Adult Antiretroviral Guidelines

US DHHS Guidelines with Australian Commentary

Substance Use Disorders and HIV

Table of Contents

Adult Guidelines > > Special Patient Populations > Substance Use Disorders and HIV
Sections
Table of Contents

Substance Use Disorders and HIV

DHHS Last Updated: September 2024Australian Commentary Last Updated: December 2024

Key Considerations and Recommendations
  • Substance use disorders (SUDs) are prevalent among people with HIV and contribute to poor health outcomes; therefore, screening for SUDs should be a routine part of clinical care (AII).
  • The most commonly used substances among people with HIV include the following (listed in alphabetical order): alcohol, benzodiazepines, cannabinoids, club drugs, opioids, stimulants (cocaine and methamphetamines), and tobacco.
  • Health care providers should be nonjudgmental when addressing substance use with people with HIV (AIII).
  • People with HIV and SUDs should be screened for additional mental health disorders (AII).
  • People with HIV and SUDs should be offered evidence-based pharmacotherapy (e.g., opioid agonist therapy, tobacco cessation treatment, alcohol use disorder treatment; see Table 15 below) as part of comprehensive HIV care in clinical settings (AI).
  • Ongoing substance use is not a contraindication to antiretroviral therapy (ART). People who use substances can achieve and maintain viral suppression with ART.
  • Substance use may increase the likelihood of HIV transmission risk behaviors, the potential for drug–drug interactions, and the risk or severity of substance-associated adverse events (e.g., increased hepatotoxicity or an increased risk of overdose).
  • Selection of antiretroviral (ARV) regimens for individuals who practice unhealthy substance and alcohol use should take into account potential adherence barriers, comorbidities that could impact care (e.g., advanced liver disease from alcohol or hepatitis viruses), potential drug–drug interactions, and possible adverse events associated with the medications (AII).
  • For people with SUDs, ARV regimens with once-daily formulations (ideally as a single-tablet regimen), high barriers to resistance, low hepatotoxicity, and low potential for drug–drug interactions are preferred (AIII).

Rating of Recommendations: A = Strong; B = Moderate; C = Weak

Rating of Evidence: I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Background on Substance Use Disorders among People with HIV

It is estimated there were 1,635 drug-induced deaths in Australia in 2023, excluding those caused by alcohol and tobacco1. There were 1,667 alcohol-induced deaths in Australia in 20232.

  1. ABS (2024) Causes of Death, Australia- external site opens in new window, ABS, Australian Government, accessed 13 January 2024.
  2. ABS (2024) Causes of Death, Australia- external site opens in new window, ABS Website, accessed 13 January 2024.

Current Australian guidelines recommend reducing the risk of harm from alcohol-related disease or injury, healthy adults should drink no more than ten standard drinks a week and no more than four standard drinks on any one day1.

  1. Australian Government Department of Health and Aged Care, How much alcohol is safe to drink?, Australian Government, accessed 13 January 2025.

Ending the HIV epidemic requires addressing substance use among people with HIV, which poses a barrier to optimal engagement in the HIV care continuum. Ongoing substance use may prevent an individual from being tested for HIV, initiating antiretroviral therapy (ART), or adhering to ART. Substance use may also increase the likelihood of risk-taking behaviors (e.g., sexual transmission risk behaviors, needle sharing, injection of substances), the potential for drug–drug interactions, and the risk or severity of substance-related adverse events (e.g., increased hepatotoxicity and increased risk of overdose). In the United States, the death toll for drug overdose (102,123 deaths as of February 2024)1 far exceeds the death toll for HIV (4,941 deaths in 2022).2 As the drug overdose epidemic continues to expand, health care providers need a basic understanding of how to screen for and treat substance use disorders (SUDs) in people with HIV in clinical settings.3

Substance use exists on a continuum, from episodic use to an SUD with its concomitant negative consequences. Research on alcohol consumption has defined a threshold at which consumption does not reach a diagnosis of SUD, but where the level of consumption is nonetheless hazardous to the person. This level of consumption has been defined as at-risk or hazardous use. A comparable category does not exist for other substances. The prevalence of substance use and SUDs is higher among people with HIV than among the general public,4 and polysubstance use is common. This section will focus on the most commonly used substances among people with HIV (listed in alphabetical order): alcohol, benzodiazepines, cannabinoids, club drugs,5 opioids, stimulants (cocaine and methamphetamines), and tobacco. Additionally, xylazine, a non-opioid veterinary analgesic that is a common substance adulterant—a substance added to another substance that may lead to negative health consequences—is also discussed.

People with HIV may use more than one substance and may not be ready to consider reducing the use of substances or seeking treatment for SUDs. Polysubstance use occurs for multiple reasons, including to improve the euphoria associated with use (e.g., use of cocaine and heroin mixtures called “speedballs”) and to reduce the adverse effects of a particular substance (e.g., the use of alcohol or benzodiazepines to reduce the anxiety caused by cocaine use).

Substance Use and Sexual Risk Taking

Gay and bisexual men typically report high rates of illicit drug use, including methamphetamine use.  A 2023 study investigated drug trends among Australian gay and bisexual men (GBM)1.

  1. Takeuchi J, Chan C, MacGibbon J, et al. Trends in illicit drug use and their association with HIV transmission risks from behavioural surveillance of Australian gay and bisexual men. Drug and alcohol review. 2023;43(2):539-550. doi:https://doi.org/10.1111/dar.13781

Study Summary

From 2012 to 2021, the trend sample comprised 69,567 surveys, averaging 6,957 per year. The mean participant age was 36.86 years, with most identifying as Anglo-Australian (69.8%), born in Australia (71.0%), gay (88.1%) or bisexual/pansexual (7.3%), and employed full-time (64.5%). A majority self-reported being HIV-negative (81.1%) and socially engaged with gay men (64.9%). Over time, variations were observed in mean age, sexual identity proportions, education levels, employment status, social engagement, and residency in areas with a higher proportion of gay residents, necessitating adjustments in trend analyses to account for these demographic changes. 

Drug use trends between 2012 and 2021 showed an overall increase in recent drug use from 58.4% to 64.1%. Party drug use initially rose from 29.3% in 2012 to 32.6% in 2020 before declining to 26.7% in 2021. Drug use for sex increased over the decade but remained stable in the last five years. Injecting drug use showed no significant changes over time. Specific drugs exhibited varied trends, with amyl nitrite, cannabis, cocaine, ketamine, and erectile dysfunction medications showing increased use, while speed and ecstasy usage declined. Crystal methamphetamine use declined over the decade but showed a slight resurgence in 2021. 

Frequent drug use (weekly or more) increased from 15.1% in 2012 to 20.3% in 2021. Frequent party drug use remained less common but rose from 2.0% to 2.6% during this period. Amyl nitrite, cannabis, and erectile dysfunction medication were the most frequently used substances. Crystal methamphetamine use rose slightly between 2020 and 2021. The frequent use of other drugs, including cocaine, ecstasy, GHB, and ketamine, showed minor upward trends but remained below 1%.

Overall, drug use patterns have shifted over the decade, with increases in both general and frequent use of specific substances such as cannabis, amyl nitrite, and erectile dysfunction medications. Party drug use exhibited fluctuations, with notable declines in 2021. Although injecting drug use remained stable, the increasing use of certain drugs, particularly for sexual purposes, highlights evolving behavioural patterns. The findings emphasise the importance of targeted interventions addressing both recreational and frequent drug use within this population.

A growing body of literature describes the intersection of substance use and sexual risk-taking, in which drugs are intentionally used to enhance sexual activity (“chemsex”). This research highlights the impact of substance use on sexual transmission risk behaviors; although no precise definition of “chemsex” exists, studies have investigated various substances used to enhance sexual pleasure, decrease inhibitions related to particular sexual acts, and combat low self-esteem. In a retrospective study in a London sexual health clinic, individuals who disclosed substance use (463 of 1,734 participants) had higher odds of acquiring new HIV infection, bacterial sexually transmitted infections (STIs), and/or hepatitis C virus (HCV).6 A much larger analysis using the European Men Who Have Sex With Men (MSM) Internet Survey, which collected data from 16,065 United Kingdom-based respondents, found that MSM who reported using methamphetamines or gamma-hydroxybutyrate (GHB) during the previous year were more likely to have gonorrhea infection than MSM who did not use these drugs, with odds ratios of 1.92 and 2.23, respectively.7 Between 2017 and 2020, the American Men’s Internet Survey collected data on chemsex drug use among MSM in the United States over the preceding 12 months. Of 30,294 MSM respondents, 3,113 (10.3%) self- reported chemsex in the past 12 months, with 3,4 methylenedioxymethamphetamine (MDMA or “ecstasy”) (65.1%), methamphetamine (42.5%), and GHB (21.7%) being the top drugs reported for use.8 A recent study in Spain using an online, self-administered questionnaire found that 81.4% of 2,919 MSM attending four HIV/STI testing sites in Madrid and Barcelona had ever used any drug, and 50% had engaged in chemsex in the past 12 months. Of those engaging in chemsex, half engaged in condomless anal sex.9 These data emphasize the need to screen people with HIV for substance use and STIs in clinical settings and to discuss strategies with these individuals to reduce potential harm.10

Substance Use and Unstable Housing

In the 2022 HIV Futures Survey 101, 0.8% (n = 6) of participants reported that they were homeless, including those living in boarding houses or crisis accommodation. This was a decrease of 0.9% compared to Futures 9 (2018-19; 1.7%, n = 16). However, this is still a larger proportion of homeless people than the general population. In the 2016 Australian census, over 116,000 people were experiencing homelessness on census night (approximately 0.49% of the population), including people living in a boarding house or crisis accommodation service as well as other forms of homelessness such as couch surfing, inadequate accommodation or no accommodation (Australian Bureau of Statistics, 2018). 

