Perinatal alcohol use among young women living with HIV in South Africa: Context, experiences, and implications for interventions

ABSTRACT

Perinatal alcohol use is common in South Africa, including among young women living with HIV (WLHIV), but there are few insights into the drivers of alcohol use in this population. Following the completion of a pilot trial of a peer support intervention for WLHIV aged 16–24 years in Cape Town, we purposively selected participants who had reported perinatal alcohol use at ≥1 study visits to complete a qualitative in-depth interview exploring their experiences of substance use. Of 119 women enrolled, 28 reported alcohol use, and 24 were interviewed, with ≥1/3 reporting drinking throughout their pregnancy. Women described living in a community where heavy perinatal alcohol consumption is normalised, including among their peers, leading to social pressure. Despite being aware of the risks of perinatal alcohol use, women described a disconnect between public health messaging and their experiences. Although most acknowledged the negative effects of alcohol in their lives, self-efficacy to reduce consumption was diminished by peer influences and the lack of formal employment and opportunities for recreation. These findings provide insights into the drivers of perinatal alcohol use in this setting, and suggest that without meaningful community-level changes, including employment opportunities and alternatives for socialising, interventions may have limited impact.

KEYWORDS:

• Alcohol
• pregnancy
• HIV
• young women
• South Africa

Introduction

High levels of alcohol use during pregnancy have been documented among women living with and without HIV in South Africa (Davis et al., 2017; Peltzer & Pengpid, 2019; Petersen Williams et al., 2014; Ramlagan et al., 2019), with one study reporting levels of biomarker-confirmed alcohol use in up to 40% of pregnant women living with HIV (WLHIV; Raggio et al., 2019). In South Africa, alcohol consumption is characterised by heavy episodic or binge drinking, including during pregnancy (Brittain et al., 2017; Desmond et al., 2012; Russell et al., 2013). Perinatal alcohol use has well-documented negative effects on maternal and foetal health (Oei, 2020) and, for WLHIV, alcohol use may have additional negative impacts on HIV treatment outcomes, including adherence to antiretroviral therapy (ART) and engagement in HIV care (Adeniyi et al., 2018; Hodgson et al., 2014; Nachega et al., 2012; Ramlagan et al., 2019; Rotheram-Borus et al., 2019).

Perinatal alcohol use is driven by multiple contextual, interpersonal, and individual factors. At the contextual level, drinking during pregnancy is normalised in certain communities in South Africa, including in township settings, or informal settlements, in Cape Town (Watt et al., 2014; Watt et al., 2016). Stemming from South Africa’s history of systemic and structural racial oppression, drinking is one of the few available opportunities for leisure in these settings (De Jong et al., 2021). Additional structural drivers of alcohol use include the availability and affordability of alcohol (Eaton et al., 2014b) and high levels of unemployment (Watt et al., 2014). At the interpersonal level, alcohol use can be influenced by the alcohol-related beliefs and behaviours of one’s peers (Watt et al., 2016) and may be a form of social connection (Watt et al., 2014). Of concern is that a high proportion of pregnant and non-pregnant women in Cape Town believe that women can drink during pregnancy without harming their foetus (Eaton et al., 2014a). Other interpersonal drivers of alcohol use include unstable relationships with male partners, intimate partner violence, and low levels of social support (Brittain et al., 2017; Macleod et al., 2020; Onah et al., 2016). At the individual level, knowledge and attitudes about alcohol use influence drinking behaviours, and alcohol use during pregnancy may be a means of coping (Macleod et al., 2020; Watt et al., 2014). In addition, drinking may be driven by poor mental health and by addiction (Eaton et al., 2014b; Onah et al., 2016).

Many of these factors likely drive perinatal alcohol use among women of all ages and irrespective of HIV status. However, pregnant and postpartum women who are young and living with HIV face additional unique challenges. Adolescence is a critical developmental stage characterised by profound change, and which is further complicated by a pregnancy and HIV (Davidson et al., 2015; Lowenthal et al., 2014). These women must transition simultaneously through adolescence, pregnancy, and the postpartum period, each with unique demands and stressors (Meleis et al., 2000). Research among WLHIV in South Africa has documented high levels of adverse childhood experiences, with over half of women in one study reporting parental separation or death, and a high proportion reporting other forms of family instability (Brittain et al., 2022). As such, many young women in this setting may be transitioning through pregnancy and motherhood with few positive experiences of parenting from their own childhood on which to draw.

