Project Summary/Abstract Heavy alcohol use has deleterious effects on antiretroviral therapy (ART) adherence and HIV clinical outcomes, and indirectly affects health by damaging the couple relationships needed for social support, economic survival, and well-being. Our formative research with HIV-affected couples in Malawi found that 50% of alcohol drinkers met criteria for heavy alcohol use. Male peer pressure, desires for friendship, and coping with poverty were common barriers to reducing consumption. Men expressed desires for an economic or peer- based intervention to reduce alcohol use, and women were very concerned with how alcohol drains family financial resources and causes conflict in the couple. Yet, there are currently no interventions that have jointly addressed the economic and relationship context of drinking in sub-Saharan Africa. To fill this gap, we developed Mlambe: a combined economic and relationship-strengthening intervention to address heavy alcohol use among couples affected by HIV. The goal of Mlambe is to redirect funds spent on alcohol into financial investments and to improve couple relationships and adherence to ART. We posit that engaging couples to work together on alcohol use and financial goals—equipped with financial and communication skills—will decrease alcohol use, and improve relationship dynamics and adherence to ART. Our pilot trial demonstrated that Mlambe was highly feasible and acceptable for couples and showed promising impacts on health and relationship dynamics. Given this strong preliminary evidence, we propose to conduct a full-scale randomized controlled trial of Mlambe with couples in Malawi. The specific aims are: (1) to evaluate the efficacy of Mlambe on our primary outcome of heavy alcohol use, defined as self-reported drinking combined with an alcohol biomarker called PEth, and on secondary outcomes of viral suppression, adherence to ART, and other alcohol use metrics; (2) to assess the effects of Mlambe on relationship dynamics (couple communication, alcohol-specific partner support, and IPV) and explore whether they meditate Mlambe’s effects on health outcomes; and (3) to compare the costs of each of the two study arms and the cost-effectiveness of Mlambe. We hypothesize that heavy alcohol use will be reduced in Mlambe as compared to the control arm and that all partners living with HIV will experience greater viral suppression regardless of drinking status. We also anticipate that Mlambe will impact alcohol and HIV outcomes through the pathway of relationship dynamics (e.g., better communication, less IPV). For the trial, we will enroll 250 HIV-affected couples with a heavy alcohol user and randomize couples to either Mlambe or an enhanced usual care (EUC) control arm. A cost analysis will be computed for each arm and a cost-effectiveness analysis will be conducted to make comparisons between Mlambe and other strategies for reducing heavy alcohol use. Alcohol interventions for people living w...