Multi-level experiences and determinants of alcohol misuse and illicit drug use among occupational groups at high-risk of HIV in sub-Saharan Africa: A thematic synthesis of qualitative findings

Figures & data

Figure 1. Social ecological model framework for the role of occupation-related factors in alcohol misuse and illicit drug use among groups at high-risk of HIV/AIDS.

Figure 2. Data extraction flow chart.

Table 1. Summary of included studies by population group.

	Study (author, year)	Study setting	Study objective	Data collection method and qualitative data sources	Study participants	Alcohol	Other drugs
	Sex workers
1	Needle et al. (2008)	Durban, South Africa 2005	To examine patterns of drug use and HIV risk behaviours among drug-using, street-based sex workers	A rapid ethnographic assessment combining KIIs, FGDs, mapping and observation	52 (27 men, 25 women) current injection and non-injection drug users in high-risk neighbourhoods.	No	Yes
2	Watt, Kimani, Skinner, and Meade (2016)	Delft, a peri-urban township located approximately 15 miles from central Cape Town, South Africa.	To qualitatively examine the experiences of sex trading among methamphetamine users in Cape Town, South Africa	IDIs	30 active methamphetamine users (17 men, 13 women) recruited from the community	No	Yes
3	Izugbara (2005)	Aba, a commercial town in Abia State, Nigeria.	(i) To describe sex work risks as they are understood, expressed, and acted upon by sex workers themselves. (ii) To evaluate the implications of lay constructions of sex work risks for the lives of sex workers, their extent of representation within mainstream accounts and understanding of sex work risks, and their influence in the planning and delivery of interventions for sex workers.	Snow ball sampling: IDIs (n = 127) 6 FGDs (n = 44), personal observations	Self-employed brothel-based, street working, casual, and free-floating female sex workers, aged 16–41 years	Yes	Yes
4	Mbonye et al., (2012a)	Women working in high HIV/STI risk environments, Kampala, Uganda. March 2010 to June 2011	To explore how gender inequities may have played a role in facilitating the entry of women into sex work	Life stories: In-depth life history interviews with repeat interviews	Peer leaders of self-identified sex workers (n = 58)	Yes	Yes
5	Mbonye et al., (2013)	Kampala, Uganda. Common sex work locations were streets/roadsides, bars and night clubs. March 2010 to June 2011	(i) To describe a setting in which women provide sex for money in a busy Kampala suburb (ii) To understand better, and potentially inform, interventions for this most at risk group of people.	Life history and work place IDIs (n = 67)	Women aged 16–49 years whose sole income was from sex work, or who engaged in sex work as a supplementary source of income	Yes	No
6	Mbonye et al., (2016)	Female sex workers attending a clinic for high risk women in Kampala, Uganda. July to December 2015	To explore perceptions and experiences regarding prompt ART initiation, after the change in ART guidelines.	Repeat IDIs (n = 15)	Female sex workers, both HIV negative and positive, some had started ART while others had deferred ART.	Yes	No
7	Langa et al. (2014)	Three major Mozambican urban centers: Beira, Nacala, Maputo. November 2007 to January 2008	To obtain information on behaviours of commercial sex workers, their perceptions of risk, and their outcomes to inform the creation and implementation of successful AIDS health and prevention measures.	International Rapid Assessment, Response and Evaluation (I-RARE) methodology. Semi-structured key informant IDIs (n = 129) FGDs (n = 17)	Commercial female sex workers (n = 236) Male clients of commercial sex workers (n = 47) Policy makers (n = 13), gender not described Health service providers (n = 50), gender not described	Yes	No
8	Onyango et al., (2015)	Kumasi, Ghana	To identify social, economic, structural, and individual-level vulnerabilities of female adolescents who sell sex in Kumasi, Ghana.	Snowball sampling: 24 IDIs, 4 FGDs	Female sex workers aged 18–20 years who had been involved in sex work for at least 2 years(n = 48)	Yes	No
9	Parry et al. (2008)	‘Hotspots’ for drug use and sexual risk in Cape Town, Durban and Pretoria, South Africa.	To examine the links between drug use and high-risk sexual practices and HIV in vulnerable drug-using populations in South Africa, including CSWs, MSM, IDUs and non-injecting drug users who are not CSWs or MSM.	Rapid assessment ethnographic study Purposive snowball sampling and street intercepts were used to recruit drug users.	Observation, mapping, key informant interviews and focus groups. Key informant interviews (n = 131, 65% male) 21 FGDs (n = 109) involved drug users and service providers, MSM, commercial sex workers. Participants aged 18–62 years	Yes	Yes