  1. Norman, T., Power, J., Rule, J., Chen, J., & Bourne., A. (2022). HIV Futures 10: Quality of life among people living with HIV in Australia (monograph series number 134). Australian Research Centre in Sex, Health and Society, La Trobe University. doi: 10.26181/21397641

 

People with HIV who inject drugs are more likely to be unhoused.11 Houselessness among people who inject drugs is associated with an increased risk of HIV acquisition.12

Among people with HIV and SUD, houselessness confers an increased risk for disruptions in the HIV care continuum independent of ongoing substance use. In a longitudinal study of people with HIV who used drugs, lack of housing was associated with a 44% decrease in the odds of progression through the HIV care continuum.13 After adjusting for multiple intersecting risks, including unhealthy alcohol use, other substance use, incarceration, unemployment, education, age, sex, and race/ethnicity, unhoused people with HIV and SUD had significantly decreased odds of ART initiation and, adherence, and of viral suppression.

Interventions supporting housing among people with HIV and SUD can result in improved HIV treatment outcomes. A randomized controlled trial of a rapid rehousing intervention for people with HIV who were houseless (n = 236, 81% with substance use) found that clients in the Enhanced Housing Placement Assistance arm were more likely to be placed and, placed faster, and were twice as likely as the control group to reach or maintain viral suppression (95% confidence interval [CI], 1.1–4.0).14,15 An observational study of applicants to a supportive housing program for low-income people with HIV and a mental health condition or SUD (n = 958; 86% with SUD) found that people who achieved stable housing were more likely to engage in HIV care and to achieve viral suppression.16 These data reflect the importance of not only addressing SUD among people with HIV, but also understanding the co-occurring structural determinants that contribute to poorer outcomes among people with HIV and SUD.

Screening for Substance Use Disorders

Australian clinicians can access Australian screening tools for substance use disorders here: https://aodscreening.flinders.edu.au/screening  

In the 2022 HIV Futures 10 survey1, people who had injected drugs were asked if they had experienced stigma or discrimination as a result of their injecting drug use. Over a quarter (29.0%, n = 20) indicated that they had experienced stigma or discrimination at least sometimes. 

Clinicians should consider the role of stigma and its negative impact on PLHIV who use drugs when consulting with their patients. Person-centred approaches should be employed to ensure the best possible outcomes for the individual. 

  1. Norman, T., Power, J., Rule, J., Chen, J., & Bourne., A. (2022). HIV Futures 10: Quality of life among people living with HIV in Australia (monograph series number 134). Australian Research Centre in Sex, Health and Society, La Trobe University. doi: 10.26181/21397641

 

Screening for SUDs should be incorporated into the routine clinical care of all people with HIV. The following questions can be used to screen for drug or alcohol use: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” and “How many times in the past year have you had X or more drinks in a day?” (X is five for men and four for women).17 Data are lacking on the appropriate threshold for alcohol use among transgender individuals with HIV, although a study among transgender individuals without HIV recommends a threshold of five standard drinks on a drinking day or a score of ≥3 on the Alcohol Use Disorders Identification Test (AUDIT-C).18 Individuals with liver disease, including active HCV infection, should not consume alcohol.

A positive response to either of the two questions above should prompt additional screening with other short screening tools (see the Screening and Assessment Tools Chart from the National Institute on Drug Abuse). These tools can identify substance use and guide decisions on appropriate treatment interventions. Currently, there are not enough data to determine how often people with HIV should be screened for SUDs; however, given the potential negative impact that SUDs may have on people with HIV, it is advisable to ask these questions during every clinical visit.

Health care providers should be nonjudgmental when discussing substance use with people who have HIV (AIII). People with HIV who experience stigma or judgment may lose trust in their health care provider’s advice, avoid future visits, and consequently experience poorer health outcomes.19 Language is one way in which stigma is communicated, and words such as “addict” and “dirty urine” convey a negative connotation. The Office of National Drug Control Policy (ONDCP), American Medical Association, American Society of Addiction Medicine, International Society of Addiction Journal Editors, and others have recommended the adoption of clinical, nonstigmatizing language for substance use, as described in the Changing the Language of Addiction report from ONDCP.

Co-occurring Mental Illness

Many people who use substances have co-occurring mental health disorders, including a history of trauma that may drive or exacerbate their substance use. Conversely, ongoing use of substances can place individuals at risk for trauma, such as sexual assault and sexual exploitation, which may further exacerbate their substance use.6,20 People with SUDs should undergo evaluation and treatment for concurrent mental health disorders using standardized screening instruments (e.g., the Patient Health Questionnaire-2, or PHQ-2, for depression). Where applicable, clinicians should use available behavioral and pharmacological interventions to address mental health concerns, because recommending that people stop their substance use without providing treatment for underlying mental health conditions has very limited efficacy.21

Selecting, Initiating, and Maintaining Antiretroviral Therapy

Opioid Agonist treatment with buprenorphine has expanded in Australia to include the long-acting depot buprenorphine formulation. Dosage is given weekly or monthly. Refer to NSW Clinical Guidelines for the use of depot buprenorphine in th treatment of opioid dependence.  

AIVL hosts a Needle Syringe Program (NSP) directory reference to provide to patients who require access to injecting equipment.

Ongoing substance use is not a contraindication for prescribing ART. ART is recommended for all people with HIV to improve their health and to prevent transmission of HIV to others (AI), including sexual partners and individuals who share drug paraphernalia. These clinical, community, and individual benefits should encourage health care providers to initiate ART in all people with HIV who use substances. Although effective ART prevents sexual transmission of HIV, its effectiveness in preventing transmission through shared needles and shared use of other drug paraphernalia remains unknown.

For people actively injecting drugs, engagement in a syringe service program (SSP) can facilitate access and adherence to ART. SSPs primarily provide clean drug preparation and injection supplies to reduce transmission of HIV, HCV, and other bloodborne, skin, and soft tissue pathogens. As a regular point of contact for people with complex health and social challenges, SSPs also provide opportunities to offer other integrated health-related and social support services,22 including those for treating SUDs.23 For people with HIV, SSPs can be adapted to provide or link to rapid initiation24,25 and maintenance of effective ART.25

When selecting ART regimens for individuals who use substances, clinicians should consider potential barriers to adherence (see Adherence to the Continuum of Care), comorbidities that could impact care (e.g., advanced liver disease from alcohol or HCV), potential drug–drug interactions, and possible adverse events that are associated with the medications. Providers and people with HIV should discuss adherence during multiple, nonjudgmental evaluations. In general, the use of simplified ART regimens should be considered to aid adherence. Regimens for people with SUDs should be easy to take, such as once-daily formulations, ideally as a single-tablet regimen,26 and should have a high barrier to resistance and a low risk of hepatotoxicity (AIII). Adherence counseling should highlight the benefits of ART use, irrespective of concurrent substance use. While a reduction in substance use may improve adherence to ART,27,28 ongoing use is not a contraindication to ART.

Long-Acting Antiretroviral Therapy

Clinicians who seek to initiate LA CAB/RPV on patients with viremia or with detectable viral load challenges should council the patient on potential risks with this approach. 

The development of long-acting (LA) injectable ART provides additional options for treatment. The combination of injectable cabotegravir (CAB) and rilpivirine (RPV) is an optimization option for people with HIV who demonstrate retention in HIV care and who are virologically suppressed on oral therapy (see Optimizing Antiretroviral Therapy in the Setting of Virologic Suppression). Current

U.S. Food and Drug Administration (FDA) approval for LA CAB/RPV is limited to individuals with expected good adherence and an ability to achieve virologic suppression on oral therapy prior to starting LA ART. Limited data from a small, ongoing observational study found that LA CAB/RPV leads to high levels of viral suppression in people with HIV who have struggled with adherence to oral ART and those who are viremic at treatment initiation, including people who use stimulants.29 Of note, the clinic in this study provided a significant amount of social support to ensure adherence to the LA CAB/RPV regimen (see Virologic Failure for additional details). It is not known if similar responses can be seen in clinics without the resources to provide a similar level of adherence support. Missing LA CAB/RPV doses or a delay in receiving scheduled injections may result in emergence of HIV drug resistance.29

The following factors should be considered when contemplating the use of LA CAB/RPV in people with HIV and SUDs:

