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Mental Health/Substance Use

Key considerations for people living with HIV

Illicit drug use is highly prevalent in people living with HIV (PLWHIV).1 Some drug users have a long history of undiagnosed mental illness. Some mental conditions may result from, or be exacerbated by the use of substances such as opioids, cocaine and alcohol.2

Epidemiology of drug users living with HIV

  • Heroin and cocaine are the drugs most closely associated with HIV infection worldwide, although the use of amphetamine-type stimulant (ATS) is growing.1
  • Estimates indicate that:
    • between 3 and 6.6 million of the 16 million injecting drug users (IDUs) worldwide are HIV positive3,4
    • at least 10% of all new HIV infections worldwide (30% if Africa is excluded) can be attributed to injecting drug use2
  • IDUs with HIV infection are at increased risk for opportunistic and other infections
    • overlapping routes of transmission put IDUs at risk of contracting hepatitis B virus (HBV) or hepatitis C virus (HCV)2
      • a recent systematic review estimated that around 10 million (range 6.0–15.2) IDUs worldwide might be positive for HCV antibodies5
      • around 80–90% of IDUs with HIV are anti-HCV antibody positive2
    • IDUs living with HIV may present with complications of active opportunistic infections such as tuberculosis, oesophageal candidiasis, herpes simplex, bacterial pneumonia or Pneumocystis jirovecii pneumonia (PCP)2

Drug use and HIV transmission

  • HIV epidemics in many parts of the world are driven by injecting drug use and sexual contact with IDUs2
  • IDUs have a poor insight into HIV transmission, which is accompanied by risky behaviours
    • a 2008 United Nations report estimated that only 36% of IDUs had been tested for HIV in the previous 12 months6

Survival of HIV-positive drug users

  • HIV-infected drug users are associated with increased morbidity and mortality compared with PLWHIV who do not use drugs2,7
    • IDU is a major risk factor for progression to AIDS and death8–11
    • HIV-positive IDUs continue to have an increased risk of death even in countries with well established, and freely available, ART delivery systems9,10

Early testing for HIV in active drug users

Despite the benefits of early detection and the availability of treatment for HIV infection:9

  • IDUs are less likely to seek early HIV counselling, testing and treatment than other HIV-infected people
  • a substantial proportion (42%) of HIV-positive IDUs receive their HIV diagnosis late (AIDS diagnosed within 12 months of HIV diagnosis)


However, IDUs who are aware of their HIV-positive status are more likely to adopt safer injecting and sexual practices,12,13 thereby reducing further spread of the virus.

Managing imprisoned injecting drug users with HIV

Up to one-quarter of HIV positive people are imprisoned.14 Treating IDUs in prisons is important since HIV transmission and drug dependence may be exacerbated in this setting2

  • Most imprisoned HIV-infected IDUs have restricted/no access to ART or drug dependence therapy;15 however, HIV-infected IDUs who do have access to ART in prison show clinical improvement while incarcerated15
  • Treatment relapse and poor continuity of care upon release result in deteriorating clinical outcomes for imprisoned PLWHIV15
    • adherence rates and virologic outcomes in HIV-infected people improved while in prison, but the benefits are often lost upon release15,16
    • return to the community should be planned to ensure continuous care and preservation of the health advances achieved in prison2

Alcohol use and HIV

Hazardous alcohol use is more prevalent in HIV-infected people than the general population.17–19

Similar to the effects of drug use on HIV, heavy alcohol use negatively affects PLWHIV in several ways, including:

  • increased HIV risk behaviors1,20
  • increased risk of HIV transmission1
  • decreased adherence to ART1,21
  • decreased likelihood of HIV suppression1
  • worsening disease progression1,20,22
  • increased risk of opportunistic infections22


