Project Summary/Abstract
Heavy alcohol use has deleterious effects on antiretroviral therapy (ART) adherence and HIV clinical
outcomes, and indirectly affects health by damaging the couple relationships needed for social support,
economic survival, and well-being. Our formative research with HIV-affected couples in Malawi found that 50%
of alcohol drinkers met criteria for heavy alcohol use. Male peer pressure, desires for friendship, and coping
with poverty were common barriers to reducing consumption. Men expressed desires for an economic or peer-
based intervention to reduce alcohol use, and women were very concerned with how alcohol drains family
financial resources and causes conflict in the couple. Yet, there are currently no interventions that have jointly
addressed the economic and relationship context of drinking in sub-Saharan Africa. To fill this gap, we
developed Mlambe: a combined economic and relationship-strengthening intervention to address heavy
alcohol use among couples affected by HIV. The goal of Mlambe is to redirect funds spent on alcohol into
financial investments and to improve couple relationships and adherence to ART. We posit that engaging
couples to work together on alcohol use and financial goals—equipped with financial and communication
skills—will decrease alcohol use, and improve relationship dynamics and adherence to ART. Our pilot trial
demonstrated that Mlambe was highly feasible and acceptable for couples and showed promising impacts on
health and relationship dynamics. Given this strong preliminary evidence, we propose to conduct a full-scale
randomized controlled trial of Mlambe with couples in Malawi. The specific aims are: (1) to evaluate the
efficacy of Mlambe on our primary outcome of heavy alcohol use, defined as self-reported drinking combined
with an alcohol biomarker called PEth, and on secondary outcomes of viral suppression, adherence to ART,
and other alcohol use metrics; (2) to assess the effects of Mlambe on relationship dynamics (couple
communication, alcohol-specific partner support, and IPV) and explore whether they meditate Mlambe’s effects
on health outcomes; and (3) to compare the costs of each of the two study arms and the cost-effectiveness of
Mlambe. We hypothesize that heavy alcohol use will be reduced in Mlambe as compared to the control arm
and that all partners living with HIV will experience greater viral suppression regardless of drinking status. We
also anticipate that Mlambe will impact alcohol and HIV outcomes through the pathway of relationship
dynamics (e.g., better communication, less IPV). For the trial, we will enroll 250 HIV-affected couples with a
heavy alcohol user and randomize couples to either Mlambe or an enhanced usual care (EUC) control arm. A
cost analysis will be computed for each arm and a cost-effectiveness analysis will be conducted to make
comparisons between Mlambe and other strategies for reducing heavy alcohol use. Alcohol interventions for
people living with HIV in SSA may register large impacts by targeting the dyadic and economic context of
alcohol use to ultimately reduce the harms of drinking on relationships, poverty, and HIV health outcomes.
