We examined the association between alcohol consumption, adherence and viral load (VL) in a cohort of 940 alcohol-consuming, human immunodeficiency virus (HIV)-positive men receiving antiretroviral therapy in Mumbai. Some of the participants (16.7%) had missed > 1 doses in the last four days and 17.6% reported > 1 treatment interruptions in the last 12 months; 60.8% of the participants consumed alcohol > 2 times/month, 62.8% consumed > 3 drinks/typical day and 11.5% reported binge drinking > 1 times/month; 76.4% of the participants had VL < 200 copies/mL. Higher alcohol consumption was associated with nonadherence (odds ratio [OR]: 1.21; 95% confidence interval [CI]: 1.11–1.31) and treatment interruptions (OR: 1.20; 95% CI: 1.11–1.31). We found no association between alcohol use and VL. There was, however, a significant interaction effect of alcohol use and nonadherence on virological failure (Adjusted Odds Ratio [AOR]: 1.23; 95% CI: 1.03–1.47) implying that alcohol negatively impacts VL outcomes but mediated through adherence. Alcohol use was associated with poor adherence, which in turn was a strong predictor of virological failure.