The PEPFAR National Alcohol Initiative and Implementation in Namibia

1. The PEPFAR National Alcohol Initiative and Implementation in Namibia Puja Seth, PhD Centers for Disease Control and Prevention, USA for Mary Glenshaw, PhD Centers for Disease Control and Prevention, Botswana Katherine Fritz, PhD International Center for Research on Women (ICRW) July 22, 2012

2. Sexual Risk and Alcohol Use Alcohol use leads to sexual disinhibition Lower condom use Earlier sexual debut Alcohol drinkers have higher risk sex partners Multiple concurrent partners Casual partners More at-risk partners Environments 85% new sex partners meet in bars 46 – 57% patrons have multiple partners Informal alcohol venues double as sex locations Sivaram et al., 2008 Fisher et al., 2008 Kalichman et al., 2007 WHO, 2005

3. Alcohol Use: HIV Driver Higher HIV, STI prevalence among drinkers Southern Africa: South Africa, Botswana, Zimbabwe, Zambia East Africa: Uganda, Tanzania, Kenya Higher odds of new HIV infection among drinkers Any alcohol use, AOR 1.8* Alcohol use before/during sex, AOR 1.9* Binge drinking, AOR 2.2* Converging epidemics in Africa Highest global HIV prevalence (>15%) Among highest global alcohol use (~43%) Shuper et al., 2010 Kalichman et al., 2007 WHO, 2005 *p<0.05

4. PEPFAR Alcohol Initiative Background Started 2007 $2.5 million USD over 4 years Most funds allocated to Namibia Collaboration between several U.S. Government agencies: CDC, USAID, DOD, SAMHSA GOAL: Prevention of sexual HIV transmission through reduction of alcohol-related risk behaviors

5. Strategic Planning • Determine research and data needs • Existing tools, partners, resources • Standardization • Follow Socio Ecological framework • Policy, legislative, environmental • Health sector • Community • Interpersonal • Individual

6. Alcohol Initiative Components Conduct assessments Develop and evaluate interventions for at-risk populations Promote health provider screening &alcohol abuse resource services Support networks of community stakeholders Support policy and structural interventions Institutionalize universal prevention messages

7. Assessments

8. 2009 AUDIT Study Needs Assessment • Purpose: To determine alcohol consumption levels in Katutura, an urban Namibian township • WHO Alcohol Use Disorders Identification Test • Reliable, sensitive • Used worldwide, including in southern Africa • Multi-Stage Stratified Sampling Strategy • 639 surveys completed

9. AUDIT Study Results (n=639) • 35% adults made or sold alcohol from home • 73% adults were current drinkers • 76% consumed ≥ 3 drinks on typical day • 49% reported binge drinking in past year • 31% reported binge drinking at least monthly × × × × HIV RISK

10. AUDIT Study Results by Sex *p<0.001

11. Develop & Evaluate Interventions for At-Risk Populations

12. Counseling Intervention Trial: Ongoing • Purpose • Determine the effectiveness of a new counseling program in reducing alcohol-related sexual risk behavior • Build upon emerging evidence • Key message: Drunk sex is unsafe sex • RCT of 550 men in HIV testing centre • Complete baseline, 3- and 6-month assessments • Outcomes • Drinking before sex • Condom use, multiple partners • Hazardous alcohol consumption • Baseline enrollment will end by Dec 2012; results in 2013

13. Promote Health Provider Screening &Alcohol Abuse Resource Services

14. Brief Motivational Interviewing (BMI) • Behavior change intervention designed to be implemented in a variety of healthcare settings. • Cost-effective • BMI pilot was conducted in Hardap region • Proved difficult for facilities to implement • Time • Perceived stigma (social desirability) • Complexity of assessing drinking levels • Training revised and re-pilot planned • Task shifting approach • I-Tech in collaboration with MOHSS and CDC will adapt the materials • Brief evaluation planned as part of the pilot

15. Alcohol Resource Center

16. Alcohol Resource Center • Substance Abuse Resource Center opened in Katutura March 2012 • Collaboration between MOHSS, NGOs, PEPFAR • Plans for “marketing” to health facilities and to the communities to increase the number of referrals received • Focus on support groups, individual counseling, youth activities as well as provision of pamphlets, materials

17. Support Networks of Stakeholder Organizations

18. Coalition on Responsible Drinking Plans to change name to Coalition on Reduction of Harmful Drinking Multi-sectoral partners Government Donors, Partners, NGOS Private industry Expansion to all 13 regions in Namibia Regional, constituency committees Guided by MoHSS social workers Plans to develop national strategy to focus more on standardized, high impact activities Plans to develop M & E tools

19. PEPFAR Southern & Eastern Africa Meeting on Alcohol and HIV, April 2011 Exchange intervention ideas and best practices Review WHO and PEPFAR strategies on alcohol Review the evidence on alcohol and HIV Assistance with strategic planning 80+ participants from 14 countries http://www.aidstar-one.com

20. Support Structural Interventions

21. Structural Interventions • Legislation • Revision of national Alcohol Abuse Prevention and Treatment Bill Alcohol Industry Efforts • Self-Regulating Alcohol Industry Forum (SAIF), Namibia • Underage drinking campaign • Drunk driving campaign • Namib Breweries, Namibia • Assisted with testing alcohol content of home/traditional brews

22. Alcohol Traders Program • Promote Traders’ rights & responsibilities, 1998 Liquor Act • Legal parameters of alcohol sales • Establish Code of Conduct • Safe server, better business guidance • Condom distribution • Community and Trader IEC materials created • Materials are being piloted by SFH (USAID contractor). • CDC Namibia/MOHSS also has developed a draft training manual (via contractor). • Pilot will be conducted and will include assessment and evaluation materials. • MOHSS will wait until both evaluations are completed prior to scaling up the program.

23. Institutionalize Universal Prevention Messages

24. Alcohol Prevention Materials Toolkit • Broad range of IEC materials for partners, providers, clients • Materials in English, Afrikaans, Oshiwambo • Currently contains 13 tools • 5x Booklets • Basic Facts About Alcohol • Alcohol & HIV • Family Drinking • Youth Drinking • Stand Up! Campaign • 1x Regional Support Services brochure • 2x Liquor Act informational flyers • Community • Alcohol Trader rights & responsibilities • 2x posters • Underage drinking • Youth drinking • 3x Facilitation Guides • C-Change Picture Codes • Lifeline/Childline Male Engagement DVD • MoHSS Guideline on the Management of Substance Intoxification & Withdrawal

25. Universal Prevention Messages Mass media & community action campaign Promote unacceptability of drunkenness, binge drinking Mobilize communities to take action Focus on affected/concerned community members STAND UP! Against Alcohol Misuse NawaLife Trust CORD MoHSS USAID CDC

26. The Campaign – Print Adverts

27. Stand Up! Campaign Print Ads

28. Acknowledgments SAMHSA Tom Kresina USAID Billy Pick Brad Corner Todd Koppenhaver Kristen Ruckstuhl Namibia MoHSS Rene Adams Verona du Preez Manny Kandjii CDC Naomi Bock Nick DeLuca Dietrich Remmert Jan Moore Jen Sabatier Sasha Mital John Pitman Dawn Broussard Sue Gerber Jeff Hanson DoD Anne Thomas Mike Grillo Helen Chun Cynthia Simon-Ardnt NIAAA Kendall Bryant

29. THANK YOU!Puja Seth, PhDDivision of Global HIV/AIDSCenters for Disease Control and PreventionEmail: pseth@cdc.gov