Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa

Heavy alcohol consumption and other drug use are prominent across Africa and increase the risk of exposure to violence, HIV acquisition, and other life-threatening injuries. This review synthesizes evidence on alcohol and other drug (AOD) interventions in Africa; evaluates the differences between interventions that do and do not specifically target populations that use AODs; and highlights the impact of comprehensive vs. brief interventions and those that address syndemic issues from a gender and contextualized lens. Literature searches were conducted to identify research outcomes of randomized interventions published between January 2010 and May 2022 that address AOD use in Africa. Thirty-five full-text articles were included in this review. Most of the identified research studies were concentrated in a few countries. Most studies were conducted in South Africa. Many of the studies comprised brief interventions. However, the most comprehensive interventions were the most effective for AOD outcomes. Several studies indicated the importance of addressing AOD use alongside gender-based violence, mental health needs, gender roles, and other social determinants that affect health outcomes. Intervening on AOD use and addressing social determinants from a gender and contextually relevant perspective is essential to ensuring the long-term health and well-being of people in Africa.


Introduction
Alcohol remains one of the most commonly used substances in the world, and it is often used in combination with other drugs [1,2]. Heavy alcohol consumption and other drug misuse are prevalent across Africa because of the historical cultural norms and social acceptability of binge drinking within patriarchal societies; the increasing popularity of home brewed beer, wine, and flavored spirit coolers with high alcohol content; and the continent's ties with the drug trafficking trade [3][4][5][6][7]. In addition to alcohol, the main substances used across the African continent include cannabis, methamphetamine, heroin, and other opiates [8,9], which are frequently mixed together or mixed with other harmful chemicals, such as battery fluid, for a stronger high [6,10]. the lifespan of key populations. Alcohol is a primary substance of use across Africa with dire consequences [22]. Interventions to reduce AOD use among key populations in Africa have been developed and tested in trials, and previous reviews of their effectiveness have been conducted [32][33][34][35][36]. However, to the best of our knowledge, no reviews have synthesized evidence in support of their effectiveness while also examining the impact of culturally adapted and gender-specific interventions. The present review begins to address this gap. More specifically, this review synthesizes the findings from randomized controlled trials (RCTs) of AOD interventions in Africa and categorizes interventions that focus specifically on AOD use as a primary outcome and those that focus on AOD use as a secondary outcome. Additionally, this review examines the impact of culturally tailored, gender-and context-specific interventions on AOD use and health outcomes. This review expands previous reviews by looking at the intersectionality of gender and context.

Methods
Initial literature searches were conducted between July and October 2021, followed by a second search conducted in June 2022, to identify outcome studies for interventions that address AOD use in Africa. PubMed, Web of Science, Scopus, and PsycINFO were searched, returning 2942 results, and 678 total unique results in each search (see Figure 1) (see search terms in Appendix A). A supplementary search in Web of Science was conducted to determine whether expanded search terms would yield more relevant results; however, after reviewing the additional results, we determined that secondary searches of all databases ducted to determine whether expanded search terms would yield more re however, after reviewing the additional results, we determined that secon of all databases were not necessary. We used Boolean search terms to ide publications that met the following criteria: (1) published between January tober 2021, and a second search was conducted to include any publications 2021 through May 2022 (since the original review); (2) reported the finding tions that either specifically addressed or measured AOD use as outcomes the findings of interventions that were conducted in the continent of Africa ten in English. We downloaded the results into an EndNote library for furth used a priori criteria to review publications. Publications were sorted by us ical folder system, where articles were labeled as "Yes," "No," or "Maybe initial review of publication abstracts. Conference abstracts, dissertation book chapters were excluded from the initial search. Two trained research the full text of articles labeled "Maybe" or "Yes" to determine whether they sion criteria. Publications were also evaluated for study design, power, an siveness to determine study rigor. Of the 4612 abstracts returned in the initial search, and 2335 in the s 1670 duplicates across databases were removed in the first search and 1657 w in the second search; then, 2942 were excluded because they were not relev view in the first search, and 676 were excluded in the second search. Ultim text articles were included in this review. Several relevant protocol [37-47 Of the 4612 abstracts returned in the initial search, and 2335 in the second search, 1670 duplicates across databases were removed in the first search and 1657 were removed in the second search; then, 2942 were excluded because they were not relevant to this review in the first search, and 676 were excluded in the second search. Ultimately, 35 full-text articles were included in this review. Several relevant protocol [37][38][39][40][41][42][43][44][45][46][47], baseline or pilot [48][49][50][51][52][53][54][55], and feasibility studies [56][57][58][59][60][61][62][63][64][65][66][67][68][69] were identified; however, they did not meet the inclusion criteria because trial outcomes were the focus of this review.
We categorized the results as follows: − Comprehensive interventions targeting individuals who use AODs, including randomized trials with at least two arms (including a control arm), a sample size of at least 100 participants, and study eligibility criterion of AOD use. These interventions address AODs and other issues-such as HIV or GBV-to distinguish them from brief intervention studies that focus on AOD only. − Single-session or screening brief intervention and referral to treatment (SBIRTs) targeting individuals who use AODs, including studies with single or brief intervention (up to four) sessions, with a study eligibility criterion of AOD use. − SBIRTs with AOD use as secondary measures; that is, AOD use was not an eligibility requirement for participants.

