Characteristics of included studies
A total of 22 studies in Africa continent that investigated alcohol use disorder in 16774 patients who were on anti-retroviral therapy in Africa have been integrated into this systematic review and meta-analysis study (7–23, 27, 28, 57–60). Considering the type of study design, 18 studies were cross-sectional type and the other four studies (11, 17, 21, 22) were cohort in design. Among the 22 studies in the meta-analysis (7–23, 27, 28, 57–60), 5 were from Ethiopia (7, 27, 28, 57, 59), 3 were from Nigeria (8–10), 4 were from Uganda (11–14), another 4 were form south Africa (15–18) and the remaining 6 studies were from Kenya, Namibia and Zambia (19–23, 60). Besides, of all included studies, three were published before 2011(9, 12, 15), eight were published b/n 2011–2015(10, 13, 14, 19, 21–23, 59), and the remaining eleven were published after 2015 (7, 8, 11, 17, 18, 20, 27, 28, 57, 58, 60). Moreover, considering the sample size utilized in the study, 10 studies (8, 13–15, 18, 21–23, 27, 60) assessed > 450 participants and the remaining 12 studies (7, 9–12, 16, 17, 19, 20, 28, 57, 59) takes a sample of < 450 participants(Table 1)
Quality Of Included Studies
In general, the summary quality assessment result of 22 included studies integrated in the current meta-analysis ranges from 7 to 10 according to the scoring system of Newcastle Ottawa quality assessment. Amongst the 22 included studies, 19 were found to have good quality and the remaining 3 were having moderate quality. However, there was no study found to have poor quality (Additional file 1)
The pooled prevalence of alcohol use disorder among HIV/AIDS patients who were on anti-retroviral therapy in Africa
Twenty two studies had been included in the final meta-analysis to determine the pooled magnitude of alcohol use disorder among patients on anti-retroviral therapy in Africa (7–23, 27, 28, 57–60). The reported magnitude of alcohol use disorders among studies included in the current review and meta-analysis ranges from as low as 1.4% in Uganda (12) to as high as 48.5% in south Africa(16). The average prevalence of alcohol use disorder among patients on anti-retroviral therapy in Africa using the random effect model was 22.03%( 95% CI: 17.18, 28.67). This average prevalence has been influenced by a significant heterogeneity (I2 = 99.8%, p-value = 0.000) from the difference between the incorporated studies (Fig. 2).
The pooled prevalence of hazardous alcohol use among HIV/AIDS patients who are on anti-retroviral therapy in Africa
Among the 22 studies included in the final analysis, Data regarding hazardous drinking was described in seven studies (8, 10, 19, 22, 27, 57, 59). The aggregate prevalence of hazardous drinking in these studies was 10.87% (95% CI: 4.82, 16.93). This average result was with considerable heterogeneity (I2 = 99.6%, P = 0.00) (Fig. 3). The pooled prevalence of hazardous drinking was 10.87% (95% CI: 0.89, 20.47) in studies that utilized a sample of > 400 (8, 22, 27, 59), and 11.15% (95% CI: 10.40, 11.90) in studies that used smaller sample (10, 19, 57).
The pooled prevalence of harmful alcohol use among HIV/AIDS patients on anti-retroviral therapy in Africa
Seven studies had reported the information regarding prevalence of harmful drinking in HIV/AIDS patients (8, 10, 19, 22, 27, 57, 59). The pooled prevalence of harmful drinking among the indicated studies was obtained to be 8.1% (95% CI: 1.04, 15.17) and was having a significant heterogeneity (I2 = 99.5%, P = 0.00) (Fig. 4). Consequently, we performed a subgroup of harmful drinking based on sample size used. The Prevalence of harmful drinking among studies that used relatively larger sample (> 400) (8, 22, 27, 59) was found to be 4.08 (95% CI: 1.14, 7.02) whereas it was 13.47% (-2.97, 29.91) in studies which used sample size < 400(10, 19, 57).
The pooled prevalence of dependent drinking among HIV/AIDS patients who are on anti-retroviral therapy in Africa
Moreover, the 7 studies (8, 10, 19, 22, 27, 57, 59) also illustrated information concerning dependent drinking among HIV/AIDS patients on anti-retroviral therapy. The average magnitude of dependent drinking was obtained to be 3.12% (95% CI: 1.45, 6.70) and an obvious heterogeneity has also been detected in the result (I2 = 99.6%, P = 0.00) (Fig. 5). The average magnitude of dependent drinking among studies that utilized sample of more than 400 (8, 18, 22, 27, 59) was 1.76% (1.16, 3.68) whereas it was 6.56% (95% CI: 2.51,17.64) among smaller sample studies(19, 57).
Subgroup analysis of the prevalence of alcohol use disorders among HIV/AIDS patients on ART therapy in Africa
Since the pooled prevalence of alcohol use disorder was influenced by a significant heterogeneity, a subgroup analysis has been implemented based on country where the study was conducted. Based on this among the 22 studies integrated in the meta-analysis (7–23, 27, 28, 57–60), 5 were from Ethiopia (7, 27, 28, 57, 59), 3 were from Nigeria (8–10), 4 were from Uganda(11–14), another 4 were form south Africa (15–18) and the remaining 6 studies were from Kenya, Namibia and Zambia (19–23, 60).