In addition to the factors driving perinatal alcohol use among women of all ages, critical factors driving use among adolescents include behavioural disinhibition, low levels of parental supervision, and peer influences (Marshall, 2014; Morojele et al., 2021). Among individuals living with HIV, additional drivers of alcohol use include experiences of discrimination and HIV-related stigma (Crockett et al., 2019; Wardell et al., 2018). Notably, WLHIV are more likely to experience mental health problems compared to their HIV-negative counterparts (Waldron et al., 2021). Taken together, young pregnant and postpartum WLHIV may experience additional, unique drivers that compound their risk of alcohol use, but there are few insights into these co-occurring drivers among young WLHIV specifically.

Despite the vulnerabilities faced by this group, pregnancy may represent a window of opportunity for interventions: pregnant women may be uniquely motivated to reduce their risk behaviours due to their desire for a healthy baby, and they have repeat contacts with health services (Phelan, 2010). Given the detrimental effects of perinatal alcohol use, interventions to reduce use during pregnancy are urgently needed. In addition, reducing alcohol use, and specifically binge drinking, in adolescents and young adults is a priority (Davidson et al., 2015), but further research is needed to inform intervention development for this age group. To address these gaps, we used qualitative interviews to explore the drivers and impact of perinatal alcohol use among young WLHIV in South Africa, as well as women’s views about the potential for behavioural interventions to mitigate risk.

Materials and methods

Study design

This qualitative study was conducted with a subset of young pregnant and postpartum WLHIV who had participated in a pilot randomised controlled trial of a peer support intervention (ClinicalTrials.gov NCT04036851). The trial was conducted in Gugulethu, a low-income community outside Cape Town which is characterised by high levels of unemployment and where unintended pregnancy and intimate partner violence are common (Bernstein et al., 2016; Iyun et al., 2018). Consistent with other informal settlements in Cape Town, systemic and structural racial oppression has led to enduring conditions of economic and social disadvantage in Gugulethu, and alcohol is widely available and affordable at informal drinking venues or taverns (De Jong et al., 2021). For the trial, pregnant and postpartum WLHIV aged 16–24 years were recruited from a public sector, primary care antenatal clinic when seeking antenatal or immediate postpartum care; report of alcohol use was not a criterion for enrolment. Participants completed an enrolment study visit and follow-up visits after three and six months. The study was approved by the Human Research Ethics Committee of the University of Cape Town Faculty of Health Sciences (ref: 334/2020), and all participants provided written informed consent. At enrolment into the trial, participants had provided consent to be contacted for future research studies, and only women who had participated in the trial were eligible to participate in this qualitative study.

Peer support intervention

Following enrolment into the broader trial, women were randomly allocated to the existing standard of care or to a peer support intervention that aimed to mitigate the negative effects of HIV-related stigma and improve retention in HIV care and HIV viral suppression (manuscript under review). Under the standard of care in this setting, women attend integrated antenatal and HIV care at the antenatal clinic during pregnancy, but are referred immediately postpartum to general adult public sector clinics for ongoing HIV care. Women allocated to the peer support intervention were similarly referred to general adult clinics after delivery, and the intervention was delivered separately from any routine HIV care. The peer support intervention consisted of monthly group meetings facilitated by two WLHIV who live and work in the community. A curriculum for these meetings was developed, with topics including ART adherence, retention in HIV care, HIV-status disclosure, pregnancy and motherhood, and family planning; the curriculum did not include a specific focus on substance use. Facilitators were trained to use the curriculum as a guide, but to allow group members to direct the conversation where appropriate; alcohol use was not discussed during group sessions. Groups were designed to include ∼8 women, with group meetings held with the same group of women for the duration of follow-up, but attendance at group sessions was low, with only 42% of women overall attending at least one session.

