Table 3. Barriers and facilitators of reduced alcohol use among adults with HIV/AIDS taking antiretroviral therapy in urban Zambia, based on adapted Andersen’s Behavioral Model.

Factors	Quantitative results (Demographic, clinical, and structural data)	Qualitative results (Interviews & focus groups)
Contextual Environment
Drinking norms	Men more likely to consume alcohol than women (63. 9% men; 36.1% women).	Drinking is a societal and cultural norm
Gender norms	Women more likely to reduce alcohol consumption.	Generational changes in the roles of men and women
Drinking and violence impeded a functional daily life	Unknown prevalence of participants who encountered violence because of alcohol consumption.	Drinking was considered unhealthy if it impacted one’s functional daily life and caused violence.
Culturally women who consumed alcohol were “judged” particularly if they were married with children. Especially if it impacted their ability to take care of their family.	Unknown percentage of women who experienced “judgement” because it was not measured.	Women who partook in alcohol consumption expressed that their spouses disliked their alcohol drinking habits.
Younger generation perceived to drink excessively	18–29 year old age group (26.1%) with greater unhealthy alcohol consumption than 40 year old people (23.2%)	Older people with notion that younger people drank more though rationale was not disclosed.
Individual Factors Among PLWHA
Male sex	At baseline, men reported unhealthy alcohol use in comparison to women.	Younger people (18–29 years old) had lower disclosure of HIV status
Younger women reported unhealthy alcohol use	Men were 60% less likely to reduce recommended alcohol reduction (AOR = 0.41, CI 0.23–0.72)	Other motivators to drink were due to HIV stigma, stress relief, to socialize with friends, for enjoyment, lack of family and social support.
Poverty	Those smoking cigarettes were significantly less likely to reduce unhealthy alcohol use (AOR = 0.49, CI 0.25–0.96).	Poverty contributed to
Alcohol addiction, smoking, unhealthy alcohol use after ART commencement	Many patients discussed that they indulged in substance abuse compared to alcohol beverage drinking to cope with negative thoughts (AOR = 0.41, CI 0.23–0.72)	Unhealthy alcohol use perceived as a coping mechanism to address issues in life
Mental health issues	Significantly low perceived need to reduce alcohol consumption (AOR = 0.49, CI 0.25–0.96)	Women more likely to consume alcohol to avoid inadvertent stress
Poor health status	People with HBV co-infection less likely to partake in unhealthy alcohol use.	Unhealthy alcohol use a method to avoid HIV status disclosure
Lack of family and social support	Not measured	People with unhealthy alcohol use perceived that their families shunned them and they did not offer moral support as needed
Those smoking cigarettes were also addicted to unhealthy alcohol use	Men (AOR, 0.41; 95% CI, 0.23–0.72) and baseline smokers (AOR, 0.49; 95% CI, 0.25–0.96) also had lower odds of reducing their alcohol use after ART commencement. There was also increased odds of alcohol reduction at Clinic B (AOR, 2.91; 95% CI, 1.695.04) compared to Clinic A.	Smokers more likely to participate in unhealthy alcohol use
Healthcare Environment (HIV health system, clinic, and provider factors)
Lack of alcohol reduction support at HIV clinics	Reduced unhealthy alcohol use was nearly 3 times more common at Clinic B compared to Clinic A (AOR = 2.91, CI 1.69–5.04), suggesting service variability and/or impact.	Insufficient and inconsistent alcohol reduction support at clinics. Support services vary among clinics.
Insufficient training of HCW in alcohol consumption assessment and treatment in PLWHA	During the first year on ART the overall prevalence of unhealthy alcohol use in the analysis group reduced significantly from 40.4% to 29.6% (P<0.01). Of the 280 with unhealthy use at baseline, 122 (43.6%) reported a lower degree of alcohol consumption at 1 year.	Little support is available at the community level. Lack of HCW training in alcohol reduction.
Inconsistent counseling/ messaging at HIV clinics	Increased odds of alcohol reduction at Clinic B (AOR, 2.91; 95% CI, 1.695.04) compared to Clinic A.	HCW provision of mixed messages to patients (reduction to safe levels vs. abstinence).