“ The HIV and substance use epidemics are deeply linked, fueling each other, creating a syndemic,” Aditi Ramakrishnan, MD, MSc, explains. “Among people living with HIV, substance use can influence engagement in care—in terms of one’s ability to attend clinic visits and take medications—and therefore can lead to poor HIV and other healthcare outcomes.”
In the Southern United States, cisgender women are disproportionately affected by HIV, but few studies have examined the intersection of HIV outcomes and patterns in substance use and treatment. This lack of research “represents an important gap” that needs to be addressed to implement effective strategies that can improve outcomes for this population, Dr. Ramakrishnan says.
For a study published in JAIDS, the researchers examined substance use and treatment among women with and without HIV across four different sites in the Women’s Interagency HIV Study: Atlanta, Birmingham/Jackson, Chapel Hill, and Miami. Participants self-reported nonmedical use of drugs within the previous year.
Engagement in Substance Use Treatment Low Overall
The study enrolled 840 women, including 608 with and 232 without HIV. Of the entire cohort, 155 reported substance use in the previous year (16% of women with HIV and 24% of women without HIV).
However, only 25% of those who reported substance use indicated receiving substance use treatment. Throughout the study, 30% reported substance use treatment at year 1, 21% at year 2, and 18% at year 3 (Figure).
For women with HIV, reports of an HIVrelated healthcare visit in the previous 6 months remained high at enrollment (88%), year 1 (87%), year 2 (91%), and year 3 (83%). While retention in HIV care did not significantly differ based on uptake of substance use treatment, viral suppression was significantly higher for women who reported substance use treatment at enrollment (P=0.03).
“Among cisgender women with HIV, viral suppression was significantly higher among women who reported engaging in substance use treatment compared with women who reported no treatment at enrollment,” Dr. Ramakrishnan notes. “However, at subsequent timepoints, viral suppression and retention in care did not significantly differ by substance use treatment status. Uptake of substance use treatment also did not differ significantly by HIV serostatus. These patterns will need to be more deeply investigated with larger sample sizes.”
Aligning HIV Care With Substance Use Treatment
Although lifetime substance use was high among women in the study, only one in four reported substance use treatment, and engagement in substance use treatment remained low over time, Dr. Ramakrishnan notes. “This represents a critical gap that clinicians and the overall healthcare system need to address.”
She continues that this is “particularly relevant” because 86% of the study population reported accessing healthcare within the previous 6 months. “This is a clear signal that we need to be more creative, innovative, and revolutionary with designing substance use and HIV care services to ensure that we truly reach and create equitable access to substance use treatment.”
Further, the current research sets a foundation for creating a substance use care continuum, according to Dr. Ramakrishnan.
“Further developing and understanding such a continuum and its potential relationship to the HIV care continuum can lead to better understanding patterns and gaps in care for this population, which can directly improve implementation of integrated services. Along with this, implementation science studies incorporating patient and community voices, humancentered design, and implementation mapping are critical to develop effective, integrated strategies and programming to improve substance use and HIV care services and outcomes.”
