Funding Opportunity Description

This PA requests research on the effectiveness of structural interventions that reduce the risk of HIV/AIDS transmission by changing the environment of alcohol use. Although a variety of structural and environmental interventions have been employed successfully to reduce other drinking-related problems, there has been little research that extends such efforts into the realm of HIV/AIDS risk reduction. Applicants are especially encouraged to examine the ramifications for HIV/AIDS risk of “naturally occurring” or already-announced changes in alcohol-related laws, regulations, programs or policies.

Research Objectives

The role played by alcohol consumption as a facilitator of HIV/AIDS infection risk has been the subject of much research.  A relationship between alcohol use and HIV/AIDS risk has been documented among men who have sex with men (Koblin et al. 2003; Seage et al. 1998), urban minority groups (Morrison et al. 1998; Fort and Norris 1994); adolescents (Henry Kaiser Family Foundation 2001), HIV-seropositive individuals (Marks and Crepaz 2001), seriously mentally ill persons (Tucker et al. 2003), non-U.S. populations (Fritz et al. 2002; Mbulaiteye et al. 2000), and others.

Nevertheless, the putative link between alcohol use and involvement in HIV-risky sexual behaviors has not been without challenge (Weatherburn et al. 1993; Messiah et al. 1998; Liegh 1993; Tubman and Langer 1995; Leigh and Miller 1995; Weinhardt et al 2001).  A growing body of evidence suggests that the relationship between drinking and risky sex is likely to be the result of a complex interaction among personality, situational, and behavioral factors, as well as the sexual experience of the partners (Temple et al. 1993; Cooper and Orcutt 1997).

In the course of this debate, it has become increasingly apparent that individual-level behavior change approaches are, by themselves, unlikely to be sufficient in halting HIV spread (e.g., Sterk 2002; Miller and Kelly 2002; DiClemente and Wingood 2003).  As a result, some researchers and funding agencies have started to look closely at the ways in which HIV spread may be curbed as a result of structural alterations (Wohlfeiler 2002; Mataure et al. 2002; Sumartojo et al. 2000; d'Crux-Grote 1996).  Structural (sometimes termed "environmental") interventions for HIV have been defined: as "programs or policies that change the environments in which risk behavior occurs, without attempting to change knowledge, attitudes or social interaction patterns of the persons at risk" (Des Jarlais 2000); and as "interventions that work by altering the context within which health is produced or reproduced" (Blankenship et al. 2000).

Such interventions may take a number of forms. Blankenship and colleagues (2000) have identified two dimensions along which structural interventions can vary. For one thing, such interventions may locate the source of health problems in factors related to availability, acceptability, or accessibility. Availability interventions are rooted in the notion that health problems result from a lack of tools, behaviors, materials, or settings necessary to promote healthy outcomes (or, conversely, the excessive availability or these items). Acceptability interventions, based in the notion that public health is partly determined by that society’s cultural values and beliefs, alter social norms as a way of promoting public health. Accessibility interventions manipulate power and resources to promote public health.  The target for the intervention constitutes the second dimension along which structural interventions can vary: that is, each of these intervention types may target the individual, the organizational/ institutional level, or the environmental (social, legal, and physical) level. In sum, then, this framework suggests no less than nine kinds of structural interventions.

A variety of structural interventions have been studied with regard to their effectiveness at reducing either alcohol consumption or various problems associated with drinking.  Many of these are based on the  substantial evidence that reducing alcohol availability can reduce alcohol consumption (Kuo et al. 2003; Skog 2000; Chaloupka et al. 1998; Rahkonen and Ahlstrom 1989).  For instance, increasing the monetary price of alcoholic beverages, usually achieved through increasing taxes on alcoholic beverages (Chaloupka et al. 1998) reduces consumption and alcohol-related problems.  Media-focused interventions can be regarded as structural-level approaches insofar as media affect the environment in which people live (Cohen and Scribner 2000).  Evidence from a community trial suggests that training in media advocacy can increase electronic and print media coverage of news events generated by local individuals, resulting in greater public and leader attention paid to specific issues as well as to local policies aimed at reducing alcohol-involved injury (Holder and Treno 1997).  Some structural approaches have sought to change community policies by directly approaching those community-level policy makers who set local priorities for allocating resources and enforcing laws related to, for example, underage alcohol sales and bar/restaurant alcohol serving practices (Holder and Reynolds 1997). As some researchers have concluded that alcohol outlet density may be related to violent assaults in nearby areas when certain conditions prevail (Gorman et al. 1998; Treno et al 2001; Speer et al. 1998; Scribner et al. 1995, 1999; Alaniz et al. 1998), some research has examined the effects of local land use and zoning practices in reducing alcohol availability, consumption and related problems (Reynolds et al., 1997). Moreover, several studies (Johnsson and Berglund 2003; Saltz 1987) have found that alcohol server intervention programs can significantly reduce hazardous alcohol use among bar/restaurant patrons.  Particularly germane to this PA is a recent analysis that indicated that more restrictive state alcohol availability policies were associated with lower rates of gonorrhea among certain age groups (CDC 2000). 

