Page 127 - HIV/AIDS Guidelines

HIV and Illicit Drug Users (Last updated March 27, 2012; last reviewed March 27, 2012)
Treatment Challenges of HIV-Infected Illicit Drug Users

Injection drug use is the second most common mode of HIV transmission in the United States. In addition,
noninjection illicit drug use may facilitate sexual transmission of HIV. Injection and noninjection illicit drugs
include the following: heroin, cocaine, marijuana, and club drugs (i.e., methamphetamine, ketamine, gamma-
hydroxybutyrate [GHB], and amyl nitrate [i.e., poppers]). The most commonly used illicit drugs associated
with HIV infection are heroin and stimulants (e.g., cocaine and amphetamines); however, the use of club
drugs has increased substantially in the past several years and is common among individuals who have HIV
infection or who are at risk of HIV infection. The association between club drugs and high-risk sexual
behavior in men who have sex with men (MSM) is strongest for methamphetamine and amyl nitrate; this
association is less consistent with the other club drugs. 1
Illicit drug use has been associated with depression and anxiety, either as part of the withdrawal process or as
a consequence of repeated use. This is particularly relevant in the treatment of HIV infection because
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depression is one of the strongest predictors of poor adherence and poor treatment outcomes. Treatment of
HIV disease in illicit drug users can be successful but HIV-infected illicit drug users present special treatment
challenges. These challenges may include the following: (1) an array of complicating comorbid medical and
mental health conditions; (2) limited access to HIV care; (3) inadequate adherence to therapy; (4) medication
side effects and toxicities; (5) the need for substance abuse treatment; and (6) drug interactions that can
complicate HIV treatment. 3
Underlying health problems in injection and noninjection drug users result in increased morbidity and
mortality, either independent of or accentuated by HIV disease. Many of these problems are the consequence
of prior exposures to infectious pathogens from nonsterile needle and syringe use. Such problems can include
hepatitis B or C virus infection, tuberculosis (TB), skin and soft tissue infections, recurrent bacterial
pneumonia, and endocarditis. Other morbidities such as alteration in levels of consciousness and neurologic
and renal disease are not uncommon. Furthermore, these comorbidities are associated with a higher risk of
drug overdoses in illicit drug users with HIV disease than in HIV-uninfected illicit drug users, due in part to
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respiratory, hepatic, and neurological impairments associated with HIV infection. Successful HIV therapy
for illicit drug users often depends on clinicians becoming familiar with and managing these comorbid
conditions and providing overdose prevention support.

Illicit drug users have less access to HIV care and are less likely to receive antiretroviral therapy (ART) than
other populations. 5-6 Factors associated with low rates of ART use among illicit drug users include active
drug use, younger age, female gender, suboptimal health care, recent incarceration, lack of access to
rehabilitation programs, and health care providers’ lack of expertise in HIV treatment. 5-6 The typically
unstable, chaotic life patterns of many illicit drug users; the powerful pull of addictive substances; and
common misperceptions about the dangers, impact, and benefits of ART all contribute to decreased
adherence. The chronic and relapsing nature of substance abuse as a biologic and medical disease,
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compounded by the high rate of mental illness that antedates and/or is exacerbated by illicit substance use,
additionally complicate the relationship between health care workers and illicit drug users. 8-9 The first step in
provision of care and treatment for these individuals is to recognize the existence of a substance abuse
problem. It is often obvious that the problem exists, but some patients may hide these problem behaviors
from clinicians. Assessment of a patient for substance abuse should be part of routine medical history taking
and should be done in a professional, straightforward, and nonjudgmental manner.

Treatment Efficacy in HIV-Infected Illicit Drug Use Populations
Although illicit drug users are underrepresented in HIV therapy clinical trials, available data indicate that
efficacy of ART in illicit drug users—when they are not actively using drugs—is similar to that seen in other

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-11

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