Study procedures

As part of the broader trial, sociodemographic and clinical characteristics were assessed at enrolment, and the Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993) was administered by trained interviewers at every study visit. At enrolment, women reported alcohol use during the past 12 months; at each follow-up visit, use during the past three months was assessed. Following the completion of the trial, the AUDIT-Consumption (AUDIT-C; Bradley et al., 2003; Bush et al., 1998) scoring system was used to classify risky drinking, defined as a pattern of consumption that increases the risk of harmful consequences. Responses to the first three items of the AUDIT, which focus on the frequency and quantity of consumption, were summed for a total score of 12, with a score ≥3 used to classify risky drinking (Bradley et al., 2003; Bush et al., 1998). Between August 2019 – February 2020, 119 women were enrolled into the broader trial, with 28 women reporting risky drinking at one or more study visits. For this qualitative study, the 28 women who had reported risky drinking during the broader trial were purposively selected to complete a single qualitative in-depth interview following completion of the trial. Of these 28 women, 24 were successfully contacted and completed a qualitative interview between February – March 2021.

All women provided consent prior to the qualitative interview, including consent to have the interview audio recorded. Given the COVID-19 pandemic, in-depth interviews were conducted telephonically. It was ensured that participants were in a private space where they were able to speak freely, and participants could pause the interview at any time if necessary to protect their privacy. Interviews were conducted in participants’ home language (primarily isiXhosa) by a highly trained and experienced fieldworker who lives within the same community. The interviewer had been involved in recruiting women into the broader trial and had conducted quantitative interviews at study visits for the trial, and thus had built rapport with participants. However, she had not been involved in delivering the peer support intervention. During this qualitative study, the principal investigator (K.B.) held weekly meetings with the qualitative interviewer in order to provide on-going supervision to ensure adherence to the interview guide, assess thematic saturation, and discuss any issues that arose. In addition, these meetings allowed the interviewer to share her own insights into the themes emerging during interviews, drawing on her knowledge of and experiences within this community.

Interview guide

A semi-structured interview guide was developed for the purpose of the qualitative interviews, drawing on Social Action Theory as an overarching understanding of health behaviours (Ewart, 1991; Traube et al., 2011). Under Social Action Theory, Ewart (1991) proposes a conceptual model with three dimensions: an action state in which the goal is to promote self-regulation to sustain health routines or habits; a process dimension in which self-change processes are linked with interpersonal environments; and a contextual dimension in which social and environmental influences can empower or constrain behavioural change. As such, the model emphasises self-regulatory processes; social interaction processes; the context in which health behaviours occur; and the mechanisms through which each of these dimensions lead to health behaviours (Traube et al., 2011). Inherent in this model is the idea that behavioural change is influenced by interdependence with others, as individuals within close social relationships can facilitate or impede the other’s health behaviour changes, and their ability to attain health-related goals. In addition, the emphasis on context within the model stems from the idea that individuals seek or create environments that support their own health-related goals, and thus that there are reciprocal relationships between individuals and environmental contexts.

The qualitative interview guide sought to explore these three dimensions inherent in Social Action Theory. Under the action state dimension, questions explored self-regulatory processes driving alcohol use, including (i) beliefs and motivations around alcohol use; (ii) goals of reducing consumption and belief in one’s capabilities to do so; and (iii) alcohol use as a means of coping. To explore the process dimension, questions focussed on social interdependence and the congruence between participant’s health-related goals and those of their social network, including (i) peer norms around alcohol use; and (ii) alcohol use as a form of social connection. Finally, the interview guide explored the contextual dimension through topics such as (i) the physical setting in which alcohol use typically occurs, and with whom women typically drink alcohol; and (ii) exposure to public health or clinical messaging around alcohol use, including women’s knowledge of the effects of alcohol use on the foetus. In addition, interviews explored the impact of alcohol use on participants’ lives and on ART outcomes, and participants’ views on possible behavioural interventions to reduce consumption. The interview guide was structured to explore alcohol use within the community and among women’s peers prior to exploring their own alcohol use, as this is a more loaded topic, followed by exploring the impact of alcohol use and women’s views on interventions.