10	Parry et al. (2009)	Drug using sex workers in Cape Town, Durban, Pretoria, South Africa:	(i) To describe the nature, extent and context of drug use, and sexual behaviour among drug-using CSW and to understand the drug using and sexual behaviours that increase vulnerability for HIV infection. (ii) To assess knowledge and understanding of HIV, drugs, and HIV services and explore views on how to improve access to services. (iii) To identify possible strategies for introducing and scaling up sustainable interventions	Rapid assessment of HIV risk behaviour. Key informant interviews (n = 67) 10 FGDs Conducted using I-RARE methodology.	Male and female street CSWs Of the 67 CSWs interviewed individually, 31 were IDUs and 24 were MSM	Yes	Yes
11	Ediomo-Ubong (2012)	Sex workers in Ikot Ekpene, Akwa Ibom State, Nigeria.	To examine drug use and sexual health risks among sex workers	IDIs and FGDs	Brothel-based female sex workers (n = 86)	Yes	Yes
12	Schulkind, Mbonye, Watts, and Seeley (2016)	Women at high risk of sexually transmitted infection (including HIV) and their regular male partners in Kampala, Uganda. July 2013–September 2014	To explore the interaction between gender-based violence and alcohol use and their links to vulnerability to HIV-infection	In-depth life history interviews. Each participant was interviewed on three separate occasions.	N = 20 (10 women and their regular male partners) Six of the women were current or former sex workers.	Yes	Yes
	Fishing communities
13	Lubega et al., (2015)	Kasensero fishing community, with HIV incidence 4.3 and 3.1 per 100 person-years in women and men, respectively. April–September 2014.	To understand the underlying contextual drivers of the high HIV rate in Kasensero from the perspective of the community itself for effective policy and preventive intervention formulation	20 IDIs (10 males, 10 females) 12 FGDs (n = 92), men and women	HIV positive and HIV negative respondents	Yes	Yes
14	Michalopoulos et al. (2017)	Migratory female fish traders sheltered in seasonal camps, Kafue flatlands, Lusaka, Zambia. August 2014–January 2015	(1) Examining trauma history, trauma symptoms and HIV risk behaviour and, (2) the relationship between these co-occurring issues among female fish traders from the Kafue flatlands in Zambia	20 semi structured qualitative interviews, 1 FGD (n = 12)	Female fish traders	Yes	Yes
15	Sileo et al. (2016)	Gerenge, Uganda, a ‘landing site’ along Lake Victoria, with presence of transient CSW and fishermen populations.	To examine motivation for alcohol use and perceptions of how alcohol use influences sexual behaviour and HIV risk. To examine contextual and structural factors influencing alcohol use during sex, as well as alcohol use and sexual risk in the general community. To elicit suggestions for interventions to reduce alcohol and HIV risk behaviours in fish landing sites	8 FGDs (n = 50; 23 male, 27 female): Separate focus groups were conducted based on participant occupation: fishermen (n = 13; all male), fishmongers (n = 13; 9 male, 4 female), alcohol sellers (n = 12; 1 male, 11 female), FSWs (n = 6; all female), and restaurant owners (n = 6; all female).	Fishermen, fishmongers, alcohol-sellers, commercial sex workers, and restaurant owners.	Yes	No
16	Abikoye (2015)	Yenagoa, Balyesa state, Niger delta, Nigeria	Exploring factors opposing the effective management of substance use disorders in	IDIs (n = 4) FGDs (n = 48, 8 groups)	Informal caregivers of patients with substance use disorders (n = 48; 36 female 12 male) Nurses, females (n = 2) Psychiatrists, men (n = 2)	No	Yes
	Uniformed personnel
17	Nwokoji and Ajuwon (2004)	Nigerian Navy personnel in Lagos	To describe the knowledge of AIDS and HIV-risk sexual behaviour of naval personnel in Lagos.	1 Group discussions (n = 4) KII (n = 4)	Nigerian military, gender not described	Yes	No
	Truckers
18	Erinosho et al. (2012)	Nigeria: in 3 communities Ugep (high HIV prevalence 12%), Olunloyo (low HIV prevalence 2.2%, Badeku))	To ascertain the risky behavioural factors that are driving the HIV/AIDS epidemic	An ethnographic semi-longitudinal study combining (n = 250), (n = 20), KII (n = 30)	Study participants including community members, opinion leaders, policymakers, healthcare practitioners and religious leaders were selected purposively, gender not described	Yes	No
19	Kohli et al. (2017)	Iringa, Tanzania – a region characterised by high levels of migration and mobility	To identify and describe the social and structural factors that may contribute to HIV risk among truck drivers	11 IDIs	Truck drivers, male	Yes	No
20	Matovu and Ssebadduka (2013)^†	Conducted at 12 hotspots*, on two major transport corridors. November–December 2008.	To explore knowledge, attitudes and barriers to condom use among FSWs and truckers operating along major transport corridors in Uganda.	Mixed methods study: 24 FGDs (n = 207)	Long distance truckers (all male, n = 96) and female sex workers (n = 111)	Yes	No
21	Lightfoot et al. (2009)	Remote Namibian mining community June 2008	(1) To assess knowledge regarding the link between HIV and alcohol use (2) To assess mechanisms affecting how alcohol consumption leads to higher-risk sexual behaviours	6 FGDs, 16 IDIs	Mine workers (n = 7) (5 men; 2 women), Foreman and supervisors (7 men) Mine workers who had received treatment for substance abuse (8 men; 1 women) Oshiwambo-speaking workers (8 men), workers’ spouses (8 women), youth (7 men)	Yes	No