  • As with all treatment conversations, providers should discuss adherence with their patients during multiple, nonjudgmental evaluations.
  • Providers and people with HIV should consider the impact of using LA CAB/RPV in the context of current or past substance use behaviors. Although some people may welcome or even prefer LA CAB/RPV,30 one qualitative study highlighted that using a needle for administering LA CAB/RPV could be a trigger for people with a history of injecting illicit substances.31
  • Studies utilizing LA CAB/RPV have included individuals with good adherence before starting the LA ART, but this should not exclude people with SUDs who are struggling with adherence from being considered for LA CAB/RPV. Rather, the clinical team should consider what additional support may be needed to help people with SUDs be successful with LA CAB/RPV and whether using LA ART without established viral suppression is warranted based on preliminary data (see Virologic Failure and Adherence to the Continuum of Care for additional details). Case management, patient navigators, and/or peer navigators should be considered to help people with HIV return for follow-up injections.
  • Given the often unpredictable lifestyles of people with SUDs, clinical care teams should be flexible in scheduling injections or accommodating walk-ins for injections. However, it should be stressed, however, that the doses should be given within the mandatory 7 days before or after the scheduled LA CAB/RPV injection date.
  • As for all people with HIV, hepatitis B virus (HBV) status should be evaluated before the initiation of LA CAB/RPV (see HBV/HIV Coinfection and Optimizing Antiretroviral Therapy in the Setting of Virologic Suppression for additional details). If not already immune or infected, HBV vaccination should be initiated while considering LA CAB/RPV, including in those with isolated hepatitis B core antibody (HBcAb).
  • LA CAB/RPV is not recommended for people with HBV/HIV coinfection unless HBV-active drugs (i.e., tenofovir, entecavir) are included in the regimen.
  • As depressive disorders have been associated with LA CAB/RPV in all populations, people with SUD also should be screened for depressive disorders and treated for depression if indicated.32 If depressive disorders worsen while on LA CAB/RPV, reevaluation should occur to determine whether continued therapy with this regimen is advisable.

Importantly, despite emerging observational data, multiple knowledge gaps exist regarding the use of LA ARVs among people with HIV and SUDs. The results from the ongoing Long-Acting Therapy to Improve Treatment Success in Daily LifE (LATITUDE) Study (NCT 03635788) will provide clinical trial results to help inform the use of LA CAB/RPV among people with HIV and SUDs who have struggled with ART adherence.33 Additional research is also needed to determine optimal methods for supporting ART adherence (including to LA ARVs) among people with HIV and SUDs. These research studies will need to take into consideration the combination of various interventions (e.g., peer support, case management, pharmacotherapy for SUDs, housing) and the appropriate individual interventions needed to support overall ART adherence.

Commonly Used Substances and Their Impact on HIV and Antiretroviral Therapy

Health care providers should have a basic understanding of evidence-based pharmacologic and behavioral (e.g., cognitive behavioral therapy, motivational interviewing, motivational enhancement therapy, contingency management) treatments for different substances, including alcohol, benzodiazepines, cannabinoids, club drugs, opioids, stimulants (cocaine and methamphetamines), and tobacco. The sections below discuss the impact of these substances on people with HIV and how these substances affect ART use.

Alcohol

The 2022 HIV Futures 10 study revealed that 82.3% of participants consumed alcohol, slightly exceeding the 79% reported for the general Australian adult population (1). A modest increase in abstinence from alcohol was observed, with 17.7% of participants reporting no alcohol consumption, compared to 14.6% in HIV Futures 9 (2018-19). Among those who drank, 57.1% consumed no more than two standard drinks per day, reflecting predominantly moderate drinking habits. 

Regarding higher-risk single-instance consumption, 51.7% of drinkers reported never consuming more than six drinks in one sitting, while 21.4% did so less than monthly. However, 11.9% engaged in this behaviour at least monthly, including 4.7% who drank six or more drinks daily, highlighting a subset of individuals at potential risk for alcohol-related harm. 

  • Norman, T., Power, J., Rule, J., Chen, J., & Bourne., A. (2022). HIV Futures 10: Quality of life among people living with HIV in Australia (monograph series number 134). Australian Research Centre in Sex, Health and Society, La Trobe University. doi: 10.26181/21397641

 

Epidemiology

Alcohol consumption is common among people with HIV. Recent estimates indicate that >50% of people with HIV in the United States consume any amount of alcohol (range, 54% to 67%).34,35 Among a sample of people with HIV across seven university-based HIV clinics in the United States, 27% of people screened positive for unhealthy alcohol use as determined by the AUDIT-C.35 Unhealthy alcohol use includes a spectrum of consumption, including at-risk or hazardous use, heavy episodic use (binge drinking), and alcohol use disorder (AUD).36

Risk-Taking Behaviors, the HIV Care Continuum, and Comorbidities

Unhealthy alcohol use has been linked to HIV acquisition because it can increase the frequency of behaviors that put a person at risk for sexual transmission of HIV.37-39 In a meta-analysis of 27 studies, any alcohol use, unhealthy alcohol use, and alcohol use in sexual contexts all were associated with condomless sex among people with HIV.38

In addition, unhealthy alcohol use has been associated with interruptions in all steps of the HIV care continuum, including lower adherence to ART.40,41 Studies have demonstrated both temporal and dose-related relationships between alcohol use and adherence, where ART is more likely to be missed on a given drinking day and the day after drinking, with a stronger association on heavy (binge) drinking days.42-44 The negative impact of unhealthy alcohol use on ART adherence is likely multifactorial and driven by the effects of intoxication, ARV regimen complexity, and patient perceptions of adverse interactions between alcohol and ARV drugs.45-47 Studies also have demonstrated an association between unhealthy alcohol use and the loss of durable viral suppression,48-50 greater time spent with a viral load >1,500 copies/mL after ART initiation,51 increased risk of viral rebound, lower retention in care,52,53 and increased mortality.54-56 Unhealthy alcohol use alone (hazardous or AUD) and in combination with other common comorbidities, including viral hepatitis coinfection, can hasten liver fibrosis progression in people with HIV.57,58 Finally, in general medical populations, unhealthy alcohol use complicates the management of diabetes mellitus, hypertension, mental health disorders, other substance use, and other chronic diseases, and it increases the risk for pneumonia, osteoporosis, a number of cancers (e.g., liver, head and neck, and breast cancers), and tuberculosis.

Management of Unhealthy Alcohol Use

Australian clinicians can refer to the Guidelines for the Treatment of Alcohol Problems. 

Ongoing alcohol use is not a contraindication for a person to receive ART. However, treatment for unhealthy alcohol use may improve HIV treatment outcomes. Behavioral treatments for unhealthy alcohol use among people with HIV demonstrate a small but significant reduction in alcohol use59,60 (see additional resources for alcohol management from the National Institute on Alcohol Abuse and Alcoholism and the Substance Abuse and Mental Health Services Administration [SAMHSA]). Pharmacotherapy also can reduce alcohol use among people with HIV. The FDA has approved three pharmacotherapies for AUD: naltrexone, disulfiram, and acamprosate (see Table 15 below).

Clinical trials have demonstrated the efficacy of naltrexone in reducing the number of heavy drinking days among those with HIV and among the general population. Naltrexone appears to be safe to use in people with HIV,61,62 and it is not associated with significant drug–drug interactions or irreversible hepatotoxicity. However, it is not recommended for individuals with decompensated liver disease and should be used with caution in individuals with elevated transaminase levels. Use of naltrexone in people with HIV and AUD can improve HIV treatment outcomes.63 In a randomized placebo- controlled trial of 100 prisoners with HIV who met the criteria for AUD, individuals who were provided depot naltrexone upon release from prison were more likely to achieve viral suppression at 6 months than the placebo group (56.7% vs. 30.3%).62

Data on the use of disulfiram and acamprosate among people with HIV are lacking. Notably, integrating treatment for AUD with treatment for HIV has been shown to increase the number of people who receive alcohol treatment medication, counseling, and formal outpatient alcohol treatment services. Integrating these treatments also may improve the likelihood that a person with HIV will achieve viral suppression on ART. A randomized controlled trial of 128 individuals with HIV and AUD compared an integrated stepped-care model of alcohol treatment in Veterans Administration HIV clinics to treatment as usual. At the end of treatment (24 weeks), integrated stepped-care resulted in more participants receiving pharmacotherapy for AUD and participating in counseling. Although differences in alcohol use and viral suppression were not seen at 24 weeks, at 52 weeks, integrated stepped-care was associated significantly with an increased number of alcohol- abstinent days, a decrease in the number of drinks per drinking day, and a decreased number of heavy drinking episodes. In addition, the participants in the stepped-care group had increased odds of achieving viral suppression (odds ratio [OR] 5.58; 95% CI, 1.11–27.99).64

Liver cirrhosis—whether related to chronic heavy alcohol use, viral hepatitis, or metabolic dysfunction–associated steatotic liver disease—can result in altered metabolism of ARV drugs. For those who have hepatic impairment due to alcohol-related liver disease, ART dosing should follow the recommendations in Appendix B, Table 10, which are based on Child-Pugh classifications.