Qualitative data analysis

Interviews were transcribed verbatim and translated into English. An independent isiXhosa-speaking research assistant (S.N.) conducted spot checks of a portion of transcripts against the recorded interviews to ensure accuracy. Anonymised transcripts were imported into NVivo 12, version 12.6, for coding and qualitative analysis using deductive thematic analysis (Braun & Clarke, 2006). An initial thematic coding structure was developed drawing on the interview guide and Social Action Theory, with themes grouped according to action states and individual self-regulatory processes; interpersonal processes and social interaction; and contextual and environmental factors. The goal of this analysis was to explore the drivers of alcohol use within each dimension. The principal investigator (K.B.) and research assistant (S.N.), both with graduate level training in public health and prior experience in coding qualitative interviews, conducted iterative thematic analysis, coding quotes and comments in the transcribed interviews and identifying common themes. These two authors reviewed a portion of the transcripts (15%) to verify consistency in coding approaches, discuss and resolve disagreements in coding and re-review transcripts where necessary, and then independently coded the remainder. Additional emergent themes were discussed and incorporated into the codebook as they arose, and previous transcripts were re-reviewed to ensure that emergent codes were captured.

Results

Demographics

As described above, 24 of the 119 women who participated in the broader trial subsequently completed a qualitative interview. Among these 24 women, the median age at the time of enrolment into the trial was 22.5 years, 58% were pregnant (versus 42% postpartum), and low levels of employment and educational attainment were reported (Table 1). Half of the women reported that their current/recent pregnancy was their first pregnancy, and almost all (96%) reported that the pregnancy was unplanned. Supplementary Table 1 presents characteristics of each individual participant.

Table 1. Participant characteristics at the time of enrolment into the broader trial.

Variable	n (%)
Number of participants	24
Median [IQR] age	22.5 [21.0, 23.0]
Currently employed or in school / studying	9 (38%)
Completed secondary / any tertiary education	8 (33%)
Lives in informal housing	9 (38%)
In a relationship	22 (92%)
Type of relationship (n = 22)
Married and/or cohabiting	6 (27%)
Neither married nor cohabiting	16 (73%)
Currently pregnant	14 (58%)
Currently postpartum	10 (42%)
Current / recent pregnancy was first pregnancy	12 (50%)
Current / recent pregnancy was unplanned	23 (96%)
Diagnosed HIV-positive during current / recent pregnancy	10 (42%)
Median [IQR] months since HIV diagnosis	14.1 [4.8, 36.9]
Random allocation in the broader trial
Standard of care	12 (50%)
Peer support intervention	12 (50%)
Risky drinking
12 months prior to enrolment into the broader trial (n = 24)	20 (83%)
3 months prior to the 3-month follow-up visit (n = 19)	3 (16%)
3 months prior to the 6-month follow-up visit (n = 23)	6 (26%)

Drinking behaviours

At enrolment into the broader trial, 83% of participants in this qualitative study had reported risky drinking during the past 12 months; at each follow-up visit, 16% and 26% reported risky drinking during the previous three months. During the qualitative interviews, these 24 women described varied patterns of alcohol use, with some only drinking occasionally; some drinking only over weekends or at the end of each month; and others drinking daily. Many women described stopping drinking when they discovered that they were pregnant, with one woman stating:

My life changed after I fell pregnant. I had to stop doing everything I used to do before my pregnancy, and I started to stay at home and only go out when I am going to work. On weekends, I started to take care of myself and of my 5-year-old child because I was done with having a nice time.

However, at least one-third of participants (n = 8) reported drinking throughout their pregnancy, including one woman who reported drinking up until two days before giving birth and resumed drinking two weeks after delivery. Women who resumed drinking after delivery similarly described varied patterns of use, ranging from drinking within a few months to waiting until stopping breastfeeding.

Descriptions of the impact of alcohol use in these women’s lives are presented below. Thereafter, we present themes related to the drivers of alcohol use emerging from these interviews, with findings arranged according to the three dimensions delineated in Social Action Theory: contextual drivers; social interaction; and individual self-regulation.

