Mental Health, Drugs, and HIV
Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) take an incredible toll on human life worldwide:1
- In 1995, at the peak of the HIV/AIDS epidemic in the U.S., there were 50,877 AIDS deaths reported.
- The number of deaths from AIDS in the U.S. has since dropped significantly, partly due to a natural decline from peak levels, but also from the success of medical treatments for HIV that were first made available in 1996.
HIV treatment, called antiretroviral therapy (ART), substantially prolongs lives, increases the quality of life for patients, and can prevent individuals with HIV from progressing to AIDS.2 Although ART enables individuals to live with the disease through older age, the effectiveness of HIV therapy and medication can be compromised by drug or alcohol abuse.3,4
Substance abuse is common among individuals with HIV/AIDS and, when present, adds to the complexity of treatment. However, it is possible to successfully receive simultaneous treatment for both HIV and addiction, as well as other chronic medical conditions such as tuberculosis and hepatitis B and C, which are common among HIV patients.5 The substances most commonly used and abused by people with HIV are opioids, alcohol, cocaine, and methamphetamine.6,7
According to 2010 data, nearly 1 in 4 people with HIV/AIDS (23.94%) needed treatment for alcohol or drug abuse.8
Among people diagnosed with HIV, 12% have another psychiatric disorder or mental health issue in addition to a substance use disorder.6 These co-morbid or “dual diagnosis” conditions can range from depression to bipolar disorder and can profoundly impact treatment efforts for both the patient’s substance abuse and HIV. Higher mortality rates have been observed in HIV/AIDS patients with untreated substance use disorder and co-morbid mental illness.6
Can You Get HIV from Using Drugs?
Intravenous drug use is the second most common method of transmitting HIV, with 10% of HIV cases attributable to injection drug use.9 Injection drug users (primarily of heroin and other opioids) can both contract and then spread HIV by sharing needles. Cocaine and methamphetamine can also be injected, and doing so imparts similar risks of transmitting the disease as well.
Intravenous drug use is the second most common method of transmitting HIV, with 10% of HIV cases attributable to injection drug use.
Illicit drug use also has a correlation with unprotected sex—the most common mode of HIV transmission. Many drugs lower inhibitions and alter the user’s sense of reality, making them more likely to engage in risky behaviors. Other risk factors for unprotected sex include exchanging sex for drugs, and instances of both voluntary and forced prostitution.
Alcohol use is associated with HIV in a similar way, reducing people’s inhibitions to high-risk behaviors including drug use, needle sharing, and unsafe sexual practices, which increase the risk of contracting and transmitting HIV.
Drug Abuse and HIV
Drugs are often the conduits of HIV transmission, but evidence has also shown that people with HIV continue or even start using drugs after they’ve contracted the disease. One reason may be that individuals were addicted pre-HIV and unable to quit even after learning of their diagnosis. Another common reason is self-medication of physical pain and mental health symptoms of the disease.
Self-medication may occur in response to psychiatric problems, such as anxiety, depression, or trauma, that were present before the HIV diagnosis or arose because of the disease. The latter scenario is especially common. One research study of people seeking testing for HIV found that depression was twice as common in HIV-positive individuals than among those who were HIV-negative.3 People with untreated HIV/AIDS can also experience physical pain, discomfort, and other negative physical and cognitive effects associated with the disease.
Illicit drugs may temporarily ease subjective pain and psychiatric issues, but in the long term, they can exacerbate HIV symptoms and pose a greater risk of not adhering to treatment. For example, marijuana use is common among individuals with HIV, likely for self-medicating purposes.10 Subjects who had become physically dependent on marijuana due to heavy, long-term usage were less likely to adhere to their HIV treatment regimens than people who used marijuana in moderate levels.10
Stages of HIV/AIDS
HIV is a virus that attacks the human immune system. The immune system is comprised of a number of disease-fighting agents including CD4+ T-helper cells, commonly referred to simply as T cells. These cells are primarily responsible for fighting off foreign pathogens that attempt to infect the body, and they are the main target of HIV.11
For 2 to 4 weeks after someone contracts HIV, they may experience fever, rash or headaches.12 This is the first stage of HIV, also called the acute stage, and it is during this stage when there is the greatest risk of spreading HIV to others.
