AIDS and Behavior

, Volume 23, Issue 1, pp 201–210 | Cite as

Couple Interdependence Impacts Alcohol Use and Adherence to Antiretroviral Therapy in Malawi

  • Amy A. ConroyEmail author
  • Stacey A. McKenna
  • Allison Ruark
Original Paper


In sub-Saharan Africa, harmful alcohol use among male drinkers is high and has deleterious consequences on adherence to antiretroviral therapy (ART), HIV clinical outcomes, and couple relationship dynamics. We conducted in-depth qualitative interviews with 25 Malawian couples on ART to understand how relationships influence adherence to ART, in which alcohol use emerged as a major theme. Almost half of men (40%) reported current or past alcohol use. Although alcohol use was linked to men’s non-adherence, women buffered this harm by encouraging husbands to reduce alcohol use and by offering adherence support when men were drinking. Men’s drinking interfered with being an effective treatment guardian for wives on ART and also weakened couple support systems needed for adherence. Relationship challenges including food insecurity, intimate partner violence, and extramarital relationships appeared to exacerbate the negative consequences of alcohol use on ART adherence. In this setting, alcohol may be best understood as a couple-level issue. Alcohol interventions for people living with HIV should consider approaches that jointly engage both partners.


Couples Alcohol Antiretroviral therapy Adherence Sub-Saharan Africa HIV/AIDS 



The authors would like to thank the tireless efforts of the research staff at Invest in Knowledge in Malawi for data collection.


This study was funded by the National Institutes of Health under Grants K01MH107331 and T32DA13911.