Impact of alcohol use

Many women described negative effects of alcohol use in their own lives, including arguments with family members, friends, or male partners. Almost all women described having encountered concern from others about their alcohol use, most commonly from mothers. However, this seemed to have little impact, with women continuing to drink and, in some cases, lying about drinking. When asked about her own mother’s concern, one woman stated that: ‘I told her that there is nothing I can do about that because I will never stop drinking alcohol’. Several described being in dangerous situations due to alcohol use, for example not remembering how they had gotten home the night before or engaging in risky sexual behaviours, for example sex with strangers while intoxicated or sex in exchange for alcohol. A few described having physically assaulted or stabbed other people while drinking. In addition, many described how alcohol has hindered their progress in life, with several having failed or dropped out of school, leading to reduced opportunities for employment, or being a reason for their pregnancy. One woman said that:

We are supposed to study then get jobs and be able to support our families. But because you are young and you drink, you end up not going to school and you don’t have a job and end up falling pregnant.

Alcohol use and ART outcomes

Negative effects of alcohol use on ART outcomes were less frequently discussed, with most women stating that they concealed their medication when they go out to take it at the correct time. However, two women described taking their medication early when they were planning to go out, and four women described skipping doses while drinking, sometimes for extended periods of time. One woman stated that:

I used to miss taking my HIV medication completely when I was drinking alcohol. I realised that I was putting my life at risk because I used to miss taking my doses for almost a week since I was drinking alcohol almost every day.

While taking doses early or skipping doses was often ascribed to concerns about inadvertent disclosure of their HIV status, some women were confused about whether to take their medication on the days that they would be drinking, as they had heard that they should not mix ART with alcohol. Finally, a few women described having missed clinic appointments after drinking the day before.

Contextual drivers of alcohol use

Community beliefs and norms

Women described their own alcohol use behaviours as consistent with norms within the community. All participants described witnessing women drinking during pregnancy or after delivery, including seeing noticeably pregnant women and women with babies drinking in taverns. One woman stated that: ‘People go to the taverns with big tummies or sometimes they would just go there to buy takeaways of their alcohol’. Another woman described that: ‘There is a place here in my area where we drink. Last week there was a lady there who was carrying a baby on her back, but she was drinking there. The baby was four or five months old’. Further, participants described how excessive drinking right up until delivery was not uncommon. When asked about pregnant women in her community, one participant stated that: ‘They drink when they are pregnant. Some drink excessively and it’s just what they have been doing for the rest of their lives’.

Women also cited community beliefs about alcohol use during pregnancy, including a belief that women who drink beer during pregnancy give birth to ‘beautiful babies’; that one should avoid liquor in favour of wine or cider; and that drinking brandy would shorten the duration of labour. In addition, women described how alcohol use begins at a young age within the community, with one woman explaining that:

The problem is that young people, as young as twelve years, start attending ‘pens down’ parties after their school exams, and at these parties they drink alcohol. What I mean is that we start associating alcohol with having fun from a young age, so it is within us to drink when we want to have fun.

Structural factors

A major reason given for the high levels of perinatal alcohol use within their community was that women have nothing else to do with their time, given high levels of unemployment. Participants who were unemployed noted that common ways to access alcohol include borrowing money or relying on friends who are employed, or using money from child support grants to buy alcohol. One woman stated:

People from my community are drinking a lot on weekends … I don’t see any reason to drink on Monday and Tuesday but, since we are unemployed, we grab whatever we get from those who are working because we can’t afford to buy alcohol. We end up being alcoholics because we don’t have anything important to do like going to work.

In addition, women described how drinking is central to recreation and socialising in this setting, particularly among young people. One woman stated that: ‘Our fun as young people these days is all about drinking alcohol … Drinking alcohol and chilling with friends is what we call happiness’. This same woman described that:

We would never braai [barbeque] and buy soft drinks; we would want alcohol in the mix. We would contribute our monies just to be able to buy expensive bottles of alcohol. We never think of going out purely for the sake of going out or eating in a restaurant. We never dress up to go out to restaurants or take photos while we are there to post on Facebook just for the sake of it without bragging about alcohol. The only thing we think about, I won’t lie, is alcohol. If we say we are going out to have fun, just know that we are going to drink alcohol.