Delivery Setting
Five of the interventions were conducted in South Africa; two in Kenya; and one each in Zimbabwe, Zambia, and Nigeria. Five interventions were conducted with PLWH or people at increased risk for HIV and two interventions were conducted with women who conduct sex work. Four interventions were delivered by trained nurses, lay counselors, or clinic staff at clinic or community health facility sites, including a Motivational Interviewing (MI) intervention via flipchart in one-on-one sessions lasting 20 min on average [70]; a 10-session intervention lasting 45 to 60 min per session was delivered by trained nurses [71]; a two session gender-stratified intervention with an additional spousal support session was delivered by lay counselors [72]; and a six-session intervention with weekly 90 min group sessions was delivered by trained paraprofessional counselors [74]. One implementation science study, which occurred over four stepped-wedge cycles, was delivered by trained clinic staff and researchers in groups at clinics and substance use rehabilitation and treatment centers [28]. One intervention comprised 20 biweekly sessions lasting 50 min each in community secondary school sites [73]. Finally, four interventions were delivered at project field sites or other private community settings by trained interventionists from the target community, including a two-session group intervention delivered by experienced, multilingual female interventionists [75], a 3-h workshop delivered by peer educators in groups of couple dyads [76], a two-session peer-facilitated group intervention with four modules each [77], and a two-session group intervention delivered by trained community interventionists during 50-min sessions [78].

Gender
Five interventions focused on women and two focused on heterosexual couples. The remainder of the interventions were not gender specific. Five interventions used gendersensitive and empowerment-driven approaches, including skill-building activities and role-playing and rehearsal to reduce AOD use, sexual risk, and violence among women and couples [28,[75][76][77][78]. One study in Kenya used culturally adapted gender stratification to avoid reinforcing the secondary status of women [74]. A two-session, gender-stratified intervention with an additional substance use support session for spousal support addressed IPV and interrelated AOD use [72]. This study also used counselors in male-female pairs to recruit heterosexual couples in which the woman reported experiencing recent IPV and measured gender norms as a secondary outcome [72]. -Women in the WHC arm were more likely to be sober at the last sex than women in the Nutrition arm -More women in the WHC arm were abstinent from drugs as compared with the control group Women who did not conduct sex work had a lower mean number of days drinking and were less likely to qualify for alcohol dependence compared with the control group * Greater reductions in drug use among WHC participants * Women who conducted sex work were less likely to report physical abuse by main partner at 6-month follow-up

Context and Culture
Many studies conducted formative work to inform cultural adaptation of the intervention, including adapting images and content depicting motivational readiness for change, real-life risk scenarios regarding victimization, and AOD use relevant to women who conduct sex work in Kenya and South Africa [70,78]. Another intervention was adapted to include focus group participants' voices within the intervention for couples in Cape Town and risks associated with drinking at local venues [76], and another for South African women living with HIV [28]. Several interventions were translated from English into local languages [28,75]. One intervention adapted a cognitive behavioral therapy (CBT) intervention [74] by referencing local Kenyan settings, using rural images in treatment materials, addressing culturally prominent misinformation about alcohol, and delivering the intervention in Kiswahili, the official language of Kenya.