Benzodiazepines

Epidemiology

While the specific epidemiologic data on the prevalence of benzodiazepine use among people with HIV are limited, benzodiazepine misuse is a growing public health concern due to its impact on both morbidity and mortality.65 Benzodiazepines cause anterograde amnesia, defined as difficulty recalling events after taking the medication. Individuals do not develop tolerance to this neurocognitive effect, and long-term use of benzodiazepines may result in impairment of neurocognitive functioning.66

Risk-Taking Behaviors and the HIV Care Continuum

People who inject drugs and who also use benzodiazepines engage in riskier behaviors than people who inject drugs but do not use benzodiazepines; these behaviors may include paying for sex, sharing injection equipment with more people, and performing more frequent injections.67 A cohort of 2,802 people who injected drugs was followed from 1996 to 2013. During that time, benzodiazepines were the substances with the greatest association with mortality.68 In a study of opioid and benzodiazepine use and all-cause mortality among 64,602 veterans (16,989 with HIV and 47,613 without) from the Veterans Aging Cohort Study (VACS) cohort (October 2008 to September 2009), long-term benzodiazepine receipt was associated with increased mortality regardless of long- term opioid receipt.69 The long-term neurocognitive impact of benzodiazepines on ART adherence among people with HIV is unclear, but prescribing a memory-impairing medication to people with HIV who are prone to neurocognitive impairments from other causes may increase the risk of poor ART adherence.70 Benzodiazepines also are used illicitly to counteract the negative side effects of stimulants, such as cocaine and methamphetamine.71

Management of Benzodiazepine Use

Repeated use of benzodiazepines can result in physiologic dependence and life-threatening withdrawal in some people. When feasible, individuals who chronically use benzodiazepines should be slowly tapered off the benzodiazepines under the supervision of an experienced clinician.

Different benzodiazepines have different potencies (e.g., alprazolam is more potent than diazepam) and, therefore, require different tapers in terms of length and graduated decrease in dosage.

Benzodiazepine and Antiretroviral Drug Interactions

Several pharmacological interactions between benzodiazepines and ARV drugs have also been described. For example, some benzodiazepines are cytochrome P450 (CYP) 3A4 substrates; thus, when these benzodiazepines are used with a ritonavir (RTV)-boosted or cobicistat (COBI)-boosted ARV drug, their half-lives and concentrations can increase significantly, leading to enhanced and prolonged sedating effects. See Drug–Drug Interactions for available data on benzodiazepine-related interactions.72

Cannabis and Cannabinoids

Medical Cannabis is available in Australia. Medical Cannabis has been used by PLHIV for its medicinal benefits since the start of the epidemic. Medicinal marijuana is an effective treatment for pain, nausea, low appetite, and insomnia, and can help with depression, anxiety, and social phobia. PLHIV also use marijuana for recreational purposes and to enhance sexual experiences, as do about a third of the general population. Recent research suggests that medicinal marijuana may also have potent anti-inflammatory properties for people with HIV.

References:

  1. Health Direct. Medical cannabis. Access at: https://www.healthdirect.gov.au/medicinal-cannabis
  2. NAPWHA. The anti-inflammatory benefits of medicinal marijuana. Published 06 Decemnber 2024. Access at: https://napwha.org.au/positive/the-anti-inflammatory-benefits-of-medicinal-marijuana/
Epidemiology

Both medical and recreational cannabis (marijuana) use are prevalent among people with HIV.73 Cannabis belongs to a class of compounds that activate cannabinoid receptors. This class, known as cannabinoids, also includes synthetic compounds, such as K2. In recent years, cannabinoids have become more popular. In 2009, two cannabinoids were reported to the National Forensic Laboratory Information System. By 2015, 84 compounds had been reported.74 These compounds most commonly cause tachycardia, agitation, and nausea, but they have a wide range of psychiatric effects, including psychosis and paranoia.75

Risk-Taking Behaviors and the HIV Care Continuum

Cannabis has not been shown to negatively impact adherence to ART or a person’s ability to achieve viral suppression. In one study, among 874 people with HIV, daily cannabis use did not predict lower

odds of ART use or achieving an undetectable HIV RNA level, except when combined with binge drinking.76 Data from the Multicenter AIDS Cohort Study have supported the idea that marijuana use does not predict problems with adherence to ART or achieving viral suppression.77 In some cases, however, cannabinoids have been listed as the cause of death in overdoses. While data are lacking among adults with HIV, the nationally representative 2015 Youth Risk Behavior Survey (which includes data from 15,624 adolescent students in Grades 9 to 12) found that students who had ever used synthetic cannabinoids engaged in riskier activities, including sex, than students who only used marijuana.78 While the available data suggest that the use of marijuana is not associated with decreased adherence to ART,79 data are lacking on the impact of synthetic cannabinoids on ART adherence. Finally, with the growing use of synthetic cannabinoids, there is concern that fentanyl could be added to these products, which may increase the risk of opioid overdose.

Management of Cannabis and Cannabinoid Use

Patients can be referred to cannabis management tools for support in minimise or ceasing use. 

Because of the aforementioned concerns regarding cannabinoid use, particularly the variety of compounds and neuropsychiatric effects, people with HIV should be discouraged from using cannabinoids until more data are available. No pharmacological treatment exists for cannabinoid use disorder; however, behavioral health treatment may be effective for some people.80-82

Club Drugs

Epidemiology

Club drugs are recreational substances that have euphoric or hallucinogenic effects or that are used to enhance sexual experiences.5 The use of multiple club drugs or other drugs simultaneously is common. Although these substances are used by many different people with HIV, the majority of data come from MSM with HIV. The use of club drugs in this population has been shown to negatively impact HIV treatment.83 Club drugs include MDMA, GHB, ketamine, benzodiazepines (see the benzodiazepine section above), and other drugs that are used to enhance sexual experiences (e.g., mephedrone, inhaled nitrates [poppers], and phosphodiesterase-5 inhibitors [PDE5] for erectile dysfunction). Survey data from users of club drugs also have revealed that efavirenz is purchased by people without HIV for its intoxicating effects.84

Risk-Taking Behaviors and the HIV Care Continuum

Club drugs have disinhibitory effects. Using club drugs increases the likelihood that a person will engage in high-risk sexual practices, which can increase the risk of HIV transmission. In addition, these disinhibitory effects can lead to poor ART adherence.72,83,85

Management of Club Drug Use

Treatment strategies for club drug use have not been well studied in controlled trials.86 No recommended pharmacotherapies exist at this time, and the most common strategy for treating people who use club drugs is to employ the behavioral interventions that are used for other drug use disorders.

Club Drug and Antiretroviral Drug Interactions

MDMA, GHB, ketamine, and methamphetamine all have the potential to interact with ARV drugs because they are metabolized, at least in part, by the CYP450 system.72,85 Overdoses secondary to interactions between club drugs (i.e., MDMA or GHB) and protease inhibitor–based ART have been reported.72,87 For instance, using PDE5 or ketamine concurrently with potent CYP3A4 inhibitors, such as RTV or COBI, can potentiate the effects of these substances.83

Cocaine

See the discussion in the section on stimulants below.

Opioids

Epidemiology

Australian clinicians can refer to RACGP Evidence-based guidance for opioids in pain management.

Naloxone is available in all states and territories with a prescription. Under the national Take Home Naloxone program, naloxone will be available free of charge and without a prescription across all participating pharmacies in Australia. Naloxone is also available over the counter from non-participating Take Home Naloxone program pharmacies for a fee.   

A list of pharmacies and other sites participating in the national Take Home Naloxone program can be found on the Pharmacy Programs Administrator Website. 

Opioids remain a significant concern for people with HIV, both for the acquisition of HIV and as major contributors to morbidity and mortality. Overdose involving opioids is the leading cause of accidental death in the United States.88 The appropriate use of opioids while caring for people with HIV and chronic pain is an important component of combating the opioid epidemic, but this subject is beyond the scope of this section. Please refer to additional resources, such as those from the Centers for Disease Control and Prevention (CDC) and the Infectious Diseases Society of America.89 To combat the opioid overdose epidemic, health care providers should prescribe naloxone for opioid overdose prevention for all people who are using opioids beyond the short-term treatment of acute pain.3

Risk-Taking Behaviors and the HIV Care Continuum

Many people who use opioids start by using opioid tablets (e.g., oxycodone) that are ingested orally or crushed and sniffed. Once tolerance develops, some individuals move from sniffing the crushed tablets to injecting heroin purchased on the streets. This transition from sniffing to injecting dramatically increases the risk of HIV and HCV infection.

Low-cost heroin is often a mix of heroin and higher-potency synthetic opioids, such as fentanyl.88 Methamphetamines and cocaine also have been combined with fentanyl but at a lower rate than heroin.90,91 With the growing use of synthetic cannabinoids, there is concern that fentanyl could be added to these as well. In all instances where fentanyl or other high-potency opioids are added to other drugs, the risk of overdose increases.

Although treatment for an opioid use disorder (OUD) can improve HIV treatment outcomes, it is not a prerequisite for treating HIV, as some people with HIV are able to adhere successfully to ART despite ongoing opioid use. Although ART coverage among people with HIV who injected drugs increased from 58% to 71% between 2009 and 2015, additional work is needed to improve ART coverage in this population.92 Data from the Johns Hopkins HIV Clinical Cohort (2001–2012) demonstrated that in the early years of the cohort, people who injected drugs were less likely to be retained in care; however, this gap in retention had closed by 2012, and people who injected drugs and noninjectors had similar probabilities of being on ART and having a suppressed viral load during the later years of the cohort.93

Management of Opioid Use

Oral naltrexone is briefly included in both National1 and State2 Opioid Treatment Guidelines. However, in current Australian clinical practice it is rarely used for relapse prevention. It also requires the patient receiving treatment to be abstinent from opioids which can be challenging. Naltrexone is currently available on the PBS for the treatment of Alcohol use Disorder. Sustained release and implant preparations of naltrexone are currently not registered in Australia and remain experimental3. 

