Background: In Botswana, an estimated 37% of adults ages 15-49 years are infected with HIV. Alcohol use is strongly associated with HIV infection in Africa; however, few population-based studies have characterized alcohol use’s associations with specific high-risk sexual behaviors.

Methods: We conducted a cross-sectional, population-based study of 1,268 adults from 5 districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks for men) and to examine gender-specific associations between heavy alcohol use and: a) unprotected sex with a non-monogamous partner; b) having multiple sexual partners; and c) paying for or selling sex in exchange for money or other resources.

Results: Thirty-one percent of men and 17% of women met criteria for heavy drinking. An additional 8% of both genders met criteria for problem drinking (>7 drinks/week for women, >14 drinks/week for men).   Forty-five percent of participants identified alcohol use as the most important factor that makes men and women vulnerable to HIV in Botswana. Adjusted correlates of heavy alcohol use included male gender (AOR=2.3, 95% CI=1.7-3.0), intergenerational relationships (>=10 years age gap) (AOR=2.7, 95% CI=2.0-3.8), higher education (AOR=1.4, 95% CI=1.0-1.8), residence in rural areas (AOR=1.5, 95% CI=1.1-2.1), and greater projected stigma related to HIV (AOR=1.1, 95% CI=1.0-1.2). Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined including unprotected sex with a non-monogamous partner (AOR=3.4, 95% CI=1.9-6.2), having multiple partners (AOR=2.4, 95% CI=1.6-3.6), and paying for sex (AOR=3.9, 95% CI=2.2-7.0). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR=3.1, 95% CI=1.7-5.6), having multiple partners (AOR=2.8, 95% CI=1.8-4.7), and selling sex in exchange for money or other resources (AOR=5.9, 95% CI=2.6-13.4). Intergenerational relationships were significantly associated with all high-risk sexual behaviors for both genders, and lack of control in sexual decision-making was strongly associated with risky sex among women.

Discussion: Alcohol use is associated with multiple risks for HIV transmission among both men and women. Findings underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.