HIV is a virus that attacks the human immune system.
The second stage of HIV is called chronic or latent HIV. During this period—which lasts for many years, up to a decade or longer—the individual may not have many symptoms, though they can still transmit HIV. The virus slowly breaks down and destroys CD4 T cells, leaving the body more and more vulnerable to other diseases, known as opportunistic infections. When T cell counts fall to 200 per mm3 of blood or lower and one or more opportunistic infections is present, the person is diagnosed with AIDS.12
AIDS is the final stage of HIV and is typically diagnosed around 10 years after someone has initially contracted HIV. Left untreated, individuals with AIDS usually live around 3 years once they’ve been diagnosed.12
Thanks to billions of dollars invested in research, the last two decades have seen incredible advancements in HIV treatment. As a result, AIDS diagnoses have dropped significantly in the U.S. The medications and treatment protocols responsible for these improvements are called antiretroviral therapy (ART). ART is recommended for everyone diagnosed with HIV.13
ART is a daily medication regimen that consists of 3 medications from at least 2 of the following drug classes:2
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors (PIs)
- Fusion and entry inhibitors
- Pharmacokinetic enhancers
- Integrase strand transfer inhibitors (INSTIs)
ART is generally well tolerated. While earlier medications were known to cause side-effects severe enough to substantially impact treatment, newer ART regimens only have treatment-limiting side effects in about 10% of people, and those who do experience side effects can usually switch to a different medication.14
Short-term side effects of modern HIV medications are generally mild and include:14
- Nausea, vomiting, and diarrhea.
- Muscle pain.
Long-term side effects of HIV treatment drugs can be more severe and may require patients to change their treatment regimen based on their doctor’s recommendation. These include:14
- Kidney failure.
- Liver damage.
- Heart disease.
- Depression and suicidal thoughts.
HIV patients who have a substance use disorder alongside other mental health conditions are shown to have lower rates of adherence to their HIV treatment regimen.15,16 This is why getting treatment for co-occurring conditions is paramount to achieving health with HIV. It is also important to note that former drug use does not appear to be strongly linked to ART nonadherence.3 This means that once a drug use disorder is successfully treated, adherence to HIV treatment is likely to be much more successful.
Risk of Coinfection
Co-occurring infections are common in individuals with HIV and make treating HIV more difficult. The most common co-occurring infections in people with HIV are viral hepatitis (hepatitis B and C) and tuberculosis. An estimated 20% of individuals with HIV are infected with hepatitis C, and among injection drug users that percentage is at least 3 times as high.5 Hepatitis B infections are present in approximately 10% of individuals with HIV.5
Hepatitis infections are diseases of the liver and, if left untreated, can lead to liver cancer, cirrhosis (liver scarring), and death. With modern medicine dramatically extending the lives of HIV-positive individuals, more people with HIV who are co-infected with hepatitis are living long enough to reach end-stage liver disease than in previous years:5
- 21% are diagnosed with cirrhosis after 20 years.
- 49% are diagnosed after 30 years.
Factors contributing to progression to liver disease in the HIV population include poor adherence to HIV treatment and heavy alcohol consumption, which damages the liver over time.
Hepatitis C can lead to a host of other medical issues, including:5
- Cardiovascular disease.
- Kidney impairment.
- Cognitive impairment.
- Insulin resistance.
Unlike hepatitis, which is transmitted primarily by sharing needles, tuberculosis (TB) is contracted through the air and into lungs from dirty, poorly ventilated areas, or after being in prolonged, close proximity to others with tuberculosis. Tuberculosis can be active or latent. Only 5–10% of individuals with latent TB ever develop active TB, which is when individuals are contagious and experience symptoms.5
Co-occurring infections are common in individuals with HIV and make treating HIV more difficult.