  1. Gowing L, Ali R, Dunlop A, Farrell M, Lintzeris N. National Guidelines for Medication-Assisted Treatment of Opioid Dependence. Commonwealth of Australia; 2014. Access at: https://www.health.gov.au/sites/default/files/national-guidelines-for-medication-assisted-treatment-of-opioid-dependence.pdf
  2. Centre for Alcohol and Other Drugs. NSW Clinical Guidelines: Treatment of Opioid Dependence 2018. NSW Health; 2018. Access at: https://www.health.nsw.gov.au/aod/Pages/nsw-clinical-guidelines-opioid.aspx
  3. Australasian Chapter of Addiction Medicine, The Royal Australasian College of Physicians. The Use of Sustained Release Formulations of Naltrexone in Opioid Dependence Position Statement. The Royal Australian College of Physicians; 2013. Access at: https://www.racp.edu.au/docs/default-source/advocacy-library/the-use-of-sustained-release-formulations-of-naltrexone-in-opioid.pdf

Australian state and territory governments have different legislative requirements to prescribe Opioid Agonist Treatment in Australia. Most require accreditation and training to prescribe. You can find the requirements by jurisdiction below: 

FDA has approved three medications for the treatment of OUD that can help decrease or eliminate opioid use, reduce the risks of morbidity and mortality that are associated with opioid use, and improve HIV treatment success. These medications—collectively termed medications for opioid use disorder (MOUD)—include buprenorphine, methadone, and naltrexone (see Table 15 below).

Buprenorphine and methadone are opioid agonists (the use of these drugs is termed opioid agonist therapy), whereas naltrexone is an opioid antagonist or “blocker.” Both buprenorphine and naltrexone can be prescribed in the setting of routine HIV clinical care.94 Prescribing buprenorphine requires specific training but no longer requires an X waiver (see the SAMHSA website for more information). Methadone must be prescribed through a licensed opioid treatment program (OTP). An OTP directory also can be found on the SAMHSA website.95

Use of buprenorphine or methadone can lead to reductions in risky behaviors associated with HIV transmission, psychosocial and medical morbidity related to OUD, and criminal behaviors. People who are receiving treatment for opioid use are already engaging with the health care system; therefore, they are more likely to initiate treatment for HIV and to be adherent to their ARV regimens. Both buprenorphine and methadone are cost-effective interventions at the societal level.96 Methadone has better retention in SUD treatment than either buprenorphine or naltrexone, and it should be considered for individuals who do not achieve successful outcomes with buprenorphine or naltrexone.97 Buprenorphine has a lower risk of overdose than methadone. In addition, it can be prescribed in primary care offices. People who are taking buprenorphine have significantly better retention in treatment than those who are taking daily oral naltrexone.98 Although several randomized, controlled clinical trials have demonstrated efficacy for naltrexone when treating OUD, subsequent study results have been disappointing; one meta-analysis revealed that oral naltrexone was equivalent to placebo.99 To address the adherence challenges with naltrexone, a depot formulation was created for monthly administration. This preparation has the potential to improve adherence; however, studies that compare opioid agonists (i.e., buprenorphine and methadone) to depot naltrexone as treatments for OUD have not been conducted. In a randomized, placebo- controlled trial in people with both HIV and OUD, participants who received at least three doses of depot naltrexone before discharge from prison achieved longer periods of continuous abstinence after transitioning from prison to the community than those who received either placebo or two or less doses of depot naltrexone.62 On the basis of these data, methadone or buprenorphine generally are used as first-line agents for the treatment of OUD. Depot naltrexone is used as an alternative treatment for people who have been released recently from correctional facilities when other options are not available.

Important pharmacokinetic interactions between these medications (particularly methadone) and certain ARV drugs are listed in Drug–Drug Interactions.

Although medications remain the backbone of treatment for OUD, there is growing recognition of the critical importance of the social drivers of health and how they impact the willingness of people to engage in treatment with the medications discussed above. A recent randomized study of 114 people with HIV compared the effectiveness of different medications for the treatment of OUD to achieve viral suppression, finding that stable housing, high school–level education or greater, and income stability were associated with a greater reduction in opioid use.95

Xylazine and Opioids

Xylazine—a non-opioid analgesic utilized in veterinary medicine that is a commonly used adulterant in opioids and other substances—has become an emerging drug threat associated with the opioid epidemic.100 The CDC has documented a 276% increase in the monthly percentage of illicitly manufactured fentanyl (IMF)–involved deaths where xylazine was detected.101 Between 2020 and 2021, the Drug Enforcement Agency reported that xylazine-associated deaths increased by over 100% in all regions of the United States and over 1,000% in the South.102 This growing body of data led the ONDCP to formally designate fentanyl adulterated with xylazine as an emerging drug threat.103

Xylazine is a substrate of CYP3A4 and, as such, when used with an ARV regimen including a CYP3A4 inhibitor, such as RTV or COBI, may lead to elevated levels and prolonged half-lives of xylazine.104 For people with HIV who continuously use opioids in areas with high rates of xylazine- adulterated IMF, providers should weigh the risks and benefits of using ARV drugs with CYP3A4 inhibitors, given potential interactions and the increase in xylazine-associated adverse effects.

Opioid adulterants, such as xylazine, increase the risk of overdose. Although naloxone only reverses opioid effects, that alone may be sufficient to reverse the overdose. This highlights the need for universal access to naloxone and the active prescribing of naloxone by health care providers. The CDC maintains information about xylazine and how to reduce its harm on its website.105

Stimulants

Epidemiology

Cocaine and methamphetamine are powerful stimulants that have been associated with multiple detrimental effects among people with HIV, including accelerated disease progression, poor ART adherence, and lack of viral suppression. Cocaine powder is snorted or injected, whereas the free- base form (crack) is smoked. Methamphetamines can be taken orally or rectally, injected, or smoked. Cocaine and methamphetamine are commonly used with other substances, including alcohol, and can be combined with fentanyl, which increases the risk of overdose.90,91 Individuals who use stimulants experience a sense of euphoria and may have heightened sexual desire and arousal. This can lead to disinhibited sexual behaviors, increasing the risk of HIV transmission.

The prevalence of stimulant use among people with HIV has been estimated to be 5% to 15% across multiple studies.106-108 Methamphetamine use is more common among MSM,109 and increased rates of cocaine use have been observed among ethnic and racial minorities and persons with a history of incarceration.110

Risk-Taking Behaviors and the HIV Care Continuum

People with HIV who use stimulants may experience multiple negative health consequences, including rapid development of dependence and adverse effects on multiple organ systems, particularly the central nervous and cardiovascular systems. Stimulant use is associated with neurocognitive impairment,111 delirium, seizures, hemorrhagic strokes, and mental health disturbances, including anxiety, psychosis, and paranoia.

Stimulant use may independently lead to HIV disease progression even among people who are taking ART and have achieved viral suppression. Research to identify the cellular mechanisms responsible for this is ongoing, but increased viral replication, direct effects on the immune system that lead to declines in CD4 T lymphocyte cell count, enhanced immune activation, and disruption of the blood- brain barrier, facilitating HIV entry into the brain, have been implicated.112-116 Stimulant use has been associated with poor HIV continuum of care outcomes, including suboptimal rates of ART adherence,117 retention in care, and viral suppression.118-120 Lack of viral suppression, combined with the increased likelihood of risky sexual behaviors that occur under the influence of stimulants, poses a threat to the HIV treatment-as-prevention paradigm.121

Management of Stimulant Use

Clinicians should discuss peer-based services with PLHIV who use stimulants and want to minimise or cease. These may not be appropriate for PLHIV with complex or regular substance use but should be discussed with the patient.

Data from the HIV Futures 9 study (2018–2019)1 revealed that current IDU was associated with higher rates of STI testing and diagnoses, increased antiretroviral therapy non-adherence due to drug use, and higher social quality of life compared to past or no IDU. 

Both past and current IDU groups reported greater mental health challenges and concerns about drug use. 

Past IDU was further linked to more physical comorbidities, lower satisfaction with clinical care, and greater difficulty affording health care.

These findings highlight unique health challenges faced by PLHIV with a history of IDU, particularly in navigating health services. Peer-based interventions aimed at enhancing access to affirming and supportive care remain a priority to address these disparities. 

  1. Power, J., Amir, S., Brown, G., & Rule., J. (2019). HIV Futures 9: Quality of life among people living with HIV in Australia (monograph series number 134). Australian Research Centre in Sex, Health and Society, La Trobe University.

Mirtazapine is an antidepressant medicine. In Australia, Mirtazapine is mainly used to treat depression and/or to prevent it from occurring again.

