis. Most (n=267, 89.0%) participants had access to a phone and of them, 26 (9.7%) shared the phone with someone else. In total, 262/300 (87.3%) of participants owned a cell phone that is turned on at least half of the time; the majority (n=269, 89.7%) rarely or never sent text messages, and over two-thirds (n=200, 66.9%) rarely or never received text messages. Most (n=214, 71.3%) had any alcohol use in the prior 3 months. In adjusted analyses, any alcohol use was not significantly associated with cell phone use (adjusted odds ratio [aOR] 0.48, 95% CI 0.18-1.25; P=.13) or sending (aOR 0.82, 95% CI 0.28-2.37; P=.71) or receiving (aOR 1.31, 95% CI 0.70-2.47; P=.40) text messages.ConclusionsThere is hope that mHealth interventions in this population can be carried out using cell phones owing to their popularity; however, the interventions may need to employ methods that do not rely on the sending and receiving of text messages only

Unhealthy Alcohol Use Is Associated With Suboptimal Adherence to Isoniazid Preventive Therapy in Persons With HIV in Southwestern Uganda.

BACKGROUND: Unhealthy alcohol use is associated with increased progression to tuberculosis (TB) disease, but its effect on adherence to isoniazid (INH) preventive therapy is not known. METHODS: This was a prospective study of persons with HIV with latent TB in southwestern Uganda reporting any current (previous 3 months) alcohol use or no alcohol consumption in the previous year (2:1 ratio). All received INH. We defined suboptimal adherence as <90% of days with at least 1 Medication Event Monitoring System cap opening, over the previous 90 days. Alcohol use was categorized as follows: none: no self-report and phosphatidylethanol (PEth) <8 ng/mL; moderate: Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) 1-2 (women) or 1-3 (men) and/or PEth 8 ≥ 50 ng/mL; and unhealthy: AUDIT-C ≥3 (women) or ≥4 (men) and/or PEth ≥50 ng/mL. We used generalized estimating equation logistic regression analyses to assess the association between the level of alcohol use and suboptimal INH adherence. RESULTS: Three hundred two persons were enrolled; 279 were on INH for 3 or more months. The prevalence of suboptimal INH adherence was 31.3% at 3 months and 43.9% at 6 months. The odds of suboptimal INH adherence were higher for unhealthy (adjusted odds ratio, 2.78; 95% confidence interval: 1.62 to 4.76) and moderate (adjusted odds ratio, 1.59; 95% confidence interval: 0.94 to 2.71) compared with no alcohol consumption. CONCLUSIONS: Suboptimal adherence to INH at 3 and 6 months was high among prospective study of persons with HIV and associated with unhealthy alcohol use. Adherence support and alcohol reduction strategies are needed for this group at high risk for active TB

Bar Attendance and Alcohol Use Before and After COVID-19 Related Restrictions Among HIV-infected Adults in South-Western Uganda

Alcohol use is especially problematic for people living with HIV (PLWH) and was likely to be impacted by the coronavirus disease (COVID-19) pandemic and its restrictions. In a study of PLWH with latent tuberculosis infection, we measured unhealthy alcohol use with the Alcohol Use Disorders Identification Test (AUDIT-C), phosphatidylethanol (PEth) and bar attendance. We analyzed data collected before and after COVID-19 restrictions, and used Generalized Estimating Equations (GEE) logistic regression models to evaluate changes in unhealthy alcohol use. While bar attendance declined from 57.0% before to 38.3% after the restrictions started, multivariable analysis controlling for bar use showed a significant increase in unhealthy alcohol use; the adjusted odds ratio for unhealthy drinking before versus after the restrictions started was 1.37 (95% CI: 0.89-2.12) which increased to 1.64 (95% CI: 1.08-2.50) when bar attendance was added to the model. Decline in bar attendance did not decrease unhealthy alcohol use

Alcohol Use and Unprotected Sex Among HIV-Infected Ugandan Adults: Findings from an Event-Level Study

While alcohol is a known risk factor for HIV infection in sub-Saharan Africa (SSA), studies designed to investigate the temporal relationship between alcohol use and unprotected sex are lacking. The purpose of this study was to determine whether alcohol used at the time of a sexual event is associated with unprotected sex at that same event. Data for this study were collected as part of two longitudinal studies of HIV-infected Ugandan adults. A structured questionnaire was administered at regularly scheduled cohort study visits in order to assess the circumstances (e.g., alcohol use, partner type) of the most recent sexual event (MRSE). Generalized estimating equation logistic regression models were used to examine the association between alcohol use (by the participant, the sexual partner, or both the participant and the partner) and the odds of unprotected sex at the sexual event while controlling for participant gender, age, months since HIV diagnosis, unhealthy alcohol use in the prior 3 months, partner type, and HIV status of partner. A total of 627 sexually active participants (57% women) reported 1817 sexual events. Of these events, 19% involved alcohol use and 53% were unprotected. Alcohol use by one's sexual partner (aOR 1.70; 95% CI 1.14, 2.54) or by both partners (aOR 1.78; 95% CI 1.07, 2.98) during the MRSE significantly increased the odds of unprotected sex at that same event. These results add to the growing event-level literature in SSA and support a temporal association between alcohol used prior to a sexual event and subsequent unprotected sex

Phosphatidylethanol confirmed alcohol use among ART-naïve HIV-infected persons who denied consumption in rural Uganda.

