Assessing substance use among patients living with HIV/AIDS: The role of harm reduction and treatment

The use of alcohol or illicit drugs is common among adolescents and adults in the United States, especially among those with HIV infection. The use of opioids, cocaine, marijuana, and other illicit drugs has been associated with several adverse health outcomes among patients with HIV infection, including lower utilization of anti-retroviral therapy, higher rates of opportunistic infections, poor treatment adherence, and high-risk sexual behaviors. Alcohol use is often overlooked in clinical practice, but also increases the risk of treatment failure and high-risk behaviors. In patients with HIV infection and substance use problems, interventions that reduce substance use also have been shown to improve treatment adherence and survival. All patients with HIV infection should be regularly screened for substance use problems. Individuals with substance use problems who do not have evidence of dependence may be successfully managed using a brief patient-centered intervention. The focus for these patients is generally on reducing substance use rather than complete abstinence. Individuals with evidence of dependence may require referral to a specialist. Opioid substitution with methadone or buprenorphine may help to improve treatment adherence and viral suppression for patients who misuse opioids. Mental health disorders are also common among those with HIV and substance use problems, and the combination of substance use and mental health problems presents a significant challenge in HIV care. These patients are less likely to enter care, to remain adherent, and to attain complete viral suppression. Minority patients are generally less likely to receive mental healthcare, and may be at especially high risk of complications due to substance use problems and mental illness. Effective communication among an interdisciplinary treatment team is essential to improve long-term treatment outcomes for these challenging patients.