Several pharmacologic and behavioral interventions for stimulant dependence have been investigated, and some trials have included people with HIV. The results of pharmacologic interventions generally have been disappointing. No FDA-approved pharmacotherapy for cocaine use disorder currently exists, despite research on multiple drug classes, including antidepressants, antipsychotics, anticonvulsants, and dopaminergic medications (e.g., disulfiram).122,123 Among people with HIV who use crack and opioids, medication-assisted treatment for OUD may improve ART adherence and viral suppression.124,125 Limited evidence indicates that some pharmacologic interventions (e.g., methylphenidate, modafinil, bupropion, naltrexone)126 can reduce methamphetamine use or cravings. A double-blind, placebo-controlled trial of extended-release injectable naltrexone plus oral extended-release bupropion in adults with moderate or severe methamphetamine use disorder demonstrated a higher response of methamphetamine-free urine samples compared to placebo; however, the overall response rate was low.127 A double-blind randomized clinical trial on people with methamphetamine use disorder evaluated daily mirtazapine versus placebo in cisgender men and transgender women who have sex with men. Over 36 weeks of follow-up, daily mirtazapine use led to reduced methamphetamine-positive urine drug tests and concurrent reductions in sexual risk behaviors.128 No specific recommended pharmacotherapy exists to treat stimulant use disorder in people with HIV.

Several behavioral interventions have shown promise in randomized trials. People with HIV who received motivational interviewing sessions, cognitive behavioral therapy, or a combination of the two experienced decreased stimulant use, improved ART adherence, and were less likely to engage in sexual transmission risk behaviors.129 Contingency management has been shown to be effective in decreasing stimulant use among people with HIV, but the sustained effects on the reduction of stimulant use and improvements in ART adherence are less clear.107,130,131 The addition of a positive affect intervention to contingency management, compared with an attention control condition, decreased HIV viral load among sexual minority men with HIV.132 Technology-based interventions, such as text messaging, may have a role in supporting ART adherence and decreasing methamphetamine use among people with HIV, but further research is needed.133 People with HIV who use stimulants benefit most from multidimensional interventions that target substance use, ART adherence, and risky sexual behaviors.129

Despite the challenges discussed above, people with HIV who use stimulants can achieve viral suppression with ART120 and should be prescribed ART even if stimulant use is ongoing.

Tobacco

The 2022 HIV Futures 10 study revealed that 59% of participants had smoked tobacco at some point in their lives, with 20.8% currently smoking, a decline from 28.1% reported in HIV Futures 9 (2018–19)1. Among current smokers, 74.7% were daily smokers, representing 15.5% of the total sample. Additionally, 38.2% of participants were former smokers who no longer smoked. While the proportion of current smokers has decreased over time, the percentage of daily smokers among them has increased. Compared to the general Australian population, daily smoking rates remain higher among PLHIV. However, consistent with national trends, the overall number of daily smokers within this cohort has declined over time (ABS, 2021).

  1. Norman, T., Power, J., Rule, J., Chen, J., & Bourne., A. (2022). HIV Futures 10: Quality of life among people living with HIV in Australia (monograph series number 134). Australian Research Centre in Sex, Health and Society, La Trobe University. doi: 10.26181/21397641

Epidemiology

The prevalence of tobacco smoking among people with HIV in the United States is approximately twice that of the general population (33.6% vs. 16.8%).134 Prevalence is even higher among specific subgroups, including those who use alcohol and/or other drugs, those who have concurrent mental health disorders, and those of a lower socioeconomic status. Although smoking rates are declining overall in the United States, people with HIV are less likely to quit smoking than people in the general population.134

Associated Risks of Tobacco Use and HIV Infection

With respect to substance use and HIV, tobacco smoking is the biggest threat to health-related gains achieved through ART. Among individuals with viral suppression on ART, more years of life may be lost from continued smoking than from HIV infection itself.135,136 Tobacco smoking among people with HIV is associated with an increased risk of numerous health conditions, including lung cancer and other smoking-related cancers, cardiovascular disease, and pulmonary disease. In a sample of 17,995 people with HIV on ART in Europe and North America, individuals who smoked had nearly twice the mortality of those who did not (mortality rate ratio 1.94; 95% CI, 1.56–2.41) with significant mortality attributed to cardiovascular disease and non-AIDS-related malignancy.135 Importantly, tobacco cessation reduces the incidence of cardiovascular disease and smoking-related cancers (although definitive data on lung cancer are not available) and improves quality of life.137-139

Managing Tobacco Use

Australian clinicians should refer to RACGP Supporting smoking cessation: A guide for health professionals. 

To maximize the survival benefits of ART, clinicians should consider using evidence-based behavioral and pharmacological140-142 cessation strategies when treating people with HIV who smoke tobacco (see the tools and recommendations provided by the CDC and the U.S. Preventive Services Task Force and recent review).143 These include (but are not limited to) advising the individual to quit smoking, using the five A’s, employing motivational interviewing, and referring them to a tobacco quitline. Pharmacotherapies for smoking cessation (nicotine replacement therapy, bupropion, and varenicline) have few clinically significant interactions with ARV drugs and can lead to enormous reductions in morbidity and mortality if the person is able to stop smoking. Nicotine replacement is efficacious144; however, bupropion doubles rates of smoking cessation compared with nicotine replacement therapy.145 Varenicline is a partial nicotine receptor agonist. In comparative studies, varenicline was more effective than bupropion in smoking cessation.145,146 Clinical trials among people with HIV have found varenicline to be both effective and safe.140,142 In a randomized controlled trial among 179 individuals with HIV who were assigned to receive 12 weeks of behavioral counseling and either varenicline or placebo, varenicline use led to an increase in the percentage of participants who achieved a 7-day abstinence period at 12 weeks (28.1% vs. 12.1%, OR 4.5; 95% CI, 1.83–11.2) and produced higher continuous abstinence between Weeks 9 and 12 (23.6% vs. 10%, OR 4.65; 95% CI, 1.71–12.67) compared to placebo.142 Although significant between-group differences were not observed after 24 weeks, these data support the use of varenicline among people with HIV. Varenicline should be used in combination with relapse prevention strategies and other measures for long-term tobacco cessation.

Table 15. Medications for Treatment of Substance Use Disorders

Opioid Agonist treatment with buprenorphine has expanded in Australia to include the long-acting depot buprenorphine formulation. Dosage is given weekly or monthly. Refer to NSW Clinical Guidelines for the use of depot buprenorphine in th treatment of opioid dependence.  

Depot formulation is NOT TGA approved in Australia. 

Oral naltrexone is briefly included in both National1 and State2 Opioid Treatment Guidelines. However, in current Australian clinical practice, it is rarely used for relapse prevention. It also requires the patient receiving treatment to be abstinent from opioids which can be challenging. Naltrexone is currently available on the PBS for the treatment of Alcohol use Disorder. Sustained release and implant preparations of naltrexone are currently not registered in Australia and remain experimental3. 

  1. Gowing L, Ali R, Dunlop A, Farrell M, Lintzeris N. National Guidelines for Medication-Assisted Treatment of Opioid Dependence. Commonwealth of Australia; 2014. Access at: https://www.health.gov.au/sites/default/files/national-guidelines-for-medication-assisted-treatment-of-opioid-dependence.pdf 
  2. Centre for Alcohol and Other Drugs. NSW Clinical Guidelines: Treatment of Opioid Dependence 2018. NSW Health; 2018. Access at: https://www.health.nsw.gov.au/aod/Pages/nsw-clinical-guidelines-opioid.aspx
  3. Australasian Chapter of Addiction Medicine, The Royal Australasian College of Physicians. The Use of Sustained Release Formulations of Naltrexone in Opioid Dependence Position Statement. The Royal Australian College of Physicians; 2013. Access at: https://www.racp.edu.au/docs/default-source/advocacy-library/the-use-of-sustained-release-formulations-of-naltrexone-in-opioid.pdf

Acamprosate and Bupropion are subsidised by the PBS in Australia for Nicotine Dependence.

In Australia, disulfiram is formulated in tablets of 200mg, with the recommended dose being 200- 400mg (1-2 tablets/day orally). Some patients can continue to drink on 200-400 mg without significant aversive effects, and the dose should be increased. The maintenance dosage should generally not exceed 600 mg a day. 

Disulfiram not subsidised by the PBS in Australia.

Naltrexone is subsidised by the PBS in Australia for Alcohol Dependence. 

Opioid Agonists Treatments (OAT) are subsidised by the PBS in Australia from the 01/07/2023.

Table 15. Medications for Treatment of Substance Use Disorders
Medication
Dose and Recommendations
Potential Interaction with ARV Drugs
Comments
Alcohol Use Disorder
Acamprosate666 mg PO three times a day
or
333 mg PO three times a day for people with CrCl 30–50 mL/min		No significant interaction with ARV drugs expected.Contraindicated in people with CrCl <30 mL/min
Disulfiram250 mg PO once dailyUse with caution when prescribing an ARV oral solution that contains ethanol and/or propylene glycol
(e.g., FPV, LPV/r, RTV).
Counsel people regarding disulfiram reaction when taken with alcohol; symptoms for the reaction may include flushing, tachycardia, nausea, vomiting, or hypotension.
Naltrexone50–100 mg PO once daily

Depot formulation is a fixed-dose monthly injection.		No significant interaction with ARV drugs expected.Has the greatest efficacy of all FDA-approved medications for AUD.
Opioid Use Disorder
BuprenorphineIndividualize buprenorphine dosing based on the person’s opioid use. The dose range is 4–24 mg sublingually.