Having a compromised or suppressed immune system (such as from HIV) poses the greatest risk of latent TB turning active or reactivating after a period of latency. For this reason, TB is one of the leading causes of death in people with HIV worldwide.5
Both TB and hepatitis can be treated in conjunction with HIV. Most ART regimens include antiviral agents that treat hepatitis as well as suppress HIV replication. Special considerations should be made with the co-treatment of HIV and TB. Pregnant women, for example, may not be able to take certain combinations of HIV and TB medications.17
Among patients who are HIV positive, those who use illicit drugs and alcohol are at greater risk of co-infection due to a number of factors:5,18
- Weakened immune system: Drug and alcohol use, especially when heavy and prolonged, can suppress the body’s natural ability to fight off disease, even in those who are HIV negative.
- Environment: Some people who struggle with chronic substance abuse may be exposed to environmental factors and poor living conditions that contribute to the spread of disease. Homelessness or low-income housing, incarceration, and general uncleanliness can all contribute to a person’s likelihood of contracting a serious illness.
- Injection drug use: People who share needles to inject drugs like heroin are more likely to contract both HIV and hepatitis C.
- Non-adherence to treatment: Heavy substance use can make patients less likely to adhere to their medication schedule and treatment regimen for both HIV and other infections, leaving them vulnerable to the effects of disease.
The gay and bisexual community, and specifically homosexual men, are the groups most affected by HIV/AIDS. According to a survey conducted by the U.S. Centers for Disease Control and Prevention, 67% of individuals with HIV are gay or bisexual men and, among these individuals, African Americans are most affected.19
Men who have sex with other men are at a greater risk for acquiring HIV for two primary reasons:19
- There is a greater risk of contracting HIV through anal sex than vaginal sex.
- The stigma of being a homosexual sometimes deters many gay men from seeking out the proper healthcare to prevent HIV.
Medical providers typically recommend the following steps to individuals seeking to limit their potential exposure to HIV, whether or not they are LGBTQ:19
- Use condoms and use them correctly.
- Limit the number of sexual partners.
- Get tested regularly for sexually transmitted diseases, including HIV.
- Consider pre-exposure prophylaxis (PrEP), a combination of two antiretroviral medications taken daily that limits the risk of contracting and transmitting HIV.
Mothers and Pregnant Woman
Of women who struggle with substance abuse, 90% are of reproductive age.20 The most common substances of abuse by pregnant women are:20
Substance use by the mother during pregnancy has a documented association with the following negative outcomes in the baby:21
- Preterm labor and delivery
- Low birth weight
- Separation of the placenta from the uterus
- Fetal distress and stillbirth
- Drug withdrawal symptoms in the baby at birth
- Other abnormalities and birth defects
Further complicating cases of drug abuse during pregnancy is maternal HIV. An estimated 1.4 million HIV-infected women give birth each year around the world, primarily in sub-Saharan Africa.22 Research has shown that a combination of ART, avoidance of breastfeeding, and cesarean birth can significantly reduce the rate of mother-to-child HIV transmission.22
Substance use by the mother during pregnancy has a documented association with negative outcomes.
To minimize the risk both of HIV transmission to the baby and birth defects from drug use, it is important for women to seek ART and substance abuse treatment simultaneously. In doing so, it is also important for HIV-infected women seeking substance abuse treatment to be aware of which therapeutic medications are safe for their unborn child, and the potential interactions and complexities in receiving ART and substance abuse treatment simultaneously.23
Medication-assisted therapy (MAT) is an approach to substance abuse treatment that includes both medication and psychotherapy. Alcohol and opioids are two substance groups for which MAT approaches are beneficial. Medications commonly used in the treatment of opioid dependence include methadone and buprenorphine.
For many decades, methadone was the gold standard treatment for opioid use disorder. However, because methadone is an opiate, there was reluctance from the medical field to prescribe methadone to pregnant women. Research studies have shown the clear benefits of methadone treatment as opposed to no treatment at all in opioid-addicted pregnant women.24
Buprenorphine is another opioid dependence medication. Compared to methadone, buprenorphine is safer and is increasingly recommended over methadone for opioid dependency. Research has found that buprenorphine is safer and more effective in pregnant women compared to methadone.25
The success of both addiction treatment and HIV management depends on several factors, including:
- Other co-occurring mental health issues, such as anxiety or depression.
- Medications taken and drug interactions.