Disconnect between public health messaging and personal and peer experiences

When asked about public health messaging in their community, most women said that they had seen advertisements on television or posters at the clinic about alcohol use. However, these seemed to have little influence on women’s behaviour, with one woman saying: ‘I don’t bother myself about such advertisements’. Another woman noted that all advertisements state that alcohol is not for sale to persons under the age of 18, but that this messaging ‘is useless because there is no age restriction in taverns around our communities’. Most women stated that nurses had provided health education about alcohol at the antenatal clinic, although a few noted that nurses only give brief information about risks. Despite this health education, many participants stated that women would not change their behaviour, either because they do not agree with the advice or because they do not like being told what to do. One woman who reported drinking during her pregnancy said that: ‘Nurses can smell alcohol if one drank the previous day and they would shout at us for drinking alcohol. We know that drinking alcohol while pregnant is not right, but we do it anyway’. Another woman stated that:

You can advise us as much as you want but the decision to change remains with us. Some of us even think that the nurses are making themselves cleverer than us, and so we decide to do what we like.

When asked about the effects of alcohol on an unborn baby, almost all women explicitly stated that alcohol use can lead to issues such as low birthweight, birth defects, and disabilities, with this information largely coming from nurses; a few stated that alcohol use can lead to Down syndrome. Despite knowledge of the risks, several participants described how women commonly justify drinking during pregnancy by arguing that they had witnessed other women drinking without negative effects. One woman who reported stopping drinking as soon as she discovered that she was pregnant described having tried to advise her pregnant friends to stop using substances. However, she said that they had laughed at her and ‘compared themselves to other women who gave birth to healthy babies although they were using substances during pregnancy’.

Drivers related to social interaction

The influence of peers

Consistent with community norms, several participants described seeing their friends using alcohol or drugs during pregnancy, including close to delivery. During interviews, women extensively discussed the influence of peers on their own drinking behaviours. In particular, friends were described as the most common drinking partners. In contrast, only one participant reported that she most commonly drinks with her sister, and one with her aunts. Notably, women reported that they anticipated negative reactions from their peers if they were to stop drinking. One woman explained:

I don’t like the fact that I sacrifice my time in the tavern to please my friends … but I don’t have a choice. I have to please my friends because they tend to be harsh on me should I complain about spending a lot of time with them instead of spending time at home with my family.

Against this backdrop of peer pressure, several women voiced concerns during interviews about their friends’ use of alcohol. As noted above, some women described having unsuccessfully attempted to convince their friends to stop using substances while pregnant. One woman stated that: ‘When you advise them, they feel that you are jealous and that you do not want them to have fun’. Another woman who described having stopped drinking and having tried to advise her pregnant friends to do the same stated that they did not listen, and that ‘They say that I think I am better than them just because I do not drink anymore’.

The influence of male partners

In contrast to peers, male partners were infrequently described as drinking companions by the women interviewed, and several noted that they were no longer in a relationship with the father of their baby. However, partners were described as influencing women’s drinking behaviours in other ways. In particular, a major reason given for the high levels of alcohol use among women in their community was that many women use alcohol as a coping mechanism because their relationships end after they disclose to their male partners that they are pregnant, with one woman saying: ‘Men out there reject their partners and deny being fathers to their children … Women end up drinking alcohol just to run away from thinking about the challenges they are facing’. Another woman similarly stated that: ‘Male partners tend to reject their pregnant women during pregnancy and they end up consoling themselves by drinking alcohol’. Others described drinking after arguments with their partner, or due to the stress of their partners being unemployed and unable to provide for their baby.

Drivers related to individual self-regulation

Motivations and coping

Most women described drinking for enjoyment, particularly the social aspects of drinking with friends, with one woman stating that: ‘When there is alcohol, I am happy. I drink and have fun with my friends’. When probed, however, many described drinking as a form of coping. As noted above, alcohol use was described as being a way for some women to cope with stress related to their male partners. Several others described how drinking serves as a distraction that allows them to forget about their problems for a while. For many, alcohol use was described as being a way to relieve the stress of unemployment, and several stated that they would be able to stop drinking if they found employment. For example, one woman said that: ‘I drink alcohol to have fun. At the same time, I drink to drown my sorrows. I think I would stop drinking alcohol if I could find a job to support my children’.

