Introduction: Harmful alcohol use is associated with significant risks to public health outcomes worldwide. Although data on harmful alcohol use have been collected by population-based HIV Impact Assessment (PHIA), there is a dearth of analysis on the effect of HIV/ART status on harmful alcohol use in the SSA countries with PHIA surveys. This study uses data from the national representative PHIA to predict the harmful alcohol use prevalence. Methods: A secondary analysis of the PHIA surveys: Namibia (n=27,382), Tanzania (n=1807), Zambia (n=2268), Zimbabwe (n=3418), Malawi (n=2098), Namibia (n=27,382), and Eswatini (n=2762). Using R version 4.2, the outcome variable and the descriptive variables were tested for association using chi square. Multivariable logistic regression analysis was used identify significant variables associated with harmful alcohol use. We employed to test and apply machine learning (ML) methods through Super Learner, Decision Tree, Random Forest (RF), Lasso Regression, Sample mean and Gradient boosting. Evaluation metrics methods specifically confusion matrix, accuracy, precision, recall, F1 score, and Area under the Receiver Operating Characteristics (AUROC) were used to evaluate the performance of predictive models. The cutoff point for statistically significant was P<0.05. Results: Of the 12,460 persons, 15% used alcohol harmfully. Harmful alcohol use varied by countries and ranged from 8.7% in Malawi to 26.1% in Namibia (P<0.001). Females were less likely to use alcohol in a harmful way (AOR = 0.32, 95% CI: 0.29-0.35, P< 0.001). Compared to those HIV negative, persons that were with HIV-positive and on ART were less likely to use alcohol in a harmful way (AOR = 0.65, 95% CI: 0.57-0.73, P<0.001) however persons that were HIV-positive and not on ART were more likely to use alcohol in a harmful way (OR = 1.49, 95% CI: 1.32-1.69, P<0.001). Being married or formally married was protective to harmful use of alcohol. The best performing models were Lasso or Super Learner or Random Forest were the best performing models while gradient boosting models or sample mean did not perform well. Conclusion: The findings highlight concerning variations in harmful alcohol use prevalence across surveyed countries, with Namibia reporting the highest rate. Males, older individuals, those HIV positive and not yet on ART, and unmarried persons demonstrated a higher likelihood of engaging in harmful alcohol use. These findings collectively contribute to a comprehensive understanding of the multiple factors influencing harmful alcohol use within the surveyed populations, the importance of targeted interventions at country and individual levels.

The authors have declared no competing interest.

The author(s) received no specific funding for this work.

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