Compliance with Ethical Standards

Conflict of interest

There are no conflicts of interest for any of the study authors.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Galvan FH, Bing EG, Fleishman JA, et al. The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study. J Stud Alcohol. 2002;63(2):179–86.Google Scholar
  2. 2.
    Hendershot CS, Stoner SA, Pantalone DW, et al. Alcohol use and antiretroviral adherence: review and meta-analysis. J Acquir Immune Defic Syndr. 2009;52(2):180–202.Google Scholar
  3. 3.
    Giordano TP, Hartman C, Gifford AL, et al. Predictors of retention in HIV care among a national cohort of US veterans. HIV Clin Trials. 2009;10(5):299–305.Google Scholar
  4. 4.
    Chander G, Lau B, Moore RD. Hazardous alcohol use: a risk factor for non-adherence and lack of suppression in HIV infection. J Acquir Immune Defic Syndr. 2006;43(4):411.Google Scholar
  5. 5.
    Baum MK, Rafie C, Lai S, et al. Alcohol use accelerates HIV disease progression. AIDS Res Hum Retroviruses. 2010;26(5):511–8.Google Scholar
  6. 6.
    Hahn JA, Samet JH. Alcohol and HIV disease progression: weighing the evidence. Curr HIV/AIDS Rep. 2010;7(4):226–33.Google Scholar
  7. 7.
    Braithwaite RS, Bryant KJ. Influence of alcohol consumption on adherence to and toxicity of antiretroviral therapy and survival. Alcohol Res Health. 2010;33(3):280.Google Scholar
  8. 8.
    Kekwaletswe CT, Morojele NK. Alcohol use, antiretroviral therapy adherence, and preferences regarding an alcohol-focused adherence intervention in patients with human immunodeficiency virus. Patient Prefer Adherence. 2014;8:401–13.Google Scholar
  9. 9.
    Conroy AA, McKenna SA, Leddy A, et al. “If she is drunk, I don’t want her to take it”: partner beliefs and influence on use of alcohol and antiretroviral therapy in South African couples. AIDS Behav. 2017;21(7):1885–91.Google Scholar
  10. 10.
    Fatch R, Emenyonu NI, Muyindike W, et al. Alcohol interactive toxicity beliefs and ART non-adherence among HIV-infected current drinkers in Mbarara, Uganda. AIDS Behav. 2016;21(7):1812–24.Google Scholar
  11. 11.
    Kalichman SC, Amaral CM, White D, et al. Prevalence and clinical implications of interactive toxicity beliefs regarding mixing alcohol and antiretroviral therapies among people living with HIV/AIDS. AIDS Patient Care STDS. 2009;23(6):449–54.Google Scholar
  12. 12.
    Kalichman SC, Amaral CM, White D, et al. Alcohol and adherence to antiretroviral medications: interactive toxicity beliefs among people living with HIV. J Assoc Nurses AIDS Care. 2012;23(6):511–20.Google Scholar
  13. 13.
    Levitt A, Derrick JL, Testa M. Relationship-specific alcohol expectancies and gender moderate the effects of relationship drinking contexts on daily relationship functioning. J Stud Alcohol Drugs. 2014;75(2):269–78.Google Scholar
  14. 14.
    Levitt A, Cooper ML. Daily alcohol use and romantic relationship functioning: evidence of bidirectional, gender-, and context-specific effects. Pers Soc Psychol Bull. 2010;36(12):1706–22.Google Scholar
  15. 15.
    Homish GG, Leonard KE. Marital quality and congruent drinking. J Stud Alcohol. 2005;66(4):488–96.Google Scholar
  16. 16.
    Rodriguez LM, Neighbors C, Knee CR. Problematic alcohol use and marital distress: an interdependence theory perspective. Addict Res Theory. 2014;22(4):294–312.Google Scholar
  17. 17.
    Leonard KE, Rothbard JC. Alcohol and the marriage effect. J Stud Alcohol (supplement). 1999;13:139–46.Google Scholar
  18. 18.
    Gotlib IH, McCabe SB. Marriage and psychopathology. In: Fincham F, Bradbury T, editors. The psychology of marriage. New York: Guilford; 1990. p. 226–57.Google Scholar
  19. 19.
    Halford WK, Bouma R, Kelly A, et al. Individual psychopathology and marital distress: analyzing the association and implications for therapy. Behav Modif. 1999;23(2):179–216.Google Scholar
  20. 20.
    O’Farrell T, Rotunda R. Couples interventions and alcohol abuse. In: Halford W, Markman H, editors. Clinical handbook of marriage and couples interventions. Chichester: Wiley; 1997. p. 555–88.Google Scholar
  21. 21.
    Homish GG, Leonard KE. The drinking partnership and marital satisfaction: the longitudinal influence of discrepant drinking. J Consult Clin Psychol. 2007;75(1):43.Google Scholar
  22. 22.
    World Health Organization. Global status report on alcohol and health. Geneva, Switzerland: World Health Organization; 2014.Google Scholar
  23. 23.
    Morojele NK, Kekwaletswe CT, Nkosi S. Associations between alcohol use, other psychosocial factors, structural factors and antiretroviral therapy (ART) adherence among South African ART recipients. AIDS Behav. 2014;18(3):519–24.Google Scholar
  24. 24.
    Sileo KM, Simbayi LC, Abrams A, et al. The role of alcohol use in antiretroviral adherence among individuals living with HIV in South Africa: event-level findings from a daily diary study. Drug Alcohol Depend. 2016;167:103–11.Google Scholar
  25. 25.
    Denison JA, Koole O, Tsui S, et al. Incomplete adherence among treatment-experienced adults on antiretroviral therapy in Tanzania, Uganda and Zambia. AIDS (London, England). 2015;29(3):361.Google Scholar
  26. 26.
    Ruark A, Kajubi P, Ruteikara S, et al. Couple relationship functioning as a source or mitigator of HIV risk: associations between relationship quality and sexual risk behavior in peri-urban Uganda. AIDS Behav. 2017;22(4):1273–87.Google Scholar
  27. 27.
    Woolf-King S, Conroy A, Fritz K, et al. Alcohol use and relationship quality among South African couples: implications for couples-based HIV interventions. In: International AIDS conference, 18–22 July 2016, Durban, South Africa; 2016.Google Scholar
  28. 28.
    Kelley HH, Thibalt JW. Interpersonal relations: a theory of interdependence. New York: Wiley; 1978.Google Scholar
  29. 29.