The average prevalence of alcohol use disorder among patients on ART in Ethiopia was 23.36% (95% CI: 17.53, 31.19) with (I2= 98.6%, p-value < 0.001). The pooled prevalence of AUD in South Africa was also found to be 28.77% (95% CI: 10.39, 47.16) with (I2 = 99.2%, p < 0.001). Besides, the average magnitude of AUD in Uganda and Nigeria were 16.61%( 95% CI: 6.86, 26.36) (I2 = 99.8%, p < 0.001) and 22.8% (95%CI: 6.83, 38.77) (I2 = 99.5%, p < 0.001) respectively.
Besides, the average prevalence of AUD in studies which were published before 2011(9, 12, 15), 2011–2015(10, 13, 14, 19, 21–23, 59), and after 2015(7, 8, 11, 17, 18, 20, 27, 28, 57, 58, 60) was found to be 13.47% (95%CI: 0.20, 26.75), 24.93% (95% CI: 15.10, 34.77) and 22.88% (95% CI: 17.71, 28.25) respectively. Moreover, the average magnitude of AUD among studies which utilized a sample size > 450 (8, 13–15, 18, 21–23, 27, 60) was obtained to be 16.71% (95% CI: 10.30, 23.12) (I2 = 98.5%, p-value < 0.001) whereas it was found to be 26.46% (95% CI: 20.21, 32.72) (I2 = 99.20%, p-value < 0.001) among studies that utilized sample size < 450(7, 9–12, 16, 17, 19, 20, 28, 57, 59) (Table 2).
Sensitivity analysis
To detect further the source of heterogeneity that influences the average prevalence of AUD in patients, we also investigate a one study leave out at a time sensitivity analysis. The result from the sensitivity analysis revealed that the average estimated magnitude of AUD obtained when each individual study were left out from analysis was with in the 95% confidence interval of average alcohol use disorder when all studies were pooled together. Therefore, the result of the average magnitude of AUD in HIV patients can be plausible. Moreover, the one study leave out at a time sensitivity analysis result revealed that the average AUD prevalence ranges between 20.77(95% CI: 16.33, 25.31) and 22.98% (95% CI: 18.05, 27.91) when each individual studies were excluded (Table 3).
Publication bias
We carried out an egger's publication bias plot to detect the presence of a publication bias but it is near the origin and the result of eggers publication bias plot had insignificant p-value(P = 0.22) on condition that no substantial publication bias for the prevalence AUD in Africa. Moreover, a visual inspection from a funnel plot for a Logit event rate of prevalence of AUD in HIV AIDS patients against its standard error suggests an additional evidence for the absence of a small study effect (Fig. 6).
Narrative description of the associated factors for Alcohol use disorders
Of 22 included studies, 12 studies that reported associated factors for alcohol use disorder among HIV AIDS patients were included in our narrative analysis (8–10, 16, 17, 20, 21, 27, 28, 57, 59, 61) (Table 4). Seven of the included studies (7, 9, 10, 16, 28, 57, 59) reported an association between being male and alcohol use disorder. Cigarette smoking was also reported as a related factor for AUD in four (7, 27, 57, 59) studies. Furthermore, family history of alcohol use(27, 28), missing ART medication(21, 27), mental distress(59), chat chewing (7, 27, 57), educational status(10, 27), low CD4 count(57), low income(10), orthodox religion(59), protestant religion(59) had a strong and significant association with alcohol use disorder in people with HIV AIDS in Africa.
The association between male sex and alcohol use disorder in HIV/AIDS patients on ART therapy
Information concerning the association of being male and higher risk of alcohol use disorder in HIV/AIDS patients was reported in seven of the included studies (7, 9, 10, 16, 28, 57, 59). The average adjusted odds ratio of increased risk of having alcohol use disorder was 5.5 (95% CI: 1.10, 9.98) (I2 = 90%, P < 0.01). This implied that male HIV/AIDS patients who were on ART were 5.5 times at higher risk of having alcohol use disorder as compared to female patients who were on ART therapy.
The association between cigarette smoking and chat chewing with alcohol use disorder
Among the 22 studies incorporated in the current meta-analysis(7–23, 27, 28, 57–60), four (7, 27, 57, 59) had reported cigarette smoking as an independent factor for alcohol use disorder in HIV patients. The average odds ratio of cigarette smoking in these studies was found to be 3.95% (95% CI: 3.00, 4.89) (I2 = 96.2%, P < 0.01). This result suggested that patient’s on ART who were smoking a cigarette were on average 4 times at increased risk of developing alcohol use disorder than patients who were not smoking cigarette. Similarly, three of the above indicated studies (7, 27, 57) had also reported chat chewing as a risk factor for alcohol use disorder. The average odds ratio of chat chewing among these studies was found to be 3.34% (95% CI: 1.71, 4.96) (I2 = 98.2%, P < 0.01). Therefore, patients who were chewing chat were on average 3.3 times more likely to have alcohol use disorder than patients who were not chewing chat.