Other Intersectional Issues
Five South African studies addressed intersectional issues of AOD use, GBV/IPV, and HIV [28,[75][76][77][78], with some incorporating components on overcoming barriers to preexposure prophylaxis (PrEP)/ART adherence [28] and healthy communication [76]. A Zambian study jointly addressed AOD, HIV and ART adherence [72]. Two interventions were grounded in CBT, including one with outpatients living with HIV focused on HIV and alcohol education, alcohol abstinence, coping with substance use triggers, problem solving, and refusal skills [74]; and another with heterosexual couples that used a joint cognitivebehavioral, multi-problem, transdiagnostic Common Elements Treatment Approach (CETA) modified to address IPV and alcohol/substance use, partner communication, and related mental health comorbidities [72]. One study used rational emotive health therapy treatment for alcohol use disorder (AUD) symptoms among PLWH, and addressed problematic beliefs related to AUD and practical techniques to reduce symptoms [73]. Another study addressed AOD and HIV risk among women at risk for victimization [70].

Single-Session or Screening Brief Intervention and Referral to Treatment Targeting Individuals Who Use Alcohol and Other Drugs
Eleven studies evaluated the effectiveness of SBIRT approaches for individuals who used alcohol or other substances as primary measures; all were behaviorally focused (see Table 2). These interventions largely had components of MI. Some combined strategies, including blending MI with problem-solving therapy, providing participants with referral and resource lists, or testing multiple intervention types together to determine their effectiveness.

Delivery Setting
Nine interventions were conducted in South Africa, and there was one intervention each in Uganda and Kenya. Ten interventions were delivered in an individual setting [79][80][81][82][83][84][85][86][87][88] and one intervention in a group setting [89]. All interventions were delivered at health clinics or study field sites. Seven interventions were delivered by trained nurses and counselors, two interventions by lay counselors recruited from the community, and one intervention by trained research staff. The interventions included components of MI and problem-solving therapy [79,80,82,83,[85][86][87], substance use reduction strategies [84,85,89], comprehensive assessments of a participant's alcohol use [86], standardized positive prevention counseling [83], referrals and resources [87], and brief counseling sessions on alcohol risk reduction [88].

Gender
Only two interventions were gender-specific, with both focusing on women who were pregnant or women at risk of an alcohol-exposed pregnancy [82,86]. One of these interventions focused on SRH to promote birth control uptake and reduce risky substance use to prevent risk for alcohol-exposed pregnancies.

Other Intersectional Issues
Two interventions addressed either HIV or tuberculosis (TB) and aimed to improve treatment outcomes by addressing risky AOD use [83,88]. Two interventions also considered mental health promotion strategies [79,84]. One study addressed HIV and AOD use using the Information-Motivation-Behavioral Skills (IMB) model and personalized Alcohol Use Disorders Identification Test (AUDIT) feedback [81].
However, no interventions addressed additional contextual factors, such as GBV/IPV, although the role of AOD use on these issues was acknowledged.

Interventions and SBIRTs with AOD Use as Secondary Measures
Fourteen studies reported on AOD use outcome measures of interventions that did not directly target AOD (see Table 3). Eight interventions were behaviorally focused interventions, two interventions were behavioral-structural interventions, and four interventions were SBIRTs.

Delivery Settings
Nine of the studies were conducted in South Africa; one multisite study was conducted across Tanzania, Kenya, and Namibia; and one study each was conducted in Kenya, Zimbabwe, Nigeria, and Uganda. Four interventions were delivered individually, and eight interventions were delivered in group settings. Six interventions were delivered by peer educators, community members, or lay counselors; and eight interventions were delivered by professionals, including educators, counselors, dieticians, and healthcare providers. These interventions enrolled women who were pregnant, men, adolescents, individuals at increased risk for or living with HIV, employees at a safety and security company, members of a market traders association, parents or caretakers of adolescents, individuals receiving treatment for pulmonary TB, and adults from prioritized communities. Intervention types included home visits [90], brief and motivational interventions [91][92][93], six 75 min intervention group sessions [94], a school-based intervention [95], four 3-h intervention sessions [96], financial incentives [97], a parenting skills intervention [98], a lifestyle behavioral intervention [99], a clinic-based intervention [100], a training workplacebased intervention [101], and a community-based structural-behavioral intervention [102]. Study samples ranged from 185 to 11,448 participants.

