We interviewed 49 (67%) of the 73 participants initially selected for an interview: 24 of the 36 participants selected for a post-intervention interview and 25 of the 37 participants selected for an in-depth interview at the six-month follow-up appointment. Of the 24 selected participants that were not interviewed, 14 (58%) were lost to follow-up, 8 (33%) refused the offer of an intervention and the interview, and 2 (8%) received at least one intervention session but did not want to be interviewed. There were no baseline differences between participants who were interviewed and those who were selected, but not interviewed (see Table 1). Interviewed participants were mainly women (67%) and were 41 years of age (SD = 9.3), on average. Three quarters of the sample reported significant symptoms of depression (76%) and their average AUDIT score was 8.6 (SD = 4.6).
Three themes emerged from the interviews that reflect participants’ perceptions of the acceptability and usefulness of this intervention. Similar themes emerged for participants interviewed post-intervention and at the six-month follow-up (6MFU), although participants at the 6MFU provided a richer description of the usefulness of the intervention and were able to provide concrete examples of how they had applied specific skills learned during the intervention to facilitate behaviour change. Participants at the post-intervention point would not have had an opportunity to apply skills learned during module 3 and 4 of the intervention. The first theme describes participants’ perceptions of the acceptability of screening and brief alcohol-focused interventions for patients living with HIV. The second theme describes participants’ views of the usefulness of the intervention for reducing alcohol use and addressing life stressors. The third theme reflects participants’ views on how the intervention could be modified for greater reach and impact. These themes are described below and are illustrated with quotes.
Acceptability of brief alcohol-focused interventions
When asked for feedback about the process of being screened for hazardous alcohol use, almost all participants felt that screening helped them understand the level of risk associated with their current pattern of alcohol use. Those participants that initially expressed ambivalence towards this screening did not view their drinking as problematic:
I did not see that I had a problem with alcohol. It (the screening) was able to open my eyes to see that I have a problem. [Male PID 7, post-intervention]
I wasn’t even aware that I have a drinking problem, I only became aware when I started talking about it. [Female PID 70; 6MFU]
Participants agreed that the brief intervention was largely acceptable. The opportunity to talk to a counsellor who was knowledgeable about alcohol use and provided a safe, confidential, and non-judgmental space to discuss problems and concerns was highly valued. This is reflected in the following comments:
My counsellor spoke to me in a friendly manner and listened to me when I talked. She would go extra lengths for me. I liked the way she listened to me.
[Female PID 54; 6MFU]
She is a person who can understand a situation and then at the end help come up with a solution, she is a friendly person. She doesn’t judge, she listens.
[Male PID 7; post-intervention]
In several instances, participants described the intervention as an essential adjunct to the clinical care they received at the facility. Participants remarked how their HIV providers only addressed their physical and HIV disease-related concerns, with little attention to emotional and social issues that impacted on their well-being. As a result, participants tended to perceive the intervention as addressing a gap in current services:
I saw this counselling as very important because of the way they have time. Here at the clinic, they don’t have that time. I am sorry to say this but here they [nurses] are only rushing so that the line can move, finish and then go home.
[Male PID 16; post-intervention]
It was helpful because we don’t get much counselling and sometimes I feel that when you have a problem, you don’t talk to them [nurses], you just come in, they sign your file, you take your treatment and you go home. … so it’s like I am getting treatment that side and advice about my life this side.
[Female PID 56; 6MFU]
When asked specifically, all participants said that they would recommend the intervention to other people living with HIV who use alcohol, and several suggested it would be suitable for all people living with HIV regardless of whether they use alcohol.
Usefulness of MI-PST for facilitating behaviour change
Almost all participants thought the intervention “was helpful” for facilitating behaviour change and improving their lives. When describing the usefulness of the intervention, participants commented:
Since I came here for counselling, I feel like a lot has changed, even my mind is functioning better. [Male PID 29; post-intervention]
I feel lighter because I was always feeling pain in my spirit and remember when I started coming here I was very hurt … and as time went I got better.
[Female PID 38; 6MFU]
Participants seemed to value the psychoeducation material contained in the intervention which provided them with feedback about their personal risks for alcohol-related harms and psychoeducation about alcohol use and health. Several participants articulated that prior to receiving the intervention they were not “aware that a lot of alcohol is not advised when one is taking treatment” and that they only “started knowing it after being part of this study.” As one participant reflected:
Sometimes you do things and you are not aware that they are wrong. I realise that if I am taking ARV’s I am not supposed to have problems or stresses, or drink too much alcohol. [Female PID 71; 6MFU]
For many participants, the information on standard drinks and container sizes was particularly salient and helped them quantify the amount of alcohol they were consuming. Many reported being surprised by exactly how much they were drinking:
So now when I drink alcohol, I am careful because I look at the fact that I am drinking 750 ml that means I am drinking 2.2 beers. I didn’t know, I thought 750 ml equals one drink. It taught me that sometimes we drink a lot of alcohol without being aware. [Male PID 49; 6MFU]
Many participants reported using the patient handbook (which contained goal setting activities and a drinking diary) to help them keep track of the amount of alcohol they were consuming. These participants experienced the handbook as a useful platform to support self-monitoring of alcohol intake and self-evaluation of progress towards their alcohol reduction goals:
What I liked about this book is that I can use it as my diary, where I keep track of my drinking habit. I write down and calculate the percentage of alcohol whenever I have a drink and see the total. [Male PID 17; post-intervention]
The PST content of the intervention also appeared to be valued by participants who agreed that the structured problem-solving approach taught during counselling had given them new skills for resolving everyday problems. Participants reflected that the PST approach had taught them to face their problems directly without having to turn to alcohol:
I accept any problem that comes my way and I can now solve problems. I don’t bottle them inside anymore, but I deal with them head on. [Female PID 54; 6MFU]
I see life with a different eye. I take things as they come and know how I should tackle them . When I come across problems I take things step by step. I no longer rush to drink when I have stress. [Female PID 49; 6MFU]
Several participants also reflected on the usefulness of the PST content that focused on strategies for accepting and managing problems that cannot be changed. This seemed particularly salient for participants who were struggling to accept their HIV diagnosis and were using alcohol to cope:
I learned to accept myself in this situation that I am in … to accept that I will take ARVs forever. I could not accept it in the beginning, now I have accepted.
