Alcohol is the most commonly used substance reported amongst PLWH in PHC facilities. The data reported here document a high lifetime and current prevalence of alcohol abuse. These findings are consistent with a countrywide estimation of substance use and are consistent with the use reported in other sub-Saharan countries.^5,19 South Africa has one of the highest per capita alcohol consumption rates in the world. Although many studies reported geographical differences in the prevalence of substance use, alcohol remains the substance used most often by South Africans.^20,21

The lifetime prevalence of alcohol use (47.8%) amongst PLWH in this study is much higher than that amongst the general population (38.7%) as reported by a South African stress and health study.^4,22 Similar alcohol consumption amongst PLWH was reported in many African countries, such as Zambia (44.3%), Tongo (40.6%) and Côte d’Ivoire (46.4%).^5,20 Some studies even demonstrate that the alcohol consumption rates amongst PLWH are almost twice as high as amongst the general population.²¹ Although alcohol consumption is widespread in the general population, hazardous use is much higher amongst PLWH, resulting in decreased overall life expectancy in this group.⁵ The psychological impact of the dual stigma of HIV infection and alcohol consumption hinder health-seeking behaviour for people who are both HIV-positive and substance users.²³ Substance users amongst PLWH often fail to attend HIV care despite early diagnosis. Even after linkage to care, a poor adherence rate is reported amongst PLWH who use substances.

It is notable that the proportion of lifetime and current substance use was high amongst younger participants than their older counterparts but the findings from the current study could not establish the age of substance use initiation. The national and international research has reported that substance use generally commences at a younger age.^14,24 Adolescence is a critical period of physical and psychological development when substance use problems and other risk-taking behaviour commence. There are many reasons for use of substances amongst adolescents, including desire of a new experience, peer pressure, stress and an attempt to deal with problem. Substance use is generally initiated around the age of 11 years or sometimes even at a younger age. The exact age for substance use screening nevertheless depends on the local prevalence and pattern of substance use.²⁵ Because the study demonstrated a high prevalence of substance use amongst PLWH, it is appropriate to commence regular screening at PHC facilities.

The findings reported heavy alcohol consumption amongst males compared with their female counterparts. Higher consumption of alcohol amongst males has been reported both in sub-Saharan Africa and in developed countries in North America and Europe.²⁶ It is attributed to the acceptance of male drinking as part of the social and masculine norm in many societies, whilst the same societies do not apply these norms for women. Overall, substance use tends to be higher amongst males than amongst females. These findings are consistent with reported research in sub-Saharan Africa.^27,28

The majority of PLWH who consume alcohol and other substances are unemployed and living in a household with a per capita income below the food poverty line (R532.00 per capita). Alcohol product in South Africa is more affordable than in most low- and middle-income countries.²⁹ This might be a possible explanation of alcohol abuse even in people of low socio-economic status. Similar results were reported in a study based on nationally representative data from South Africa, which stated that the harmful use of alcohol amongst PLWH was much higher amongst people of low socio-economic status. In contrast, Probst et al. reported that there was no difference in consumption of alcohol amongst PLWH in different socio-economic classes in South Africa, but high HIV-associated mortality and poor clinical outcomes were attributed to low socio-economic status amongst PLWH.³⁰ Furthermore, it states that affordability of alcohol products is an important determinant of demand and increase in taxes and prices can limit the consumption and demand of alcoholic products.²⁹

The majority of substance users amongst PLWH have a low-to-moderate (score < 27) risk, according to the ASSIST tools. Primary care workers therefore have an ideal opportunity for early intervention before serious substance dependency develops. Many research findings support the notion that low-to-moderate risk of substance use has shown significant improvement when simple motivational interviewing techniques are used.³¹ Furthermore, it is stated that this brief intervention may easily be integrated within context-specific PHC settings. In particular, brief intervention for alcohol use has emerged as a cost-effective and practical approach for PHC settings. These interventions are particularly short in duration and promote positive behavioural changes. Although brief intervention is often not feasible as a treatment on its own for high-risk patients, it provides the foundation for PHC workers for detailed clinical assessments and appropriate specialist referrals.^18,21