Gender and Culture
One intervention focused on women, and three interventions focused on men, one of which engaged men in conversations about masculinity and "responsible manhood." The woman-focused intervention used home visits to promote maternal health and monitor mental health needs and AOD consumption [90]. One intervention focused on men used same-gender community facilitators to discuss HIV risk-reduction and condom use, and increase HIV/STI knowledge [94]; another intervention promoted healthy masculinity and reducing violence among rural and peri-urban men [96]; and another intervention focused on men and evaluated the effectiveness of financial incentives in reducing spending on alcohol, gambling, and transactional sex [97].  Brief motivational intervention and a referral resource list No significant between-group differences * Observed that those who reduced alcohol consumption also reported reduced aggressive behaviors   Community-level analyses found no differences between groups * Declines in alcohol use, frequency of use, and quantity of drinks were found in intervention and control sites at relatively equal levels

Louwagie et al.(2022) [93]
South Africa: 574 adults beginning treatment for drug-sensitive pulmonary TB Lay health workers delivering three MI sessions along with SMS messages to bolster intervention content EtOH, TB ProLife Intervention: Participants created plans to address alcohol and tobacco use and TB adherence followed by 10 SMS messages supporting TB treatment adherence Reductions in AUDIT scores at follow-up but no significant intervention effect consisted of screening and a brief intervention to reduce IPV related to HIV disclosure and address risk behaviors * Proportion of women experiencing IPV lower among intervention participants * Women's rates of HIV disclosure were higher in the intervention group * Lower HIV incidence among men in the intervention group

Other Intersectional Issues
Four interventions addressed SRH, explaining and addressing the ways that AOD use can lead to risky sexual behavior. One intervention addressed IPV among women who were pregnant [90]; another intervention addressed IPV related to HIV disclosure [103]. One intervention also jointly addressed mental health through dialogue and monitoring pregnant and postpartum women in home visits [90], and one intervention jointly addressed gambling and AOD use through financial incentives promoting healthy behaviors [97] and employee wellness [101]. One intervention focused on parenting skills and reducing violence between parents and their adolescent children. Another intervention focused on adherence to TB treatment. Another intervention that focused on nutrition and hypertension also addressed excessive alcohol use through a lifestyle and behavioral interventions that incorporated physical fitness promotion and health knowledge [99].
Many of the interventions that used AOD use as a secondary measure did so to promote adherence to HIV treatment or HIV prevention outcomes. One intervention aimed to reduce violence related to HIV disclosure [103], whereas others were HIV risk-reduction interventions [94,102]. Two interventions worked directly with individuals living with HIV [91,100] (see Table 3).

