Signs and Symptoms

Substance use in People Living with HIV

The signs and symptoms of drug and alcohol use in people living with HIV (PLWHIV) may manifest either as a result of the practice of drug or alcohol use, or medical complications that arise from their use.

Examination findings suggestive of substance use/addiction, or its complications, in PLWHIV include:1

  • general signs
    • detection of alcohol on breath
    • detection of marijuana on clothing
    • detection of nicotine or smoke on breath or clothing
    • poor nutritional status
    • poor personal hygiene
  • behavior:
    • intoxicated behaviour during examination
    • slurred speech
    • staggered gait
    • scratching
  • immune system:
    • swollen/ enlarged lymph nodes (lymphadenopathy)
  • gastrointestinal:
    • enlarged liver (hepatomegaly)
    • liver tenderness
    • blood in the stools (positive stool haemoccult)
  • skin:
    • signs of physical injury
    • bruises/lacerations/scratches/burns
    • needle marks
    • skin abscesses
    • cellulitis
    • jaundice
    • reddening of the palms (palmar erythema) or puffy hands
    • hair loss
    • excess perspiration or sweating (diaphoresis)
    • rash
  • pulmonary:
    • breath sounds (wheezing/rales/snoring-like sound)
    • cough
    • respiratory depression
  • head, eyes, ears, nose, throat:
    • conjunctival irritation or injection
    • inflamed nasal mucosa
    • perforated nasal septum
    • blanched nasal septum
    • sinus tenderness
    • gum disease, gingivitis
    • gingival ulceration
    • rhinitis/ sinusitis
    • pale mucosa of the mouth
    • burns in oral cavity
  • neurological:
    • sensory/memory/motor impairment
    • paralysis/weakness of muscles that control eye movement (ophthalmoplegia)
    • muscle weakness (myopathy)
    • nervous system disorder (neuropathy)
    • tremor
    • cognitive deficits
    • gross lack of co-ordinated muscle movement (ataxia)
    • pupil dilation or constriction
  • cardiovascular:
    • high blood pressure (hypertension)
    • rapid heartbeat (tachycardia) at rest
    • cardiac arrhythmia
    • heart murmurs/clicks
    • oedema/swelling
  • female reproductive/endocrine:
    • pelvic tenderness
    • vaginal discharge
  • male reproductive/endocrine:
    • testicular atrophy
    • penile discharge
    • breast enlargement (gynecomastia)

Co-infections associated with drug use in people living with HIV


  • Tuberculosis is one of the most common HIV-related opportunistic infections in the World Health Organisation (WHO) European region1
    • it is a leading cause of death in PLWHIV1
  • Injecting drug use, alcohol abuse and imprisonment are all risk factors for co-infection with tuberculosis in PLWHIV1
  • Management of tuberculosis in PLWHIV who are injecting drug users (IDUs) is challenging due to:1
    • interactions between tuberculosis drugs and ARVs with illicit drugs and opioid substitution therapy (e.g. methadone)
    • decreased adherence to therapy
    • decreased access to health care systems

Read more about tuberculosis co-infection in PLWHIV. 

Hepatitis C

  • Antibodies to the hepatitis C virus (HCV) are prevalent in 80–90% of IDUs1
  • HCV is easily transmitted among IDUs due to the sharing of needles and other drug taking paraphernalia (e.g. syringes, straws, swabs, cookers), sharing a drug dose from a common syringe, and accidental needle sticks1
    • injecting drug use is the most common route of HCV transmission among HIV-infected people1

Read more about hepatitis C co-infection in PLWHIV.


  1. World Health Organization. HIV/AIDS Treatment and Care. Clinical Protocols for the WHO European Region, 2007. Accessed 25 October 2011.