- Co-infections like TB or hepatitis.
- Social or financial barriers to treatment (homelessness, lack of health insurance, social stigmas).
HIV-positive patients looking to enter treatment for substance abuse should seek a facility that offers evidence-based psychological therapy as well as comprehensive medical care for HIV symptoms and any co-infections. Patients should continue their ART regimen during the detox phase of drug treatment, so finding a treatment center that understands the complexities of treating both HIV and substance abuse during detox is key.
Drug rehabilitation centers generally offer either inpatient or outpatient treatment services:
- Inpatient treatment is around-the-clock care and requires individuals to live at the treatment center for a period of time—typically from 30 to 90 days. Inpatient care is intensive and usually requires individuals to take leave from work, school, or other obligations in order to focus on their recovery.
- Outpatient treatment provides similar therapeutic interventions as inpatient treatment, but for only a few hours, a few times a week. For those with relatively less severe addiction issues or whose work schedules are inflexible, outpatient treatment may be a good fit. Outpatient treatment works best for patients who have a strong support network to lean on at home.
Regardless of the type of rehab facility you select, finding a program that can specifically address your individual needs and effectively manage your HIV and related illnesses during rehab will significantly improve your chances for successfully quitting drugs or alcohol for good.
Recovery and Aftercare
Treatment for substance use disorders can save the lives of HIV-positive drug abusers, but maintaining sobriety and good health is not limited to the length of time spent at a rehab facility. During rehab, you and your treatment provider will develop an aftercare plan that will help you avoid triggers to drug or alcohol use and adhere to your HIV treatment regimen.
Post-treatment recovery and support groups are key to maintaining sobriety and there are several options available. These include support groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), as well as continued individual therapy and group counseling. A community of other HIV-positive people who have completed treatment for substance abuse can provide emotional support and offer guidance.
An often overlooked but extremely important element of recovery throughout the aftercare phase involves proper nutrition and overall wellness maintenance. Arguably, this is one area that HIV-positive individuals have the most control over. Individuals with HIV should be especially careful to avoid excess fats, sugar, salt, and alcohol to promote good health and a strong immune system. Because HIV is an immunosuppressive disease, foods and water sources that contain dangerous pathogens should also be avoided. Examples are raw or undercooked meat, unfiltered water or water from lakes/rivers, and unwashed vegetables.26
Special Considerations for Treatment Providers
It is important for providers across the healthcare spectrum to understand the many factors that complicate treatment for HIV-positive individuals who suffer with substance use disorder. Co-occurring psychiatric disorders, diseases of co-infection, the severity of drug abuse, the substance being abused, interactions between various treatment medications, and the patient’s personal situation must all be considered.
A significant portion of individuals with HIV are gay or bisexual and may feel apprehensive about entering addiction treatment for fear of being judged or treated differently.
Treatment providers should be aware of the inherent complexities that come with having HIV. For many, there are social stigmas associated with HIV. For example, a significant portion of individuals with HIV are gay or bisexual and may feel apprehensive about entering addiction treatment for fear of being judged or treated differently. Women, especially pregnant women, often feel deeply ashamed for using drugs or having HIV. Additionally, women who have been forced into involuntary sex work and/or are victims of domestic violence are at greater risk for HIV and are likely to suffer from post-traumatic stress.27
The therapeutic drugs used in ART for HIV and MAT for substance abuse treatments can have side effects, both independently and when taken together. Other medical conditions like hepatitis and TB can add to this complexity. Simultaneous treatment of HIV and hepatitis C, for example, can alter liver functioning that can then have an impact on absorption and metabolism of opioid maintenance drugs like methadone or buprenorphine.28
There are many reasons behind the correlation between HIV and drug abuse, but evidence suggests that successfully treating substance use disorder has many positive implications for the outcome of HIV treatment therapy and overall patient health. Patients should work with their doctors to personalize a treatment plan that will help them live longer and more fulfilling lives.
- Osmond D. (2003). Epidemiology of HIV/AIDS in the United States. The University of California, San Francisco HIV InSite.
- U.S. Dept. of Health and Human Services. (2017). FDA-Approved HIV Medications. AIDSinfo.