Goals of reducing consumption

Although some women stated that they intended to stop drinking in the future, at least one woman said that she had no intention of stopping. Even in the absence of quitting, however, many women described having reduced their consumption at some point. The major motivating factor seemed to be the desire to prioritise their children and be a good mother, which included spending money that they would previously have spent on alcohol on baby items. When asked what made it easy for her to reduce her consumption, one woman said that: ‘It was easy after I found out that I was pregnant. I had to stop to protect my baby and to save money to buy baby stuff’. Several women described changing other aspects of their drinking behaviour after giving birth, for example drinking at home rather than going out. However, a few described leaving their babies with family members or neighbours while they were out drinking with friends.

Individual capabilities in the face of structural and interpersonal factors

Finally, despite women acknowledging the negative effects of alcohol use in their lives, and some stating that they intended to stop drinking, women’s beliefs in their individual capabilities to reduce consumption were diminished in the face of two factors: (i) peer influences, and (ii) the lack of anything else to do with their time. When asked what would help them stop drinking, the most common response was that participants would need to physically distance themselves from their friends. One woman who described drinking with her friends because she was lonely, despite wanting to reduce her consumption, said: ‘I invited my friends to go with me to join a netball club in my community, but they refused, saying they can’t leave alcohol for netball. I gave up’. When asked whether she has tried to stop using alcohol, another participant responded that:

I have been wanting to. In fact, I want to but because of friends I am unable to do so. Especially if I go out with them, it gets difficult to resist alcohol … I drink because I don’t want to be the boring one. I want them to see that I drink as well.

The second common limiting factor was the lack of anything better to do, with women saying that it would be easy to stop drinking if they had some way of keeping themselves busy, either through formal employment or voluntary work on community projects. One woman said that:

I think I would stop drinking alcohol if I could find a job to support my children … I am drinking alcohol because my mother is stressing me since I am unemployed, otherwise it wouldn’t be difficult for me to stop it. I could stop drinking alcohol immediately if I could find myself a job. It is not a good thing to go to work intoxicated and I will never play with my job should I find it.

Another woman suggested that a project for individuals who are unemployed would help to reduce substance use, stating: ‘For example, a vegetable or poultry project. They will not get a chance to drink or smoke because they will be busy with the project; they will know what to do and have responsibilities’.

Discussion

This study provides a rich exploration of the drivers of perinatal alcohol use among young WLHIV, including the notable impact of context. Living in a community where heavy alcohol consumption is normalised, including among pregnant women, where unemployment is rife, and where alcohol use is a major form of recreation and opportunity for social connection has clear adverse effects on women’s behaviours. Despite recognising the risks to their unborn baby and acknowledging the negative effects of alcohol in their lives, participants seemed to have limited motivation or agency to go against the norm of drinking with peers, compounded by the lack of job and leisure time opportunities. Overall, the structural, interpersonal, and individual drivers of perinatal alcohol use described here are consistent with the broader literature, and several of our findings are notable and warrant discussion.

First, it is clear that context is critical to both understanding the factors that shape drinking behaviours as well as considering the alternatives to alcohol use. In addition, our findings suggest that women’s beliefs in their own capabilities to reduce consumption, which are important for individual self-regulation, are diminished by structural factors. In this study, participants described how unemployment results in heightened financial stress as well as a lack of meaningful activities, both of which drive alcohol use, and that this is compounded by the fact that there are few recreational opportunities that are not centred around alcohol use in this setting. Consistent with our findings, pregnant women and mothers in Lesotho have described how limited recreation activities contribute to a culture where alcohol use is an aspect of daily life (Marlow et al., 2021). There is a clear need to create opportunities for formal work or engagement in community programmes in these settings, as well as to develop alternative opportunities for socialising and leisure (De Jong et al., 2021). Ultimately, interventions which build on intrinsic motivation to reduce perinatal alcohol use are needed, but these must be delivered within environments that make reducing consumption easier by providing meaningful alternatives (Fletcher et al., 2018). Others have similarly argued that a combination of structural- and individual-level interventions are needed to support alcohol reduction among pregnant women (Eaton et al., 2014b).