  1. Altice F, Kamarulzaman A, Soriano V, et al. Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet 2010;376:367–387.
  2. World Health Organization. HIV/AIDS Treatment and Care. Clinical Protocols for the WHO European Region, 2007. Accessed 25 October 2011.
  3. World Health Organization. UNAIDS report on the global AIDS epidemic, 2010.
  4. Horton R, Das P. Rescuing people with HIV who use drugs. Lancet 2010;376:207–208.
  5. Nelson P, Mathers B, Cowie B, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet 2011;378:571–83.
  6. Mathers B, Degenhardt L, Adam P, et al. Estimating the level of HIV prevention coverage, knowledge and protective behavior among injecting drug users: what does the 2008 UNGASS reporting round tell us? J Acquir Immune Defic Syndr 2009;52(suppl 2):S132–142.
  7. May M, Sterne JA, Sabin C, et al, for the Antiretroviral Therapy (ART) Cohort Collaboration. Prognosis of HIV-1-infected patients up to 5 years after initiation of HAART: collaborative analysis of prospective studies. AIDS 2007;21(9):1185–1197.
  8. van Sighem A, Danner S, Ghani A, et al. Mortality in patients with successful initial response to highly active antiretroviral therapy is still higher than in non-HIV-infected individuals. J Acquir Immune Defic Syndr 2005;40:212–218.
  9. Grigoryan A, Hall HI, Durant T, Wei X. Late HIV diagnosis and determinants of progression to AIDS or death after HIV diagnosis among injection drug users, 33 US states, 1996–2004. PLoS ONE 2009;4(2):e4445.
  10. Malta M, Bastos F, da Silva C, et al. Differential survival benefit of universal HAART access in Brazil: a nation-wide comparison of injecting drug users versus men who have sex with men. J Acquir Immune Defic Syndr 2009;52:629–635.
  11. Mocroft A, Gatell J, Reiss P, et al. Causes of death in HIV infection: the key determinant to define the clinical response to anti-HIV therapy. AIDS 2004;18:2333–2337.
  12. Des Jarlais D, Perlis T, Arasteh M, et al. ‘Informed altruism’ and ‘partner restriction’ in the reduction of HIV infection in injecting drug users entering detoxification treatment in New York city, 1990–2001.  J Acquir Immune Defic Syndr 2004;35:158–166.
  13. Weinhardt L, Carey M, Johnson B, Bickham N. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985–1997. Am J Public Health 1999;89:1397–1405.
  14. World Health Organization. Effectiveness of interventions to address HIV in prisons, 2007. Accessed 25 November 2011.
  15. Springer SA, Pesanti E, Hodges J, et al. Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis 2004;28:1754–1760.
  16. Stephenson BL, Wohl DA, Golin CE, et al. Effect of release from prison and re-incarceration on the viral loads of HIV-infected individuals. Public Health Rep 2005;120:84–88.
  17. Lefevre F, O'Leary B, Moran M, et al. Alcohol consumption among HIV-infected patients.  J Gen Intern Med 1995;10:458–460.
  18. Conigliaro J, Gordon AJ, McGinnis KA, Rabeneck L, Justice AC; Veterans Aging Cohort 3-Site Study. How harmful is hazardous alcohol use and abuse in HIV infection: do health care providers know who is at risk?  J Acquir Immune Defic Syndr 2003;33:521–525.
  19. Samet JH, Phillips SJ, Horton NJ, Traphagen ET, Freedberg KA. Detecting alcohol problems in HIV-infected patients: use of the CAGE questionnaire. AIDS Res Hum Retroviruses 2004;20:151–155.
  20. Shuper PA, Neuman M, Kanteres F, et al. Causal considerations on alcohol and HIV/AIDS: a systematic review. Alcohol Alcohol 2010;45:159–166.
  21. Hendershot CS, Stoner SA, Pantalone DW, Simoni JM. Alcohol use and antiretroviral adherence: review and meta-analysis. J Acquir Immune Defic Syndr  2009;52:180–202.
  22. Baum MK, Rafie C, Lai S, et al. Alcohol use accelerates HIV progression. AIDS Res Hum Retroviruses 2010;26:511–518.