Under-reporting of alcohol use by HIV-infected patients could adversely impact clinical care. This study examined factors associated with under-reporting of alcohol consumption by patients who denied alcohol use in clinical and research settings using an alcohol biomarker. We enrolled ART-naïve, HIV-infected adults at Mbarara Hospital HIV clinic in Uganda. We conducted baseline interviews on alcohol use, demographics, Spirituality and Religiosity Index (SRI), health and functional status; and tested for breath alcohol content and collected blood for phosphatidylethanol (PEth), a sensitive and specific biomarker of alcohol use. We determined PEth status among participants who denied alcohol consumption to clinic counselors (Group 1, n = 104), and those who denied alcohol use on their research interview (Group 2, n = 198). A positive PEth was defined as ≥8 ng/ml. Multiple logistic regression models were used to examine whether testing PEth-positive varied by demographics, literacy, spirituality, socially desirable reporting and physical health status. Results showed that, among the 104 participants in Group 1, 28.8% were PEth-positive. The odds of being PEth-positive were higher for those reporting prior unhealthy drinking (adjusted odds ratio (AOR): 4.7, 95% confidence interval (CI): 1.8, 12.5). No other factors were statistically significant. Among the 198 participants in Group 2, 13.1% were PEth-positive. The odds of being PEth-positive were higher for those reporting past unhealthy drinking (AOR: 4.6, 95% CI: 1.8, 12.2), the Catholics (AOR: 3.8, 95% CI: 1.3, 11.0) compared to Protestants and lower for the literate participants (AOR: 0.3, 95% CI: 0.1, 0.8). We concluded that under-reporting of alcohol use to HIV clinic staff was substantial, but it was lower in a research setting that conducted testing for breath alcohol and PEth. A report of past unhealthy drinking may highlight current alcohol use among deniers. Strategies to improve alcohol self-report are needed within HIV care settings in Uganda

Alcohol Use and HIV Disease Progression in an Antiretroviral Naive Cohort.

BACKGROUND:Alcohol use has been shown to accelerate disease progression in experimental studies of simian immunodeficiency virus in macaques, but the results in observational studies of HIV have been conflicting. METHODS:We conducted a prospective cohort study of the impact of unhealthy alcohol use on CD4 cell count among HIV-infected persons in southwestern Uganda not yet eligible for antiretroviral treatment (ART). Unhealthy alcohol consumption was 3-month Alcohol Use Disorders Identification Test-Consumption positive (≥3 for women, ≥4 for men) and/or phosphatidylethanol (PEth-an alcohol biomarker) ≥50 ng/mL, modeled as a time-dependent variable in a linear mixed effects model of CD4 count. RESULTS:At baseline, 43% of the 446 participants were drinking at unhealthy levels and the median CD4 cell count was 550 cells/mm (interquartile range 416-685). The estimated CD4 cell count decline per year was -14.5 cells/mm (95% confidence interval: -38.6 to 9.5) for unhealthy drinking vs. -24.0 cells/mm (95% confidence interval: -43.6 to -4.5) for refraining from unhealthy drinking, with no significant difference in decline by unhealthy alcohol use (P value 0.54), adjusting for age, sex, religion, time since HIV diagnosis, and HIV viral load. Additional analyses exploring alternative alcohol measures, participant subgroups, and time-dependent confounding yielded similar findings. CONCLUSION:Unhealthy alcohol use had no apparent impact on the short-term rate of CD4 count decline among HIV-infected ART naive individuals in Uganda, using biological markers to augment self-report and examining disease progression before ART initiation to avoid unmeasured confounding because of misclassification of ART adherence

Alcohol Use and HIV Disease Progression in an Antiretroviral Naive Cohort.

BACKGROUND:Alcohol use has been shown to accelerate disease progression in experimental studies of simian immunodeficiency virus in macaques, but the results in observational studies of HIV have been conflicting. METHODS:We conducted a prospective cohort study of the impact of unhealthy alcohol use on CD4 cell count among HIV-infected persons in southwestern Uganda not yet eligible for antiretroviral treatment (ART). Unhealthy alcohol consumption was 3-month Alcohol Use Disorders Identification Test-Consumption positive (≥3 for women, ≥4 for men) and/or phosphatidylethanol (PEth-an alcohol biomarker) ≥50 ng/mL, modeled as a time-dependent variable in a linear mixed effects model of CD4 count. RESULTS:At baseline, 43% of the 446 participants were drinking at unhealthy levels and the median CD4 cell count was 550 cells/mm (interquartile range 416-685). The estimated CD4 cell count decline per year was -14.5 cells/mm (95% confidence interval: -38.6 to 9.5) for unhealthy drinking vs. -24.0 cells/mm (95% confidence interval: -43.6 to -4.5) for refraining from unhealthy drinking, with no significant difference in decline by unhealthy alcohol use (P value 0.54), adjusting for age, sex, religion, time since HIV diagnosis, and HIV viral load. Additional analyses exploring alternative alcohol measures, participant subgroups, and time-dependent confounding yielded similar findings. CONCLUSION:Unhealthy alcohol use had no apparent impact on the short-term rate of CD4 count decline among HIV-infected ART naive individuals in Uganda, using biological markers to augment self-report and examining disease progression before ART initiation to avoid unmeasured confounding because of misclassification of ART adherence