Dosing is once daily or twice daily.
Potential interaction with ARV drugs that are CYP inhibitors or inducers. See Drug-Drug Interactions for further recommendations.Buprenorphine has 90% first- pass hepatic metabolism. Verify that the person is using the appropriate technique for sublingual administration before adjusting the dose, because improper administration will result in poor absorption and low drug levels.
MethadoneIndividualize the dose. People who receive higher doses (>100 mg) are more likely to remain in treatment.Potential interaction with ARV drugs that are CYP inhibitors or inducers. See Drug-Drug Interactions for further recommendations.QTc prolongation is a concern at higher doses. Methadone can be prescribed for OUD only by a licensed OTP.
Naltrexone50–100 mg PO once daily

Depot formulation is a fixed-dose monthly injection.		No significant interaction with ARV drugs expected.Longer time of continuous abstinence in those who received depot formulation naltrexone compared with placebo after transition from prison to community.
Nicotine Use Disorder
Nicotine Replacement TherapyThe FDA has approved a wide variety of nicotine replacement products. All formulations are effective.No significant interaction with ARV drugs expected.Work with the person to identify the route of delivery that they will use and find most helpful.
BupropionStart at 150 mg PO daily for 3 days, then increase to either 150 mg twice daily or 300 mg once daily (use only formulations that are approved for once-daily dosing).Concentration may be reduced when used with ARV drugs that are CYP2D6 inducers. See Drug-Drug Interactions for further recommendations.For optimal results, tobacco quit date should occur 1 week after starting therapy.
VareniclineTitrate the dose based on tolerability until the desired effect is achieved. The goal is to reach a dose of 1 mg PO twice daily.
Requires dose adjustment in people with CrCl
<30 mL/min.
No significant interaction with ARV drugs expected.Tobacco quit date ideally should be 1 week after starting therapy.

Key: ARV = antiretroviral; AUD = alcohol use disorder; CrCl = creatinine clearance; CYP = cytochrome P450; FDA = U.S. Food and Drug Administration; FPV = fosamprenavir; LPV/r = lopinavir/ritonavir; OTP = opioid treatment program; OUD = opioid use disorder; PO = orally; QTc = QT corrected for heart rate; RTV = ritonavir

References

  1. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2024.Available at: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose- data.htm?utm_source=substack&utm_medium=email.

  2. National Center for Health Statistics. AIDS and HIV. Centers for Disease Control and Prevention. 2024. Available at: https://www.cdc.gov/nchs/fastats/aids-hiv.htm.

  3. Bowman S, Eiserman J, Beletsky L, Stancliff S, Bruce RD. Reducing the health consequences of opioid addiction in primary care. Am J Med. 2013;126(7):565-571. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23664112.

  4. Shiau S, Arpadi SM, Yin MT, Martins SS. Patterns of drug use and HIV infection among adults in a nationally representative sample. Addict Behav. 2017;68:39-44. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28088742.

  5. National Institute on Drug Abuse. Club drugs. 2024. Available at: https://www.drugabuse.gov/drugs-abuse/club-drugs

  6. Pakianathan M, Whittaker W, Lee MJ, et al. Chemsex and new HIV diagnosis in gay, bisexual and other men who have sex with men attending sexual health clinics. HIV Med. 2018. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29790254.

  7. Kohli M, Hickson F, Free C, Reid D, Weatherburn P. Cross-sectional analysis of chemsex drug use and gonorrhoea diagnosis among men who have sex with men in the UK. Sex Health. 2019. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30760386.

  8. Ivey K, Bernstein KT, Kirkcaldy RD, et al. Chemsex drug use among a national sample of sexually active men who have sex with men, – American Men’s Internet Survey, 2017–2020. Subst Use Misuse. 2023;58(5):728-734. Available at: https://pubmed.ncbi.nlm.nih.gov/36872623.

  9. Guerras JM, Hoyos J, Donat M, et al. Sexualized drug use among men who have sex with men in Madrid and Barcelona: the gateway to new drug use? Front Public Health. 2022;10:997730. Available at: https://pubmed.ncbi.nlm.nih.gov/36457321.

  10. Strong C, Huang P, Li CW, Ku SW, Wu HJ, Bourne A. HIV, chemsex, and the need for harm-reduction interventions to support gay, bisexual, and other men who have sex with men. Lancet HIV. 2022;9(10):e717-e725. Available at: https://pubmed.ncbi.nlm.nih.gov/35926550.

  11. Dasgupta S, Tie Y, Lemons-Lyn A, Broz D, Buchacz K, Shouse RL. HIV-positive persons who inject drugs experience poor health outcomes and unmet needs for care services. AIDS Care. 2021;33(9):1146-1154. Available at: https://pubmed.ncbi.nlm.nih.gov/32985227.
  12. Arum C, Fraser H, Artenie AA, et al. Homelessness, unstable housing, and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta- analysis. Lancet Public Health. 2021;6(5):e309-e323. Available at: https://pubmed.ncbi.nlm.nih.gov/33780656.
  13. Reddon H, Fairbairn N, Grant C, Milloy MJ. Experiencing homelessness and progression through the HIV cascade of care among people who use drugs. AIDS. 2023;37(9):1431-1440. Available at: https://pubmed.ncbi.nlm.nih.gov/37070552.
  14. Towe VL, Wiewel EW, Zhong Y, Linnemayr S, Johnson R, Rojas J. A randomized controlled trial of a rapid re-housing intervention for homeless persons living with HIV/AIDS: impact on housing and HIV medical outcomes. AIDS Behav. 2019;23(9):2315- 2325. Available at: https://pubmed.ncbi.nlm.nih.gov/30879212.
  15. Hall G, Singh T, Lim SW. Supportive housing promotes AIDS-free survival for chronically homeless HIV positive persons with behavioral health conditions. AIDS Behav. 2019;23(3):776-783. Available at: https://pubmed.ncbi.nlm.nih.gov/30684098.
  16. Wiewel EW, Singh TP, Zhong Y, et al. Housing subsidies and housing stability are associated with better HIV medical outcomes among persons who experienced homelessness and live with HIV and mental illness or substance use disorder. AIDS Behav. 2020;24(11):3252-3263. Available at: https://pubmed.ncbi.nlm.nih.gov/32180090.
  17. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155-1160. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20625025.
  18. Flentje A, Barger BT, Capriotti MR, et al. Screening gender minority people for harmful alcohol use. PLOS One. 2020. Available at: https://doi.org/10.1371/journal.pone.0231022.
  19. Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr. 2001;28(1):47-58. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11579277.
  20. Marinetti L, Montgomery MA. The use of GHB to facilitate sexual assault. Forensic Sci Rev. 2010;22(1):41-59. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26242455.
  21. Basu S, Chwastiak LA, Bruce RD. Clinical management of depression and anxiety in HIV- infected adults. AIDS. 2005;19(18):2057-2067. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16284454.

  22. Broz D, Carnes N, Chapin-Bardales J, et al. Syringe services programs’ role in ending the HIV epidemic in the U.S.: why we cannot do it without them. Am J Prev Med. 2021;61(5 Suppl 1):S118-S129. Available at: https://pubmed.ncbi.nlm.nih.gov/34686281.

