Identification of studies
A total of 1357 articles were identified in our electronic search using the specified databases. and a manual search for the reference lists other articles resulted in 5 additional articles. This makes the total number of search results to be 1362 articles. Of these, 28 were duplicates and removed. A detailed screening of the remaining articles resulted in only 62 articles to be reviewed their full text for eligibility. Finally, only twenty-two articles were included in the analysis by fulfilling our pre-specified inclusion criteria (Figure 1).
Characteristics of included studies
A total of 22 studies in the Africa continent that investigated AUD in 16774 patients on anti-retroviral therapy have been included in this systematic review and meta-analysis study (7-23, 27, 28, 49-52). Based on the type of study design, 18 studies were cross-sectional type (8-10, 12-16, 18-20, 23, 27, 28, 49, 51, 52, 55) 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, 49-52), 5 were from Ethiopia (7, 27, 28, 49, 51), 3 from Nigeria (8-10), 4 from Uganda (11-14), 4 form south Africa (15-18) and the remaining 6 studies were from Kenya, Namibia, and Zambia (19-23, 52).
Considering study publication, three were published before 2011(9, 12, 15), eight were published b/n 2011-2015(10, 13, 14, 19, 21-23, 51), and the remaining eleven were published after 2015 (7, 8, 11, 17, 18, 20, 27, 28, 49, 50, 52). Ten of the included studies (8, 13-15, 18, 21-23, 27, 52) studied a sample of greater than 450 participants and the remaining 12 studies (7, 9-12, 16, 17, 19, 20, 28, 49, 51) studied a sample less than 450 participants (Table 1).
Quality of Included Studies
In general, the summary quality assessment result of cohort studies included in the current meta-analysis ranges from 7 to 10 according to the scoring system of Newcastle Ottawa scale; one with moderate and three with good quality. The quality assessment for the remaining 18 cross-sectional studies based on the JBI checklist for prevalence studies ranges from 6 to 10; implying an appropriate methodological quality of the included studies.
The average prevalence of alcohol use disorder among HIV/AIDS patients who were on antiretroviral therapy in Africa
Twenty-two studies had been included in the final meta-analysis to determine the average prevalence of AUD among patients on antiretroviral therapy in Africa (7-23, 27, 28, 49-52). The reported prevalence of AUD among included studies in this review and meta-analysis study ranges from as low as 1.4% in Uganda (12) to as high as 48.5% in South Africa (16). The average prevalence of AUD among patients on antiretroviral 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 < 0.001) from the difference between the incorporated studies (Figure 2).
The prevalence of alcohol use disorders among HIV/AIDS patients based on country of origin and year of the study
Since the average prevalence of AUD was influenced by a significant heterogeneity during the analysis, a subgroup analysis has been implemented based on the country where the study was conducted, year of publication of the study, and sample size used in the study. Based on this among the 22 studies integrated with the meta-analysis (7-23, 27, 28, 49-52), 5 were from Ethiopia (7, 27, 28, 49, 51), 3 were from Nigeria (8-10), 4 were from Uganda(11-14), another 4 were from South Africa (15-18) and the remaining 6 studies were from Kenya, Namibia, and Zambia (19-23, 52).
The average prevalence of AUD among patients on ART in Ethiopia was 23.36% (95% CI: 17.53, 31.19) with (I2= 98.6%, p-value < 0.001). The average 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). On the other hand, the average prevalence 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.
Considering year of publication, the average prevalence of AUD in studies published before 2011(9, 12, 15), 2011-2015(10, 13, 14, 19, 21-23, 51), and after 2015(7, 8, 11, 17, 18, 20, 27, 28, 49, 50, 52) 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. The average prevalence of AUD among studies which utilized a sample size > 450 (8, 13-15, 18, 21-23, 27, 52) was also obtained to be 16.71% (95% CI: 10.30, 23.12) (I2= 98.5%, p-value < 0.001) whereas it was 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, 49, 51)(Figure 3) and (Table 2).