- Chander G., Himelhoch S., & Moore R. (2006). Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy. Drugs. 66(6):769–789.
- Lucas G., Cheever L., Chaisson R., et. al. (2001). Detrimental effects of continued illicit drug use on the treatment of HIV-1 infection. JAIDS. 27(3):251–259.
- Altice F, Kamarulzaman A., Soriano V., et. al. (2010). Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. The Lancet. 376(9738):367–387.
- DeLorenze G., Satre D., Quesenberry C., et. al. (2010). Mortality after diagnosis of psychiatric disorders and co-occurring substance use disorders among HIV-infected patients. AIDS Patient Care STDs. 24(11):705–712.
- Van Tieu H. & Koblin B. (2009). HIV, alcohol, and noninjection drug use. Current Opinion in HIV and AIDS. 4(4):314–318.
- Substance Abuse and Mental Health Services Administration. (2010). The NSDUH Report: HIV/AIDS and Substance Use.
- Centers for Disease Control and Prevention. (2016). HIV and Injection Drug Use.
- Bonn-Miller M., Oser M., Bucossi M., et. al. (2014). Cannabis use and HIV antiretroviral therapy adherence and HIV-related symptoms. Journal of Behavioral Medicine. 37(1):1–10.
- National Institute on Drug Abuse. (2012). What is HIV/AIDS?
- U.S. Dept. of Health and Human Services. (2016). The Stages of HIV Infection. AIDSinfo.
- U.S. Dept. of Health and Human Services. (2017). When to Start Antiretroviral Therapy. AIDSinfo.
- U.S. Dept. of Health and Human Services. (2017). HIV Medicines and Side Effects. AIDSinfo.
- Azar M., Springer S., Meyer J., et. al. (2010). A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization. Drug and Alcohol Dependence. 112(3):178–193.
- Palepu A., Horton N., Tibbetts N., et. al. (2004). Uptake and adherence to highly active antiretroviral therapy among HIV?infected people with alcohol and other substance use problems: the impact of substance abuse treatment. Addiction. 99(3):361–368.
- U.S. Dept. of Health and Human Services. (2016). Considerations for Antiretroviral Use in Patients with Coinfections. AIDSinfo.
- Centers for Disease Control and Prevention. (2016). TB Risk Factors.
- U.S. Dept. of Health and Human Services. (2017). HIV and Gay and Bisexual Men. AIDSinfo.
- Kuczkowski K. (2007). The effects of drug abuse on pregnancy. Current Opinion in Obstetrics and Gynecology. 19(6):578–585.
- El-Mohandes A., Herman A., Nabil El-Khorazaty M., et. al. (2003). Prenatal care reduces the impact of illicit drug use on perinatal outcomes. Journal of Perinatology. 23(5):354–360.
- Nachega J., Uthman O., Anderson J., et. al. (2012). Adherence to antiretroviral therapy during and after pregnancy in low-, middle and high income countries: a systematic review and meta-analysis. AIDS. 26(16):2039.
- McCance-Katz E. (2011). Drug interactions associated with methadone, buprenorphine, cocaine, and HIV medications: implications for pregnant women. Life Sciences. 88(21):953–958.
- Jones H., Martin P., Heil S., et. al. (2008). Treatment of opioid-dependent pregnant women: Clinical and research issues. Journal of Substance Abuse Treatment. 35(3):245–259.
- Meyer M., Johnston A., Crocker A., et. al. (2015). Methadone and buprenorphine for opioid dependence during pregnancy: a retrospective cohort study. Journal of Addiction Medicine. 9(2):81–86.
- HIV.gov. (2017). Food Safety and Nutrition.
- Azim T., Bontell I., & Strathdee S. (2015). Women, Drugs and HIV. International Journal of Drug Policy. 26(S1):S16–S21.
- Bednasz C., Venuto C., Ma Q., et. al. (2017). Pharmacokinetic Considerations for Combining Antiretroviral Therapy, Direct?Acting Antiviral Agents for Hepatitis C Virus, and Addiction Treatment Medications. Clinical Pharmacology in Drug Development. 6(2):135–139.