    Karney BR, Hops H, Redding CA, et al. A framework for incorporating dyads in models of HIV-prevention. AIDS Behav. 2010;14(2):189–203.Google Scholar
  30. 30.
    Rusbult C, Arriaga X. Interdependence theory. In: Duck S, editor. Handbook of personal relationships. 2nd ed. London: Wiley; 1997.Google Scholar
  31. 31.
    Conroy A, Leddy A, Johnson M, et al. ‘I told her this is your life’: relationship dynamics, partner support and adherence to antiretroviral therapy among South African couples. Cult Health Sex. 2017;19(11):1239–53.Google Scholar
  32. 32.
    Conroy AA, McKenna SA, Comfort ML, et al. Marital infidelity, food insecurity, and couple instability: a web of challenges for dyadic coordination around antiretroviral therapy. Soc Sci Med. 2018;214:110–7.Google Scholar
  33. 33.
    Singer M. A dose of drugs, a touch of violence, a case of AIDS, part 2: further conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 2006;34(1):39–53.Google Scholar
  34. 34.
    Singer M. A dose of durgs, a touch of violence, a case of AIDS: conceptualizing the SAVA epidemic. Free Inq Creat Sociol. 1996;24(2):99–110.Google Scholar
  35. 35.
    Russell BS, Eaton LA, Petersen-Williams P. Intersecting epidemics among pregnant women: alcohol use, interpersonal violence, and HIV infection in South Africa. Curr HIV/AIDS Rep. 2013;10(1):103–10.Google Scholar
  36. 36.
    Hatcher AM, Colvin CJ, Ndlovud N, et al. Intimate partner violence among rural South African men: alcohol use, sexual decision-making, and partner communication. Cult Health Sex. 2014;16(9):1023–39.Google Scholar
  37. 37.
    Tsai A, Burns B. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139:26–35.Google Scholar
  38. 38.
    Parsons JT, Grov C, Golub SA. Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health. 2012;102(1):156–62.Google Scholar
  39. 39.
    Miller CL, Bangsberg DR, Tuller DM, et al. Food insecurity and sexual risk in an HIV endemic community in Uganda. AIDS Behav. 2011;15:1512–9.Google Scholar
  40. 40.
    Weiser SD, Palar K, Frongillo EA, et al. Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda. AIDS. 2014;28:115–20.Google Scholar
  41. 41.
    Weiser SD, Tuller DM, Frongillo EA, et al. Food insecurity as a barrier to sustained antiretroviral therapy adherence in Uganda. PLoS ONE. 2010;5(4):e10340.Google Scholar
  42. 42.
    Friedman MR, Stall R, Plankey M, et al. Effects of syndemics on HIV viral load and medication adherence in the multicenter AIDS cohort study. AIDS (London, England). 2015;29(9):1087.Google Scholar
  43. 43.
    Blashill AJ, Bedoya CA, Mayer KH, et al. Psychosocial syndemics are additively associated with worse ART adherence in HIV-infected individuals. AIDS Behav. 2015;19(6):981–6.Google Scholar
  44. 44.
    Kuhns LM, Hotton AL, Garofalo R, et al. An index of multiple psychosocial, syndemic conditions is associated with antiretroviral medication adherence among HIV-positive youth. AIDS Patient Care STDS. 2016;30(4):185–92.Google Scholar
  45. 45.
    Starks TJ, Tuck AN, Millar BM, et al. Linking syndemic stress and behavioral indicators of main partner HIV transmission risk in gay male couples. AIDS Behav. 2016;20(2):439–48.Google Scholar
  46. 46.
    Msyamboza KP, Ngwira B, Dzowela T, et al. The burden of selected chronic non-communicable diseases and their risk factors in Malawi: nationwide STEPS survey. PLoS ONE. 2011;6(5):e20316.Google Scholar
  47. 47.
    Bush K, Kivlahan D, McDonell M, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789–95.Google Scholar
  48. 48.
    National Statistical Office (NSO) [Malawi] and ICF. Malawi Demographic and Health Survey 2015–2016. Zomba: NSO and ICF; 2017.Google Scholar
  49. 49.
    UNAIDS. UNAIDS Country Report on Malawi. 2018.
  50. 50.
    Ministry of Health Malawi. 3rd Edition of the Malawi Guidelines for Clinical Management of HIV in Children and Adults. Malawi: Lilongwe; 2016.Google Scholar
  51. 51.
    Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–62.Google Scholar
  52. 52.
    Ritchie J, Lewis J, Nicholls CM, et al. Qualitative research practice: A guide for social science students and researchers. London: Sage; 2013.Google Scholar
  53. 53.
    Starmann E, Collumbien M, Kyegombe N, et al. Exploring couples’ processes of change in the context of SASA! A violence against women and HIV prevention intervention in Uganda. Prev Sci. 2017;18(2):233–44.Google Scholar
  54. 54.
    Mugweni E, Pearson S, Omar M. Concurrent sexual partnerships among married Zimbabweans—implications for HIV prevention. Int J Women’s Health. 2015;7:819.Google Scholar
  55. 55.
    Lyimo RA, de Bruin M, van den Boogaard J, et al. Determinants of antiretroviral therapy adherence in northern Tanzania: a comprehensive picture from the patient perspective. BMC Public Health. 2012;12(1):716.Google Scholar
  56. 56.
    Powers MB, Vedel E, Emmelkamp PM. Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis. Clin Psychol Rev. 2008;28(6):952–62.Google Scholar
  57. 57.
    Fals-Stewart W, Clinton-Sherrod M. Treating intimate partner violence among substance-abusing dyads: the effect of couples therapy. Prof Psychol Res Pract. 2009;40(3):257.Google Scholar
  58. 58.
    Wechsberg WM, Zule WA, El-Bassel N, et al. The male factor: outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township. Drug Alcohol Depend. 2016;161:307–15.Google Scholar
  59. 59.
    Timko C, Young LB, Moos RH. Al-Anon family groups: origins, conceptual basis, outcomes, and research opportunities. J Groups Addict Recov. 2012;7(2–4):279–96.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Prevention Sciences, Department of Medicine, Center for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoUSA
  2. 2.Stacey McKenna, LLCFort CollinsUSA
  3. 3.Department of MedicineBrown UniversityProvidenceUSA

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