HIV-infected individuals who use alcohol and other drugs, and virologic suppression

ABSTRACT

People living with HIV (PLWH) on antiretroviral therapy (ART) who use substances were examined to (a) describe those with virologic control and (b) determine which substance use-factors are associated with lack of virologic control. Participants were adult PLWH taking ART with either past 12-month DSM-IV substance dependence or past 30-day alcohol or illicit drug use. Substance use factors included number of DSM-IV alcohol or drug dependence criteria and past 30-day specific substance use. Associations with HIV viral load (HVL) (<200 vs. ≥200 copies/mL) were tested using logistic regression models. Multivariable analyses adjusted for age, sex, homelessness and anxiety or depression. Participants (n = 202) were median age 50 years, 66% male, 51% African American and 75% self-reported ≥90% past 30-day ART adherence. Though HVL suppression (HVL <200 copies/mL) was achieved in 78% (158/202), past 30-day substance use was common among this group: 77% cigarette use; 51% heavy alcohol use; 50% marijuana; 27% cocaine; 16% heroin; and 15% illicit prescription opioid use. After adjusting for covariates, specific substance use was not associated with a detectable HVL, however number of past 12-month DSM-IV drug dependence criteria was (adjusted odds ratio = 1.23 for each additional criterion, 95% CI: 1.04–1.46). Three-quarters of a substance-using cohort of PLWH receiving ART had virologic control and ≥90% ART adherence. Substance dependence criteria (particularly drug dependence), not specifically substance use, were associated with lack of virologic control. Optimal HIV outcomes can be achieved by individuals who use alcohol or drugs and addressing symptoms of substance dependence may improve HIV-related outcomes.

KEYWORDS:

• HIV
• antiretroviral
• medication adherence
• injection drug use
• substance use

Acknowledgements

The authors thank the Boston ARCH Cohort study participants for their contribution to the research, as well as current and past researchers and staff at Boston University for their support. Specifically, we want to acknowledge Margo Godersky, Kate Haworth, Keshia Toussaint and Laura Vercammen for their work in recruitment, data collection and participant retention.

Disclosure statement

Dr. Saitz is and has been principal investigator of grants awarded to Boston Medical Center and Boston University from the National Institutes of Health (including NIAAA and NIDA, and the Substance Abuse and Mental Health Services Administration) to study the management of unhealthy substance use, including to test the accuracy of screening and the efficacy of screening, brief intervention and referral to treatment and the effectiveness of integrated care. He has been paid to speak or had travel reimbursed to speak or to consult for/at numerous professional and scientific organizations, all non-profit organizations for over a decade, such as the American Society of Addiction Medicine (ASAM), RAND, the Research Society on Alcoholism, The BMJ, the Institute for Research and Training in the Addictions, the International Conference on Treatment of Addictive Behaviors, and the International Network on Brief Intervention for Alcohol and other drugs (INEBRIA), and numerous universities and hospitals. He is an author and editor for Springer, UpToDate, the American Society of Addiction Medicine, the BMJ and the Massachusetts Medical Society (royalties and/or honoraria). Wolters Kluwer has supported conference travel to an editors meeting. Systembolaget, a Swedish government agency that aims to minimize alcohol related problems, supported transportation and lodging for a presentation on brief intervention at an INEBRIA thematic meeting in 2016. Alkermes provided medication for an NIH-funded trial of alcohol disorder treatment effectiveness. He has been paid to serve as an expert witness in malpractice cases related to the management of alcohol and other drug disorders. In 2009 he consulted for Inflexxion and Medical Directions, in 2008 and 2004 for Saatchi and Saatchi healthcare, in 2006 for Fusion Medical Education, in 2004 for the Lewin Group, in 2002 for Axis-Shield ASA and Forest Pharmaceuticals. He has also consulted regarding research for Yale University, Brandeis University, Group Health Inc, Beth Israel-Deaconess Hospital, and other universities. He spoke at a National Press Foundation event on the terminology of addiction and received no compensation but the meeting was funded by ASAM, Open Society Foundations, Pew Charitable Trusts, Shatterproof, Hazelden Betty Ford Foundation and the Addiction Technology Transfer Center Network. All other authors have no conflicts to declare.

Notes

1. The VAS instrument used in this study included designated lines at 10% intervals between 0 and 100% (i.e., a line at 90% and not 95%), though participants were encouraged to mark anywhere on the line that best represented their adherence, we chose to use a past 30-day ART adherence cutoff value of <90% vs. > 90%.

Additional information

Funding

This work was supported by the National Institutes of Health/National Institute on Alcohol Abuse and Alcoholism under [grant number U01AA020784, U24AA020778 and U24AA020779]; and the National Institutes of Health/National Institute on Drug Abuse under the[grant number R25DA033211]; and the National Institutes of Health/National Centre for Advancing Translational Sciences under the [grant number UL1TR001430].