Exploring the neglected overlap between HIV and substance use disorders


Substance use disorders (SUD) are common within the population of people with HIV, and this can have a detrimental effect on their progression along the HIV care continuum. Despite this, SUD services are not currently integrated into AIDS service organisations as well as they might be.


Dr Bryan Garner at RTI International and his team identified that integrating these services within community-based ASOs is one of the keys to addressing SUDs among people with HIV.


Read more in Research Outreach


Read the original article: https://doi.org/10.1007/s10461-021-03473-9


Image credit: Piotr Pabijan/ Shutterstock





Hello and welcome to Research Pod! Thank you for listening and joining us today.


In this episode we will be learning about the research of Dr Bryan Garner into HIV and substance use disorders.


Dr Bryan Garner is a Senior Implementation Research Scientist with RTI International. His latest research explores the neglected overlap between HIV and substance use disorders (or SUDs). In May 2019, clients of AIDS service organisations (or ASOs), as well as ASO staff, and HIV/AIDS Planning Council members participated in a novel Stakeholder-Engaged Real-Time Delphi (or Stakeholder-Engaged-RTD) survey. This novel interactive survey explored the perceived prevalence and individual-level negative impact of five SUDs for people with HIV (or PWH). Overall, Dr Garner and his team found alcohol use disorder, methamphetamine use disorder, and opioid use disorder to have the greatest population-level negative impact scores. Their findings underscore the urgent need to better integrate SUD services within HIV settings as part of the United States Ending the HIV Epidemic initiative launched in late 2019, just before the COVID-19 pandemic emerged.


Besides advancing knowledge of the individual-level and population-level negative impacts of five different SUDs on PWH across the United States, the study findings also support the argument for integrating SUD services within HIV service settings. The results may also help public health policy makers, HIV planning councils (or HPCs), and ASOs to most efficiently distribute funding to address the HIV-SUD syndemic (meaning synergistic, dual epidemic) in the United States.


Tom Donohoe is a professor of Family Medicine at the David Geffen School of Medicine at UCLA. He also directs the Pacific AIDS Education and Training Center in the Los Angeles Area. With over thirty years of experience in this area, he is uniquely well-equipped to speak about the real-world benefits of the study. In Donohoe’s words: ‘what many people don’t think about is that people are still dying because of HIV because they are not in care and on HIV medications, often because of their drug use, or because of depression or mental illness directly related to their drug use. He goes on to say, ‘We need to do everything we can to connect people to SUD treatment wherever they touch services, but especially HIV services. Dr Garner as an implementation scientist takes this to the next level by asking what SUDs are most negatively impacting people with HIV with SUDs in a certain region.’


Substance use disorders are common within the population of people with HIV, and this can have a detrimental effect on their progression along the HIV care continuum. Dr Garner and his team identified that integrating SUD services within community-based ASOs is one of the keys to addressing SUDs among PWH. This includes screening, referral to specialist SUD treatment, and SUD-related wraparound services. Such integrated onsite services have been shown to be cost-effective and lead to better patient outcomes.


Despite this, SUD services are not currently well integrated into ASOs as well as they might. Therefore, Dr Garner and his research team aim to bolster understanding of the convergence of SUD and HIV so that ASOs and the people working for them may better prioritise their limited resources. Furthermore, this increased understanding may help to highlight the severity of the methamphetamine use problem, for example, bringing it to the attention of policymakers, in a similar way to the opioid epidemic.


A previous study by Hartzler and colleagues in 2017 found that 48% of people with HIV had an SUD. This is 6.5 times higher than the US population in general. However, Dr Garner and his team recognised a gap in the literature regarding the prevalence of specific SUDs among PWH from broader samples than surveys of those treated in academic medical centres. Furthermore, they recognised that no previous research had reported on people’s perceptions of the impact of different SUDs, either in the general population or among PWH.


Dr Garner and team set out to better understand the prevalence of five different SUDs – alcohol, cannabis, cocaine, methamphetamines, and opioids – among PWH in the US. In addition, they assessed the perceived negative impacts for PWH who have these SUDs, as well as the estimated population-level negative impacts of these five SUDs among PWH.

After screening, 805 people with HIV, ASO staff, and HPC members were eligible to participate. Just over half identified as female (52.1%), while 41.7% identified as male, and 5.1% identified as transgender, genderqueer, or gender non-conforming. Most participants were white (58.9%), about a third were black or African American (36.4%), and around a quarter (23.2%) were Hispanic or Latino. The majority (65.2%) were ASO staff, and the South was the most represented region. Eligibility criteria included: being at least 18 years old; having personal, professional, or other experience with SUDs for at least one of the five substances studied; living in the US; and being HIV-positive (if an ASO client).


