Switch On Your HIV Smarts.

Drinking in Control

, by Emily Land

Sarah Woolf-King pic

Sarah Woolf-King, PhD

“HIV researchers have called alcohol the ‘forgotten drug’ in the HIV epidemic,” explains Sarah Woolf-King, PhD, MPH. “It’s so ubiquitous and normative, people tend to forget that when it’s overused or misused, it can still have significant negative consequences.”

Woolf-King, Assistant Professor at the University of California, San Francisco, has devoted the past decade of her research career investigating the role of alcohol in sexual decision making and HIV transmission—with an eye on ultimately being able to help people be healthier and make safer choices when they drink.

She explained to BETA that, without a doubt, alcohol has played some part in contributing to the HIV epidemic. “The association between alcohol, sex without condoms, and HIV transmission is ubiquitous. In nearly every country, in every subpopulation where it has been studied, people who use alcohol are more likely to be HIV positive, and they’re more likely to have unprotected sex,” notes Woolf-King.

But, alcohol doesn’t always equate to unprotected sex—alcohol’s causal role is more nuanced. The relationship between alcohol and unprotected sex is moderated by other factors, such as how long a person has been with their current sex partner. Alcohol is more likely to influence a person’s decision to have unprotected sex if he or she is with a first time—versus longer term—sexual partner. People with longer-term partners are more likely to have established sexual routines, and thus more likely to do the same thing whether or not they’ve been drinking.

This relationship is also moderated by how much a person has been drinking, how much the partner has been drinking, and how many times the person has had sex with that specific partner, even if it’s just a casual partner. So, sums Woolf-King, “The more we look at it, the more we realize that—yes—alcohol is associated with unprotected sex that may increase the likelihood of HIV transmission. But, it depends on a lot of things that are specific to the situation in which it’s occurring.”

She explains that sometimes, people who know of her research are surprised to find out that she drinks alcohol. Even knowing that alcohol can sometimes cause negative consequences doesn’t mean she thinks people should stop drinking. Rather, she takes a harm reduction approach.

“There’s a way to enjoy alcohol that’s not very likely to result in negative consequences. I’m interested in interventions that help people learn how to use alcohol in a way that’s safe and that won’t result in something they don’t want it to result in.”

So, how can drinkers reduce the negative consequences of alcohol use?

Woolf-King makes the distinction between individuals that are physiologically dependent on alcohol—versus those that aren’t. She cautions that the harm reduction techniques she promotes aren’t likely to help individuals who have developed a chemical dependency on alcohol.

However, for someone who experiences problems related to alcohol consumption and wants to reduce negative consequences, she recommends developing a plan for how to drink. “Say, ‘I’m only going to have four drinks tonight, and I am going to try and space them out over several hours. If I start drinking at nine, by midnight or one that’s when I’ll decide to go home.’”

She explains that counting the number of drinks consumed will help, especially if people have an understanding of what their blood alcohol concentration (BAC) will reach based on their weight and gender. She does caution that counting drinks can sometimes be difficult to do.

“With mixed drinks, you have to know what’s being put in your drink. You might think you’re only having one, but you’re really having two. It’s the same with beer. Really one drink is 12 ounces of 4% alcohol by volume. But most of the IPAs are really double that alcohol by volume, and you’re getting a 16 ounce pint rather than a 12 ounce beer.”

She highlights other tactics people can use such as noting the time when they start drinking, and how much time passes before they order another drink. Drinking water in between alcoholic drinks helps, as does making sure to eat something before beginning a night of drinking.

Woolf-King also recommends thinking about how alcohol makes you feel—so that you’re able to maximize its positive effects, such as feeling more social or “that warm, fuzzy feeling that people get from having no more than a couple of drinks.”

She explains that if you drink between one or two drinks an hour, and not more than four, then you’ll enhance the positive effects of alcohol—what’s termed the “upward limb.” This is the realm where you’ll likely want to stay. Drinking beyond this puts you on the “downward limb,” where you’ll experience the more depressant effects of alcohol, like sleepiness, slurred speech, and impaired decision making.

For nights when a person decides to drink more, she says it’s helpful to think ahead of time about how to address other issues like sex or driving home. Woolf-King suggests one strategy of relying on a friend who hasn’t been drinking or has been drinking less. This person could make sure that their other friends have condoms, get home safely, or take time to think before going home with another person.

People living with HIV can also adopt harm reduction approaches when drinking. Living with HIV doesn’t mean that a person can’t have wine with dinner—or drink too much at the bar every now and then—but there are some special considerations. Woolf-King points to the issue of medication adherence, explaining that it’s best to plan to take antiretroviral medications ahead of time if a person is planning on going out at night to drink.

In addition, she notes that it’s important for people to know that there aren’t any interactive toxicities between alcohol and HIV medications. “So, if you’re drunk, and you realize you forgot to take your medication that day, you should still take it. It’s not going to interact with the alcohol and make you sick. It’s much better for you to take the medication.”

Finally, alcohol does affect the immune system, both for people who are negative and for people who are positive. “When you’re negative, it makes you more susceptible to infections, both chronic alcohol use and being acutely intoxicated. And when you’re positive, anything you can do to help your body—to not deplete your immune system—is a good thing.”

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Interested in hearing more about drinking alcohol in the best way possible? Join San Francisco AIDS Foundation on Tuesday, November 4 for a discussion about drinking booze, having the party we want, and keeping ourselves, our partners, and others safe. Read more about Can You Party Smart? Let’s Talk Booze, here.

Further reading

Maisto, S. A. and others. The effects of alcohol and sexual arousal on determinants of sexual risk in men who have sex with men. Archives of Sexual Behavior, 41(4), 971-986. August, 2012.

Woolf-King, S. E. and others. Alcohol use and HIV disease management: The impact of individual and partner-level alcohol use among HIV-positive men who have sex with men. AIDS Care, 26(6). 702-708. 2014.

Woolf-King, S. E. and Maisto, S. A. Alcohol use and risk of HIV infection among men who have sex with men. AIDS and Behavior, 13(4), 757-782. August 2009.


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