Discussion
This review aimed to present an overview of the research and the commitment of researchers to the issue of AOD use with gender and context in mind in Africa. However, only a few countries were represented, possibly because our review was limited to studies written in English and randomized trials; also, studies with tobacco only were not included. Sixty-three percent of the reported interventions were conducted in South Africa. In South Africa, especially the Western Cape, there are numerous winelands and a large alcohol industry that in the past has paid farmworkers wages with alcohol [104], which contributed to alcohol use for generations [105,106] that continues today [107]. Studies also indicated various drug use, which often changes over time and across regions. South Africa had greater methamphetamine and amphetamine type drug use; and more recently, methaqualone mixed with cannabis. Nonetheless, alcohol either as the primary or secondary outcome, was the major drug reported. Consequently, a focus on key populations who use AODs in areas of scarce resources and underemployment is essential. Several studies highlighted the importance not only of individual differences in AOD use, but also of GBV, mental health needs, gender, and other social determinants, and how these intersect to affect health outcomes.
Multiple intersecting issues, including the syndemics of gender violence, HIV/STIs, and sexual risk as well as mental health comorbidities and psychological trauma arising from exposure to violence, are highly prevalent among many of the targeted study populations [34,[108][109][110]. This review is important because it highlights the need to include HIV and target gender issues in interventions. Although South Africa had the most interventions tested, it is also where more people are living with HIV than anywhere in the world [12,111]. Some interventions have advanced from being purely behavioral to biobehavioral, as the rollout of HIV medication has been successful for treatment and treatment as prevention [112]. As science builds on itself, there are ongoing advancements in the measures available for AOD use; understanding of context, gender differences, and cultural nuances; and on-the-ground implementation. Focusing on AOD alone may not lead to durability of outcomes without addressing the intersectional issues that underpin AOD use. As noted, only the larger randomized trials with formative phases mentioned adaptations to culture and gender within their interventions.
The importance of and ability to integrate services for AOD use with HIV and other chronic disease, such as TB, and antenatal and emergency care is essential [113]. People who use AODs often perceive stigma and experience structural barriers to accessing healthcare [114]. Consequently, early intervention reduces these barriers to care and takes pressure off the overwhelmed AOD treatment system [115]. Further evidence from this review suggests which comprehensive and brief interventions have promising effects. Opportunities for scaling up, adoption, and sustained implementation could realize the promises of these interventions; however, this will take years of commitment from local healthcare systems [28,116].
As noted, several interventions were delivered by peers within their communities, and this review of trials shows that this type of delivery is not only efficient but may increase the intervention's credibility and acceptance. Brief interventions consisting of one session do not appear to have a great impact, whereas the more comprehensive the intervention, the greater the effect.
Applied researchers may be most comfortable implementing individual or group interventions, as we found few structural interventions. Further, there was a concentrated effort in only a few African countries [117]. Consequently, it is timely for more cliniclevel interventions addressing stigma around people who use AODs and community-level interventions for destigmatizing people who use AODs and are living with HIV and to help support the rollout of HIV PrEP for prevention for those at risk. Barriers that women may face when accessing treatment are often different than the barriers men may face. Consequently, sensitivity is needed to the unique needs of underserved populations, along with viewing these needs through a gender lens so that people who use AODs do not feel stigmatized when attempting to access health services [118,119].
Applied research and the impact it has can change policy and ultimately practice. As the world is pushing a social justice agenda, Africa, with its deep patriarchal roots, is lagging in gender equality. Yet, Africa also has some of the most innovative strategists and thought leaders committed to making change within their communities. For example, the first human-to-human heart transplant was in Cape Town, South Africa, by Dr. Christiaan Barnard, a South African surgeon [120].
Despite challenges, it is important to celebrate the achievements of AOD use treatment and prevention efforts in several African countries. For example, there are innovative treatment programs in resource-poor areas, such as the treatment camp approach in Uganda [121]. However, not all of these programs have been rigorously evaluated. Epidemiological evidence has been instrumental in developing formative and pilot studies. These stages are necessary for testing these intervention approaches in RCTs for proving efficacy and effectiveness. Now science is progressing to implementation science to support sustained implementation of evidence-based treatment approaches that improve outcomes [28]. However, one serious limitation among the studies was the lack of interventions addressing injecting drug use beyond exploratory and qualitative studies, as opiate use is continuing to increase in Africa, along with intersectional HIV risk [122]. Within this review, we also recognize sample size limitations that reduce power and the ability to demonstrate significant outcomes over longer follow-up periods. Notably, one project faced a reduced follow-up sample because of COVID-19 [93].
However, several examples of lasting change have been translations of the research focused on AODs and other outcomes into practice. For example, the MATRIX program was first implemented in Cape Town in 2007 and is now provided at many substance use treatment facilities [123,124]. The Women's Health CoOp has governmental commitments to ongoing training and implementation as part of the usual care treatment system [125,126]. The Teachable Moments Programme was also implemented in South African emergency centers, having been developed as an extension of Sorsdahl et al., 2015 SBIRT [79,127]. However, more implementation data on cost-effectiveness analysis and economic evaluations are needed to demonstrate life cost savings and build an economic case for investment in these interventions [128]. Focus on both and PrEP among couples where AOD-impaired sex is a targeted behavior will be essential to ending the HIV epidemic. These combination interventions can reach people within their communities while also considering community-focused strategies to help with the de-stigmatization of people who use AODs and to reduce their risk of HIV.
A growing body of research is also evaluating implementation science outcomes of AOD use prevention and treatment interventions that address many of the intersectional topics mentioned herein. Confidence and commitment to implementing these kinds of programs is imperative for the long-term sustainability of interventions, which includes having ongoing support from management and higher-level staff, having financial resources, and providing support for clinic staff [126].

Conclusions
Identifying and addressing AOD use within the context of social determinants is the key to ensuring the long-term health and well-being of people in Africa. The lack of RCT studies addressing injecting drug use in Africa and RCT studies in Northern Africa indicates a need to expand this science further. Additionally, ensuring gender and cultural sensitivity of AOD interventions is essential for optimizing impact. Addressing barriers to treatment and stigma around AOD use and other coexisting conditions, such as HIV, from a structural level at the clinic and community levels is the next frontier, as both are important areas to examine for healthy outcomes and healthy communities.  Data Availability Statement: This is a review paper. All manuscripts have been published previously.

Acknowledgments:
The authors wish to thank Susan Murchie and Jeffrey Novey for editorial assistance.