Using an innovative Stakeholder-Engaged-RTD method, participants were asked to report their perceptions of the prevalence of SUDs among PWH in their area of the US as well as individual-level negative effects of each particular SUD on four HIV care continuum indicators along with four other important aspects of life. This type of survey is more complicated to administer than a standard cross-sectional survey. However, Dr Garner and his team chose the Stakeholder-Engaged-RTD method because it allows each participant to share their reasons for each response anonymously, review other participants’ responses and reasons, and change their response and reasons – for example, after finding out new information from other participants. Importantly, this reduces the likelihood that between-group differences are simply due to lack of information, knowledge, or understanding. Consequently, remaining differences between participants are more likely to be meaningful differences for subsequent research and/or practice to address.


In addition to the main benefits of a traditional Delphi survey – including anonymity, controlled feedback of responses to all group members, iteration, and statistical aggregation of individual responses – Real-Time Delphi surveys have been shown to produce similar results more quickly and efficiently, with feedback provided instantly.


Participants were asked to report whether they had ever used each substance or ever met two or more of the 11 Diagnostic and Statistical Manual of Mental Disorders SUD criteria during a 12-month timeframe. The criteria are: spending a lot of time using the substance and/or recovering from use of the substance; taking the substance in large amounts or more often than they should be taken; failing to meet responsibilities at work, school, or home because of use of the substance; continuing to use the substance in spite of knowing that using the substance may have caused a physical or psychological problem to happen or get worse. Participants were also asked to report whether they had an affected family member, friend, or client.


Additionally, they were asked to estimate the percentage of PWH in their area who had a use disorder for each substance. Participants were also asked to rate the negative impact of having a use disorder for each substance on 1) being linked to HIV care, 2) being retained in HIV care, 3) being prescribed HIV medications, 4) being virally suppressed, 5) having stable housing, 6) having a reliable mode of transport, 7) being employed, and 8) having a strong social support system. The individual-level negative impact score was then weighted by the proportion of PWH perceived to have the particular SUD to get the population-level negative impact score.


The survey revealed that the highest perceived rates of SUDs were for alcohol and cannabis use disorders, with all of the five SUDs having at least one significant regional difference. In general, the perceived prevalence of alcohol, cannabis, cocaine, and opioid use disorders was lower in the West than in other regions, while the perceived prevalence of methamphetamine use disorder was greater in the West. These findings differ in comparison to the wider US population within which rates of alcohol and illegal drug use disorder are comparatively lower in the South and higher in the West. Furthermore, while Dr Garner and team found that the three groups of participants surveyed generally agreed, they discovered that rates reported by ASO staff were significantly lower than rates reported by PWH for both cocaine use disorder and methamphetamine use disorder.


The survey results showed that cannabis use disorder is perceived to be the most prevalent. Use disorder for this substance produced the lowest population-level negative impact score across regions and stakeholders. This mirrors national population-based research showing reductions in the perception of risk associated with cannabis use among the general public. However, the recent significant changes in marijuana policies and legislation should be taken into account when considering perceptions around cannabis. Cannabis use is a complex and evolving issue, as disordered use results in negative mental health and other impacts. Yet conversely, cannabis may have a positive impact on health, including benefits related to HIV care. Therefore, more high-quality research is needed to elucidate this issue.


Dr Garner and team found that methamphetamine use disorder had the highest individual-level negative impact with opioid use disorder having the second highest. They also found a significant difference between these two use disorders and each of the others. For cocaine use disorder and alcohol use disorder, the individual-level negative impacts were similar, with both shown to be significantly greater than cannabis use disorder. The SUDs with the greatest population-level negative impact scores (with a possible range of 0–24) were 1) alcohol use disorder (with a population-level negative impact of 6.9; and perceived prevalence of 41.9%), 2) methamphetamine use disorder (with a population-level negative impact of 6.5; and perceived prevalence of 3.2%), and 3) opioid use disorder (with a population-level negative impact of 6.4; and perceived prevalence of 34.6%).


Dr Garner and his colleagues made suggestions for future research to further develop the knowledge base surrounding the SUD-HIV syndemic, including examining the extent to which the negative impacts on the HIV care path vary according to severity of substance use and SUD. Unprecedented efforts have been rightly mounted to tackle the opioid crisis in the US in recent years. However, as Dr Garner and his team highlights, it is important that this problem does not overshadow efforts to tackle use disorders for other substances, particularly methamphetamine and alcohol.


Tom Donohoe draws attention to a new federal program called Ending the HIV Epidemic (EHE). Looking to the future, Donohoe says ‘I think Dr. Garner’s research can help guide us to be most impactful and efficient, especially as EHE and other resources are made available. I’m most excited about having more tools to address Meth use among people with HIV in the future’.


The team’s future research will help to establish the best treatment interventions and implementation strategies for tackling simultaneous HIV and SUDs within HIV service settings.


That’s all for this episode – thanks for listening, and stay subscribed to Research Pod for more of the latest science. See you again soon.

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