Thus, previous studies have manipulated a number of structural "handles" in attempting to reduce the problems associated with alcohol use. Many such projects have been supported by NIAAA. However, few of these alcohol-related structures have been examined for their potential in reducing the behavioral risks that lead to HIV/AIDS infection. Furthermore, while HIV/AIDS prevention approaches long have reported some success in altering community behavioral norms through the dissemination of relevant HIV/AIDS information and risk reduction techniques through high-risk social networks utilizing street outreach workers (Neaigus et al., 1990) and community “peers” (Broadhead et al., 1998; Kelly et al., 1992) as behavioral change endorsers, this Announcement seeks to stimulate research that assesses the effectiveness of truly “structural” changes that can be expected to impact alcohol-related HIV/AIDS risk. These alterations in laws, regulations, programs, policies, systems, and environmental factors that influence the consumption of alcohol—-specifically, how, who, when, where, how often, and how much alcohol is consumed—-may also be examined for their effects in changing individual attitudes and perceptions related to alcohol-related HIV/AIDS risk. Potential applicants are especially encouraged to examine the ramifications for HIV/AIDS risk of “naturally occurring” or already-announced changes in alcohol-related laws, regulations, programs or policies, specifically by evaluating the impacts of such changes against those observed in appropriate comparison sites/communities. In sum, then, this PA attempts to move prevention science toward the investigation of the effects of structural or environmental interventions in altering drinking environments as a way of stemming alcohol-related HIV/AIDS risk behaviors and infection rates.

Areas of Research Interest

This PA focuses on intermediate-level factors that directly affect the drinking environment. Hence, applications responsive to this announcement will assess the impacts on HIV/AIDS risk of changes in one or more features of the alcohol consumption environment, including—but not limited to—changes in:

• local zoning of alcohol outlets
• the form of alcohol availability (e.g., the sale of distilled spirits by the individual drink; ban on beer keg sales to individuals; Holder, 2002)
• retail prices of alcoholic beverages
• alcohol server training programs
• the access of underage persons to alcohol.  Such access might be reduced through stepped-up enforcement of the minimum purchase age
• keg registration policies that facilitate the prosecution of individuals who supply alcohol to underage youth
• establishment/enforcement of curfews to limit hours of alcohol sales to young people, including restrictions on “happy hours” at alcohol-serving establishments (Smart and Adlaf, 1986; Babor et al., 1978)
• alcohol counter-advertising campaigns (Saffer, 2002)
• increased alcohol taxes earmarked for prevention, education, and treatment programs
• restrictions placed on alcohol advertisements
• enforcement of restrictions on public drinking
• establishment of Employee Assistance Programs implemented at work settings to aid workers in curbing their alcohol use and related problems
• enforcement of college and university policies aimed at limiting drinking at campus events
• government monopoly of alcohol retail sales
• comparison of multiple structural interventions and HIV/AIDS-related outcomes
• The above list is not intended to be exhaustive. Prospective researchers might well consider evaluating a combination of such strategies in their project (see Wallin et al., 2003; Holder et al., 2000). For example, one community-based approach aimed at preventing underage sales of alcohol combined elements of enforcement of underage sales laws, responsible beverage service training, and media advocacy (Grube, 1997).
• tailor alcohol abuse and HIV prevention messages (e.g., media, social marketing) to address health disparities by ethnicity, sex, income level, or region
• integrate screening, assessment, and referral for intervention/treatment for mental disorders and HIV risk behavior into clinical care or other health services (e.g., primary health care, voluntary counseling and testing, sexually transmitted infections clinics)

While this PA is primarily directed toward reducing alcohol-related risks, structural interventions also may focus on secondary prevention among individuals who are already infected with HIV. Such interventions may focus on increasing: the screening and identification of HIV+ alcoholics (often a hard-to-reach population), their engagement and retention in AIDS treatment protocols, or the development of new technologies to improve alcohol and HIV/AIDS treatment among multiply-diagnosed persons to address medically significant end points, such as liver failure. Importantly, structural alterations may address the stigma endured by HIV-positive persons with drinking problems, particularly the manifold ways in which felt stigma may hinder the retention of such persons in alcohol and HIV/AIDS treatment programs.

Prepared:  March 9, 2006