Second, our findings suggest that interpersonal factors similarly diminish women’s beliefs in their capabilities to reduce consumption. Peer influences on alcohol use are salient during adolescence (Morojele et al., 2021) and, as discussed during these interviews, extend into young adulthood. Similar findings have been documented among women of all ages in another community in Cape Town, with women describing how drinking during pregnancy is heavily influenced by social pressures (Fletcher et al., 2018). Given that heavy alcohol use is the norm in this setting (Brittain et al., 2017; Davis et al., 2017; Petersen Williams et al., 2014), the high reported levels of alcohol use prior to pregnancy in this study are unsurprising. Notably, our findings suggest that a pregnancy may not be a sufficiently motivating factor to reduce alcohol use, with many women continuing to drink during pregnancy.

In this study, women cited some incorrect beliefs within their community about alcohol use during pregnancy, but had relatively good knowledge of the effects on an unborn baby. Interventions that focus solely on providing education to pregnant women assume that knowledge of the risks will be sufficient motivation for women to reduce their consumption. However, our findings suggest that a major barrier to education-based interventions is that many women reported knowing of others who had drunk heavily during their pregnancy without any noticeable effects on their child, thus diminishing their own perceived risk. A further limitation to education-based interventions is that they focus on individual behaviour change, without consideration of contextual factors such as power relations around gender, class and culture (Matebese et al., 2021). In line with this, others have argued that there needs to be a shift from an exclusive focus on the health of the baby to incorporating an acknowledgement of a pregnant woman’s circumstances in designing interventions (De Jong et al., 2021). Consistent with the literature, our findings suggest that young pregnant and postpartum WLHIV face unique vulnerabilities which must be taken into account when designing interventions.

Our findings must be considered in light of several limitations. Participants were recruited from one antenatal clinic in Cape Town, and their experiences may differ from those of young women in other settings. Women were enrolled into the trial between August 2019 – February 2020, and in-depth interviews were conducted between February – March 2021, thus recall is a concern. Participation in the intervention may have led to changes in women’s behaviours or have altered their responses to interview questions, but levels of participation at intervention sessions were low and the qualitative interviewer had not been involved in intervention delivery. The COVID-19 pandemic meant that interviews were conducted telephonically, but it was ensured that participants were able to speak freely prior to beginning the interview. National restrictions on the sale of alcohol during COVID-19 lockdowns may have influenced alcohol use behaviours, although illegal purchasing of alcohol was common during this time (Theron et al., 2022). Finally, social desirability is a concern, given the sensitive nature of the topic, but women generally provided rich descriptions of their own drinking behaviours, thus social desirability may have had minimal effects on our findings.

Despite some limitations, these findings provide important insights into perinatal alcohol use among young WLHIV, as well as considerations for intervention development. Our research suggests that interventions that target only the individual level, for example those that focus solely on providing education about the risks of alcohol use to pregnant women, are unlikely to be effective. Given the critical role that context plays in shaping women’s drinking behaviours, interventions that support women to negotiate the contextual challenges they face are needed. In a setting where perinatal alcohol use is common, drawing on the experiences of women who have successfully reduced their consumption during pregnancy may be helpful to explore the factors that motivate them to engage in health behaviours that go against the norm. This understanding may be critical in supporting other women to counter negative pressure from peers, and potentially designing peer-based models of support. Finally, our findings suggest that the impact of interventions will be limited in the absence of providing opportunities for work or community engagement, and meaningful alternatives for recreation and socialising. As such, there is an urgent need to involve communities in designing interventions to foster social capital and health-enabling environments, including appealing alternatives to alcohol use.

Acknowledgements

The authors would like to thank the women who participated in this study, as well as the study staff for their support of this research. This research was supported by a Providence/Boston Center for AIDS Research (CFAR) international developmental award with co-funding from the National Institute Of Allergy And Infectious Diseases (NIAID) under award number P30AI042853. The authors would like to thank the CFAR Substance Use Research Core for their input into development of the in-depth interview guide. The primary trial was funded by the Fogarty International Center, National Institute of Mental Health (NIMH) of the National Institutes of Health under award number R21TW011047. Dr. Pellowski was supported by a career development grant from the NIMH (K01MH112443). Drs. Mellins and Remien are supported by a grant from the NIMH to the HIV Center for Clinical and Behavioral Studies (P30-MH45320).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Fogarty International Center: [Grant Number R21TW011047]; Providence/Boston Center for AIDS Research: [Grant Number P30AI042853].