*A hotspot was defined as an area frequented by female sex workers and characterised by high levels of illicit sex.

^†The study was conducted among sex workers and truckers.

Table 2. Methodological quality of included studies (n = 21).

		Agreed assessment for each study
		Met criterion (n)	Did not meet criterion (n)	Unclear (n)
1	Is this study qualitative research?	21	–	–
2	Are research questions clearly stated?	18	3 (Erinosho et al., 2012; Langa et al., 2014; Watt et al., 2016)	–
3	Is the qualitative approach clearly described?	18	1 (Kohli et al., 2017)	2 (Erinosho et al., 2012; Nwokoji & Ajuwon, 2004)
4	Is the approach appropriate for the research question?	18	2 (Nwokoji & Ajuwon, 2004) (Erinosho et al., 2012)	1 (Parry et al., 2008)
5	Is the study context clearly described?	18	3 (Erinosho et al., 2012; Nwokoji & Ajuwon, 2004) (Kohli et al., 2017)	–
6	Is the role of the researcher clearly described?	16	4 (Erinosho et al., 2012; Matovu & Ssebadduka, 2013; Nelson, 2012; Nwokoji & Ajuwon, 2004)	1 (Kohli et al., 2017)
7	Is the sampling strategy clearly described?	17	3 (Erinosho et al., 2012; Nelson, 2012; Nwokoji & Ajuwon, 2004)	1 (Kohli et al., 2017)
8	Is the sampling strategy appropriate for the research question?	19	1 (Erinosho et al., 2012)	1 (Nwokoji & Ajuwon, 2004)
9	Is the method of data collection clearly described?	17	2 (Nelson, 2012; Nwokoji & Ajuwon, 2004)	1 (Kohli et al., 2017)
10	Is the data collection method appropriate to the research question?	21	–	–
11	Is the method of the analysis clearly described?	19	2 (Erinosho et al., 2012) (Nwokoji & Ajuwon, 2004)	–
12	Is the analysis appropriate for the research question?	19	1 (Erinosho et al., 2012)	1 (Nwokoji & Ajuwon, 2004)
13	Are the claims made supported by sufficient evidence?	20	1 (Erinosho et al., 2012)	–

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