The average prevalence of hazardous alcohol use among HIV/AIDS patients who are on antiretroviral 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, 49, 51). 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-value < 0.001) (Figure 4).
The average prevalence of harmful alcohol use among HIV/AIDS patients on antiretroviral therapy in Africa
Seven studies reported data on the prevalence of harmful drinking in HIV/AIDS patients (8, 10, 19, 22, 27, 49, 51). The average prevalence of harmful drinking among these studies was obtained to be 8.1% (95% CI: 1.04, 15.17) and was having a significant heterogeneity (I2=99.5%, p-value < 0.001) (Figure 5). Consequently, we performed a subgroup of harmful drinking based on the sample size used. The Prevalence of harmful drinking among studies that used relatively larger sample (>400) (8, 22, 27, 51) 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, 49).
The average prevalence of dependent drinking among HIV/AIDS patients who are on antiretroviral therapy in Africa
Seven other studies (8, 10, 19, 22, 27, 49, 51) also reported dependent drinking in HIV/AIDS patients on antiretroviral therapy. The average prevalence of dependent drinking in these studies was 3.12 % (95% CI: 1.45, 6.70) and an obvious heterogeneity has also been detected in the result (I2=99.6%, p-value < 0.001) (Figure 6). The average prevalence of dependent drinking among studies that utilized a sample of more than 400 (8, 18, 22, 27, 51) was 1.76% (1.16, 3.68) whereas it was 6.56% (95% CI: 2.51,17.64) among smaller sample studies(19, 49).
Sensitivity analysis
To detect further the source of heterogeneity that influences the average prevalence of AUD, we also did one study leave out at a time sensitivity analysis. The result from the sensitivity analysis revealed that the average estimated prevalence of AUD obtained when each study was left out from analysis was within the 95% confidence interval of the average prevalence of AUD when all studies were run together. Therefore, the result of the average prevalence of AUD in HIV patients was not influenced by a single particular study. Moreover, the 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 study was excluded (Table 3).
Publication bias
We carried out an Egger's publication bias plot to detect the presence of 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 additional evidence for the absence of a small study effect (Figure 7).
Narrative description of the associated factors for Alcohol use disorders
Of 22 included studies, 12 studies that reported associated factors for AUD among HIV AIDS patients were included in our narrative analysis (8-10, 16, 17, 20, 21, 27, 28, 49, 51, 55) (Table 4). Seven of the included studies (7, 9, 10, 16, 28, 49, 51) reported an association between being male and AUD. Cigarette smoking was also reported as a related factor for AUD in four (7, 27, 49, 51) studies. Family history of alcohol use (27, 28), missing ART medication(21, 27), mental distress (51), khat chewing (7, 27, 49), educational status(10, 27), low CD4 count(49), low income(10), orthodox religion(51), protestant religion(51) had also a strong and significant association with AUD in people with HIV AIDS in Africa.
The association between male sex and alcohol use disorder in HIV/AIDS patients
The association of being a male and higher risk of AUD in HIV/AIDS patients was reported in seven of the included studies (7, 9, 10, 16, 28, 49, 51). The average adjusted odds ratio of the increased risk of having AUD 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 an alcohol use disorder
Among the 22 studies incorporated in the current meta-analysis(7-23, 27, 28, 49-52), four (7, 27, 49, 51) had reported cigarette smoking as an independent factor for AUD in HIV patients. The average adjusted 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 AUD than patients who were not smoking a cigarette. Similarly, three of the above-indicated studies (7, 27, 49) had also reported khat chewing as a risk factor for AUD. The average adjusted odds ratio of khat chewing among these studies was found to be 3.34% (95% CI: 1.71, 4.96) (I2=98.2%, P< 0.01). This implied that patients who were chewing khat were on average 3.3 times more likely to have AUD than patients who were not chewing khat.