clinical news & resources
Identifying Substance Abuse in HIV-Infected Patients
By Glenn J. Treisman, MD, PhD
Director of AIDS Psychiatry Services
Professor, Department of Psychiatry and Behavioral Sciences
Johns Hopkins School of Medicine, Baltimore, MD
Needle sharing is a well known route of HIV transmission, but substance abuse contributes to HIV transmission in other ways. National surveys show that more than 4 out of 5 persons living with HIV previously used an illicit drug; almost 1 out of 3 used illicit drugs and more than 1 out of 4 engaged in binge drinking during the month preceding the survey. The most commonly used substances include alcohol, marijuana, stimulants (cocaine including crack cocaine, methamphetamine), opiates, and benzodiazepines. Substances that are abused are all “behaviorally reinforcing," meaning that the use of these substances increases the likelihood of the behaviors associated with their use. This has important implications for patient management.
Substance abuse leads to risk behaviors. Ongoing drug use and lifestyle correlates associated with drug acquisition such as risky sexual behaviors all adversely affect the course of HIV infection.[4,5] Risky sexual behaviors include transactional sex (or trading sex for drugs or money) and engaging in unplanned sexual activities or unprotected sex. Illicit drug use often precedes risky sexual behaviors for a number of reasons including disinhibition, impulsivity, decreased risk perception, impaired judgment, and the belief that alcohol and other drugs enhance sexual arousal and performance.[6,7] Disturbingly, studies have shown that substance use and alcohol consumption before sex continue even after a diagnosis of HIV has been established despite clear evidence that such risky sexual behaviors can lead to STD acquisition and transmission (including hepatitis C) as well as an increased risk of HIV transmission.[4,6] Because of the powerful nature of brain rewards associated with drugs of abuse, many of the high risk behaviors become associated with drug use and therefore are craved and habituated as part of the experience.
Effect of Substance Abuse on Adherence
ART adherence is essential for maximal and durable reduction of viral load, minimization of viral resistance, immunologic recovery, and reduction in HIV-related morbidity and mortality. Current substance abuse is a well-recognized barrier to ART adherence.[8,9] In one study, 68 percent of previous cocaine-using HIV-infected patients adhered to ART compared with only 27 percent of those currently using cocaine, with viral load suppression in 46 percent and 13 percent, respectively. In addition, depression is common among substance abusing HIV-infected persons, and depression is an independent barrier to ART adherence.
Screening HIV-Infected Patients for Substance Abuse
Identifying HIV-infected patients whose substance and alcohol abuse leads to risky sexual behaviors is an important component of HIV care. Therefore, HIV providers should screen all HIV-infected patients for substance use at least at baseline and then annually. More frequent screening may by warranted for patients presenting with obvious physical signs such as track or needle marks or other evidence of substance abuse such as missed appointments, problems with adherence, unexplained homelessness, job loss, relationship or legal problems, or the inability to answer questions clearly about what they are doing with their lives currently. Physicians already know these red flags and may have to push themselves to ask the right questions. Additional red flags are poor adherence, poor response to HIV medications (they can be sold for drug money) and new STDs. Clinicians who have a sense of mastery about what to do when they identify substance abuse are much more likely to inquire about illicit drug use than are clinicians with less experience. The questions should be open-ended and are fairly straightforward such as: “How often do you get high?” or “How much are you partying?”
Screening for substance abuse is particularly important in HIV-infected persons because it is associated with an increased risk of transmission. Addressing substance abuse problems can help improve ART adherence and encourage risk-reducing behaviors.
- When assessing and treating HIV-infected persons with substance abuse problems, remember that abused substances are behaviorally reinforcing, increasing the likelihood of risky sexual behaviors associated with their use.
- Identifying HIV-infected patients whose substance and alcohol abuse leads to risky sexual behaviors is an important component of HIV care, and HIV providers should screen all HIV-infected patients for substance use at least at baseline and then annually.
- Consider screening patients for substance abuse more frequently than annually when they miss appointments or present with track or needle marks, problems with adherence, unexplained homelessness, job loss, relationship or legal problems, or the inability to answer questions clearly about what they are doing with their lives currently.
- When screening for substance abuse, ask straightforward open-ended questions such as "How often do you get high?" or "How much are you partying?"
2. New York State Department of Health AIDS Institute. Screening and ongoing assessment for substance use in HIV-infected patients. February 2009. Available at:
3. Treisman G. The "triple-threat" patient: psychiatric problems, substance abuse disorders, and HIV. Adv Studies Med. 2006;6(Suppl 3A):S138-144.
4. Khalsa JH, Elkashef A. Interventions for HIV and hepatitis C virus infections in recreational drug users. Clin Infect Dis. 2010;50:1505-1511.
6. Gerbi GB, Habtemariam T, Tameru B, et al. A comparative study of substance use before and after establishing HIV infection status among people living with HIV/AIDS. J Subst Use. 2011;16:464-475.
7. Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA. 2001;286:2857-2864.
8. Arnsten JH, Demas PA, Grant RW, et al. Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users. J Gen Intern Med. 2002;17:377-381.
9. Wood E. Montaner JS, Yip B, et al. Adherence and plasma HIV RNA responses to highly active antiretroviral therapy and survival in HIV-infected injection drug users. CMAJ. 2003;169:656-661.
10. Starace F, Ammassari A, Trotta MP, et al. Depression is a risk factor for suboptimal adherence to highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31(Suppl 3):S136-139.