[Male PID 23; post-intervention]
All participants interviewed at the six-month timepoint reported applying these skills to make changes to their alcohol consumption. Although a few participants reported that they had stopped drinking, the majority described how they had “reduced drinking” and “now limited (their) alcohol intake” but had not stopped drinking completely. One participant spoke of how reducing his alcohol intake had improved his health and financial situation:
I have reduced my alcohol and I no longer drink a lot. I used to drink Monday to Monday, now alcohol no longer controls me. I no longer get sick easily, I am healthy, I am alright. I can do my budget and see what we are short of at home. Before I used to just drink money. I can afford a lot of things now because I no longer waste money like before. [Male PID 72; 6MFU]
Despite these perceived benefits, alcohol cessation remained an important goal for several participants, who described wanting to “totally quit” but finding it “difficult and quite challenging to stop.” For these participants, reducing their alcohol intake was an incremental step towards their goal of abstinence.
I have started to reduce. Sometimes I drink, but not too much. Eventually I want to stop drinking altogether, as times goes on. [Female PID 9; post-intervention]
You don’t just easily stop drinking, you can’t say you will stop tomorrow. I will try to reduce my alcohol intake. [Male PID 17; post-intervention]
At the six-month end-point, most participants provided concrete examples of how they had applied their newly acquired skills to resolve some of the problems in their lives that triggered or contributed to excessive alcohol use. Participants described using these skills to manage a range of life problems, including unemployment (with a few reporting that they had found part-time employment or started income-generation activities), relationship difficulties and interpersonal conflicts. These were salient life problems for men and women. PST skills seemed particularly helpful for aiding the regulation of negative emotions such as anger, anxiety and despair:
I was a person who had anger … I would turn small issues into big ones and I was quick to get angry. Since I have spoken to the counsellors, they have advised me what to do. I tried to do what they said and now I can see that at least I am not too quick to get angry. [Female PID 67; 6MFU]
In counselling, they taught me how to cope with negative thoughts. I am maybe not going to allow this thought to consume my mind. I usually have stress when I am alone and I think about a lot of things. [Female PID 71; 6MFU]
Suggestions for modifications to the intervention
Participants made several suggestions for how to improve the reach and impact of the intervention. These recommendations relate primarily to the content, delivery, and dosage of the intervention. In terms of content, some participants requested more detail about how alcohol affects HIV disease progression (in addition to information on how it affects ART adherence). These participants wanted to “know exactly what alcohol does to the body”. Furthermore, the intervention focused on promoting alcohol reduction and provides little guidance on the benefits of alcohol abstinence. Several participants (who wanted to stop drinking) thought the intervention should be expanded to include more information on alcohol cessation:
They can teach you more in terms of how you can stop instead of only how you can reduce. [Male PID 70; 6MFU]
Some participants also requested additional supplementary material that addressed some of the structural drivers of alcohol use in their context such as unemployment and a lack of work and income-generation skills. These participants suggested supplementing the individual behavior change intervention to include additional components focused on developing income generation skills and work preparedness:
You should try to help find jobs for us. Help us find jobs so that the stress that we have can be reduced … or projects so that even where are no jobs we have something to hold on to. [Female PID 4; post-intervention]
Only a few participants made recommendations for modifications to the delivery of the intervention. Hardly any participants reported barriers to attending intervention sessions at the health facility. A few did mention initial difficulties in taking time off work to attend these sessions but described how these barriers were addressed by the counsellors being able to accommodate them on weekends. Some participants mentioned that they would have preferred to have received counselling at their homes or in their communities rather than at the facilities. These were mainly men who were concerned about HIV-related stigma and did not want to be seen frequenting the health facility.
Most people have a problem of stigma, especially men we don’t even come to the clinic. So stigma is the main problem for men, there are a lot of people who have it. If you did house to house, it was something else… if you did house to house you will see a lot who have secrets. [Male PID 58; 6MFU]
When asked about whether the dosage of the intervention was sufficient to meet their counselling needs, a few participations considered four sessions delivered over two days adequate to meet their counselling expectations. This was particularly the case for those who reported low risk drinking. However, participants who reported excessive alcohol use expressed interest in receiving additional sessions to support their efforts to change and to help them stop drinking completely:
I would have liked to have more sessions and then maybe I would be able to take out what is in my heart, because at least there is someone who I can talk to. I can say they have helped me because I was able to see my problems, but for now I have not yet found a solution … we only had two sessions, so in those two sessions I can’t just make a decision. [Female PID 7; post-intervention]
Some of the participants who expressed interest in receiving additional sessions thought that these sessions could be offered as optional booster sessions that could be accessed on an as-needed basis, rather than making these additional sessions a mandatory part of the intervention package. According to these participants, this would provide them with opportunities to contact their counsellor when difficult problems arise for which they need additional support:
Sometimes I would come across problems and I wouldn’t know how to solve them, so if I could be able to come here and talk to her so that she can help me.
[Female PID 61; 6MFU]