The 2008 World Health Organization (WHO) Report found that South Africa had the highest tuberculosis (TB) incidence in the world, at over 5 times the average incidence rate found in the 22 high-burden countries. In 2006, South Africa with only 0.7% of the world's population had an estimated 28% of HIV positive adult TB cases reported globally. Over the last 5 years TB case notification has increased by a massive 81%, from 188 695 cases in 2001 to 341 165 cases in 2006. In 2006 KwaZulu-Natal, one of the nine provinces in South Africa, had the highest total TB caseload accounting for 31% of all TB cases nationally .This increase is mostly associated with the co-morbidity between HIV and TB. However, other factors, such as poverty and alcohol misuse is also associated with TB incidence. The role of alcohol misuse in increasing TB incidence has been under-studied within the South African context and has consequently not been adequately addressed in TB prevention efforts.
Excessive alcohol use has been causally linked to TB incidence. Two pathways are involved: the first is biological via weakening of the immune system, and the second is social via social exclusion and drift, resulting in about a threefold increased risk of TB . Alcohol use was estimated to have been responsible for 939 000 disability-adjusted life-years lost in South Africa for TB and HIV/AIDS alone in 2004 (253 000 for women, 687 000 for men). This figure corresponds to 4.6% of the overall disease burden in South Africa (2.5% for women, 6.6% for men). These numbers show the potential for reducing alcohol-attributable infectious disease burden in South Africa, since cost-effective measures for reducing alcohol-attributable harm in developing societies exist and could be applied .
There are numerous studies cited in the literature that support the strong association between alcohol use, alcohol use disorders and TB [3–8]. Numerous studies show pathogenic impact of alcohol on the immune system causing susceptibility to TB among drinkers [4, 7, 9]. "Alcohol use strongly influences both the incidence and the outcome of the disease and was found to be linked to altered pharmacokinetics of medicines used in the treatment of TB, social marginalization and drift, higher rate of re-infection, higher rate of treatment defaults and development of drug-resistant forms of TB; about 10% of the TB cases globally were estimated to be attributable to alcohol" . People that drink heavily show higher relapse rates, a higher probability of an unfavourable clinical course and a higher probability of experiencing the most destructive forms of TB. High prevalence of alcohol misuse in most population groups have been reported in South Africa. A household survey conducted in Mamre in the Western Cape Province (a community of approximately 5 000 people) found a positive association between TB and alcohol problems in the households .
Hazardous and/or harmful alcohol use is on the increase in developing/middle income countries including South Africa. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk for adverse health events, while harmful drinking is defined as alcohol consumption that results in adverse events (e.g., physical or psychological harm) . In South Africa more than 22% of men and women engage in hazardous or harmful drinking during weekends . Among a primary health care outpatient sample of 600 rural South Africans 37.4% of men and 10.7% of women were found to be hazardous drinkers, and 9.2% of men and 0.3% of women meet criteria for probable alcohol dependence or harmful drinking as defined by the AUDIT . Prevalence estimates range from 4% to 29% for hazardous drinking and from less than 1% to 10% for harmful drinking . In a another multi-country study a prevalence of hazardous alcohol use of 18% (after non-drinkers and alcoholics had been excluded) was found among patients attending primary health care facilities in Australia, Bulgaria, Kenya, Mexico, Norway and the USA . Similar prevalence rates of hazardous drinking in primary care outpatients were found in Nigeria (28.6%)  and 25% in Harare, Zimbabwe , and a low prevalence of above 1.7% alcohol dependency or harmful drinking in Nigeria .
In March 2006, in line with a WHO/AFRO decision of African Health Ministers, a TB Crisis Management Plan was launched by the Minister of Health in South Africa. The plan focused on 4 districts in South Africa which had a quarter of the national TB case load. These districts were: Amatole and Nelson Mandela Metro in the Eastern Cape Province, EThekwini Metro in KwaZulu-Natal Province, and the Johannesburg Metro in Gauteng Province. The mainstay of the plan was social mobilization to ensure that TB is de-stigmatized, that people seek treatment early, and that patients complete treatment .
Screening and brief interventions for alcohol use disorders
Increasing emphasis has been placed on the detection and treatment of hazardous and harmful drinking disorders, particularly among patients who are seen in primary health care settings . Screening instruments such as the Alcohol Use Disorders Identification Test (AUDIT), CAGE, and Screening and Brief Interventions (SBIs) have been found to be useful in detecting and treating alcohol use disorders in a number of settings [13, 19, 20]. The interventions are based on cognitive- behavioural interventions and motivational interviewing techniques and have been found to be effective and efficient in the treatment of alcohol use disorders in most chronic conditions. In previous studies screening and brief intervention for alcohol problems have been successfully implemented by nurses in demonstration projects in South Africa as part of a WHO strategy to expand screening and brief intervention for alcohol problems in developing countries funded by WHO and NIAAA [13, 19]. Community health workers have been identified as strategic implementation agents for screening and brief intervention of alcohol problems in primary care in South Africa.
Whilst there have been studies conducted on screening for alcohol misuse and brief interventions producing favourable results, there is a dearth of scientific literature on evidence-based best practice methods to screen for alcohol misuse and brief interventions amongst individuals with active TB. Given the fact that in South Africa the target rate for TB cure has not been met, and the fact that alcohol use and misuse is known to be a causal factor in TB onset, there is an urgent need to conduct a cluster randomized control trial to evaluate SBIs for alcohol use disorders among TB patients. This should be perceived as a key intervention to improve the outcomes for TB treatment and control. The alcohol-related risk reduction intervention programme proposed in this study, will be based on a modified Information Motivation and Behavioural Skills (IMB) model of health promoting behaviours and alcohol risk reduction intervention to reduce hazardous and/or harmful alcohol consumption.
Aim of the study
The aim of this study is to conduct a cluster randomized control trial to assess the effectiveness of SBI for alcohol use disorders among TB patients. Consenting patients who are starting TB treatment and screen for alcohol use risk are randomized, with the primary care clinic being the unit of randomization into one of two arms: The first arm being a Brief Intervention for alcohol misuse arm (treatment arm) and the second arm being the treatment as usual where patients receive an alcohol education leaflet (control arm).
1. To screen for alcohol misuse among TB patients in the selected sites.
2. To implement Screening and Brief Interventions (SBI) among TB patients that screen positive for alcohol misuse.
3. To monitor and evaluate the treatment outcomes for both alcohol misuse and TB among TB patients.
4. To report on the outcome of the intervention (SBI) and make recommendations for future interventions for reduction in alcohol use.