  23. Suarez E, Jr., Bartholomew TS, Plesons M, et al. Adaptation of the tele-harm reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study. Ann Med. 2023;55(1):733-743. Available at: https://pubmed.ncbi.nlm.nih.gov/36856571.
  24. Peters PJ, Pontones P, Hoover KW, et al. HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015. N Engl J Med. 2016;375(3):229-239. Available at: https://pubmed.ncbi.nlm.nih.gov/27468059.
  25. Tookes HE, Bartholomew TS, Suarez E, et al. Acceptability, feasibility, and pilot results of the tele-harm reduction intervention for rapid initiation of antiretrovirals among people who inject drugs. Drug Alcohol Depend. 2021;229(Pt A):109124. Available at: https://pubmed.ncbi.nlm.nih.gov/34781096.
  26. Griffith DC, Farmer C, Gebo KA, et al. Uptake and virological outcomes of single- versus multi-tablet antiretroviral regimens among treatment-naive youth in the HIV Research Network. HIV Med. 2019;20(2):169-174. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30561888.
  27. Feldman MB, Kepler KL, Irvine MK, Thomas JA. Associations between drug use patterns and viral load suppression among HIV-positive individuals who use support services in New York City. Drug Alcohol Depend. 2019;197:15-21. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30743195.
  28. Nance RM, Trejo MEP, Whitney BM, et al. Impact of abstinence and of reducing illicit drug use without abstinence on human immunodeficiency virus viral load. Clin Infect Dis. 2020;70(5):867-874. Available at: https://pubmed.ncbi.nlm.nih.gov/30994900.
  29. Gandhi M, Hickey M, Imbert E, et al. Demonstration project of long-acting antiretroviral therapy in a diverse population of people with HIV. Ann Intern Med. 2023;176(7):969-974. Available at: https://pubmed.ncbi.nlm.nih.gov/37399555.
  30. Williams J, Sayles HR, Meza JL, et al. Long-acting parenteral nanoformulated antiretroviral therapy: interest and attitudes of HIV-infected patients. Nanomedicine (Lond). 2013;8(11):1807-1813. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23611617.
  31. Philbin MM, Parish C, Bergen S, et al. A qualitative exploration of women’s interest in long- acting injectable antiretroviral therapy across six cities in the women’s interagency HIV study: intersections with current and past injectable medication and substance use. AIDS Patient Care and STDs. 2021;35(1). Available at: https://www.liebertpub.com/doi/10.1089/apc.2020.0164.
  32. Food and Drug Administration. Cabenuva [package insert]. 2023. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/212888s011lbl.pdf.
  33. ClinicalTrials.gov. The LATITUDE Study: Long-Acting Therapy to Improve Treatment SUccess in Daily LifE. 2020. Available at: https://www.clinicaltrials.gov/study/NCT03635788.
  34. Williams EC, Joo YS, Lipira L, Glass JE. Psychosocial stressors and alcohol use, severity, and treatment receipt across human immunodeficiency virus (HIV) status in a nationally representative sample of US residents. Subst Abus. 2017;38(3):269-277. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27925867.
  35. Crane HM, McCaul ME, Chander G, et al. Prevalence and factors associated with hazardous alcohol use among persons living with HIV across the US in the current era of antiretroviral treatment. AIDS Behav. 2017;21(7):1914-1925. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28285434.
  36. Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352(6):596-607. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15703424.
  37. Scott-Sheldon LA, Carey KB, Cunningham K, Johnson BT, Carey MP, Team MR. Alcohol use predicts sexual decision-making: a systematic review and meta-analysis of the experimental literature. AIDS Behav. 2016;20 Suppl 1:S19-39. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26080689.
  38. Shuper PA, Joharchi N, Monti PM, Loutfy M, Rehm J. Acute alcohol consumption directly increases HIV transmission risk: a randomized controlled experiment. J Acquir Immune Defic Syndr. 2017;76(5):493-500. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28930769.
  39. Rehm J, Shield KD, Joharchi N, Shuper PA. Alcohol consumption and the intention to engage in unprotected sex: systematic review and meta-analysis of experimental studies. Addiction. 2012;107(1):51-59. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22151318.
  40. Williams EC, McGinnis KA, Edelman EJ, et al. Level of alcohol use associated with HIV care continuum targets in a national U.S. sample of persons living with HIV receiving healthcare. AIDS Behav. 2019;23(1):140-151. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29995206.
  41. Vagenas P, Azar MM, Copenhaver MM, Springer SA, Molina PE, Altice FL. The impact of alcohol use and related disorders on the HIV continuum of care: a systematic review: alcohol and the HIV continuum of care. Curr HIV/AIDS Rep. 2015;12(4):421-436. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26412084.
  42. Braithwaite RS, McGinnis KA, Conigliaro J, et al. A temporal and dose-response association between alcohol consumption and medication adherence among veterans in care. Alcohol Clin Exp Res. 2005;29(7):1190-1197. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16046874.
  43. Braithwaite RS, Bryant KJ. Influence of alcohol consumption on adherence to and toxicity of antiretroviral therapy and survival. Alcohol Res Health. 2010;33(3):280-287. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23584069.
  44. Parsons JT, Rosof E, Mustanski B. Patient-related factors predicting HIV medication adherence among men and women with alcohol problems. J Health Psychol. 2007;12(2):357-370. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17284499.
  45. Kalichman SC, Grebler T, Amaral CM, et al. Viral suppression and antiretroviral medication adherence among alcohol using HIV-positive adults. Int J Behav Med. 2014;21(5):811-820. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24085706.
  46. Pellowski JA, Kalichman SC, Kalichman MO, Cherry C. Alcohol-antiretroviral therapy interactive toxicity beliefs and daily medication adherence and alcohol use among people living with HIV. AIDS Care. 2016;28(8):963-970. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26964014.
  47. Williams EC, Hahn JA, Saitz R, Bryant K, Lira MC, Samet JH. Alcohol use and human immunodeficiency virus (HIV) infection: current knowledge, implications, and future directions. Alcohol Clin Exp Res. 2016;40(10):2056-2072. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27696523.
  48. Kelso NE, Sheps DS, Cook RL. The association between alcohol use and cardiovascular disease among people living with HIV: a systematic review. Am J Drug Alcohol Abuse. 2015;41(6):479-488. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26286352.
  49. Kahler CW, Liu T, Cioe PA, et al. Direct and indirect effects of heavy alcohol use on clinical outcomes in a longitudinal study of HIV patients on ART. AIDS and Behavior. 2017;21(7):1825-1835. Available at: https://doi.org/10.1007/s10461-016-1474-y.
  50. Cook RL, Zhou Z, Kelso-Chichetto NE, et al. Alcohol consumption patterns and HIV viral suppression among persons receiving HIV care in Florida: an observational study. Addiction Science & Clinical Practice. 2017;12(1):22. Available at: https://doi.org/10.1186/s13722- 017-0090-0.
  51. Lesko CR, Lau B, Chander G, Moore RD. Time spent with HIV viral load >1500 copies/mL among persons engaged in continuity HIV care in an urban clinic in the United States, 2010– 2015. AIDS Behav. 2018;22(11):3443-3450. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29541913.
  52. Monroe AK, Lau B, Mugavero MJ, et al. Heavy alcohol use is associated with worse retention in HIV care. J Acquir Immune Defic Syndr. 2016;73(4):419-425. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27243904.
  53. Ladak F, Socias E, Nolan S, et al. Substance use patterns and HIV-1 RNA viral load rebound among HIV-positive illicit drug users in a Canadian setting. Antivir Ther. 2019;24(1):19-25. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30230474.
  54. DeLorenze GN, Weisner C, Tsai AL, Satre DD, Quesenberry CP, Jr. Excess mortality among HIV-infected patients diagnosed with substance use dependence or abuse receiving care in a fully integrated medical care program. Alcohol Clin Exp Res. 2011;35(2):203-210. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21058961.
  55. Canan CE, Lau B, McCaul ME, Keruly J, Moore RD, Chander G. Effect of alcohol consumption on all-cause and liver-related mortality among HIV-infected individuals. HIV Med. 2017;18(5):332-341. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27679418.
  56. Eyawo O, McGinnis KA, Justice AC, et al. Alcohol and mortality: combining self-reported (AUDIT-C) and biomarker detected (PEth) alcohol measures among HIV infected and uninfected. J Acquir Immune Defic Syndr. 2018;77(2):135-143. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29112041.
  57. Marcellin F, Roux P, Loko MA, et al. High levels of alcohol consumption increase the risk of advanced hepatic fibrosis in HIV/hepatitis C virus-coinfected patients: a sex-based analysis using transient elastography at enrollment in the HEPAVIH ANRS CO13 cohort. Clin Infect Dis. 2014;59(8):1190-1192. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25015913.
  58. Lim JK, Tate JP, Fultz SL, et al. Relationship between alcohol use categories and noninvasive markers of advanced hepatic fibrosis in HIV-infected, chronic hepatitis C virus- infected, and uninfected patients. Clin Infect Dis. 2014;58(10):1449-1458. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24569533.
  59. Scott-Sheldon LAJ, Carey KB, Johnson BT, Carey MP, MASH Research Team. Behavioral interventions targeting alcohol use among people living with HIV/AIDS: a systematic review and meta-analysis. AIDS Behav. 2017;21(Suppl 2):126-143. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28831609.
  60. McGinnis KA, Skanderson M, Edelman EJ, et al. Impact of behavioral and medication treatment for alcohol use disorder on changes in HIV-related outcomes among patients with HIV: a longitudinal analysis. Drug Alcohol Depend. 2020;217:108272. Available at: https://pubmed.ncbi.nlm.nih.gov/32971391.
  61. Edelman EJ, Moore BA, Holt SR, et al. Efficacy of extended-release naltrexone on HIV- related and drinking outcomes among HIV-positive patients: a randomized-controlled trial. AIDS Behav. 2019;23(1):211-221. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30073637.
  62. Springer SA, Di Paola A, Azar MM, et al. Extended-release naltrexone improves viral suppression among incarcerated persons living with HIV with opioid use disorders transitioning to the community: results of a double-blind, placebo-controlled randomized trial. J Acquir Immune Defic Syndr. 2018;78(1):43-53. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29373393.
  63. Farhadian N, Moradi S, Zamanian MH, et al. Effectiveness of naltrexone treatment for alcohol use disorders in HIV: a systematic review. Subst Abuse Treat Prev Policy. 2020;15(1):24. Available at: https://pubmed.ncbi.nlm.nih.gov/32188486.
  64. Edelman EJ, Maisto SA, Hansen NB, et al. Integrated stepped alcohol treatment for patients with HIV and alcohol use disorder: a randomised controlled trial. Lancet HIV. 2019. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31109915.
  65. Votaw VR, Geyer R, Rieselbach MM, McHugh RK. The epidemiology of benzodiazepine misuse: a systematic review. Drug Alcohol Depend. 2019;200:95-114. Available at: https://pubmed.ncbi.nlm.nih.gov/31121495.
  66. Barker MJ, Greenwood KM, Jackson M, Crowe SF. Cognitive effects of long-term benzodiazepine use: a meta-analysis. CNS Drugs. 2004;18(1):37-48. Available at: https://www.ncbi.nlm.nih.gov/pubmed/14731058.
  67. Darke S, Hall W, Ross M, Wodak A. Benzodiazepine use and HIV risk-taking behaviour among injecting drug users. Drug Alcohol Depend. 1992;31(1):31-36. Available at: https://www.ncbi.nlm.nih.gov/pubmed/1358587.
  68. Walton GR, Hayashi K, Bach P, et al. The impact of benzodiazepine use on mortality among polysubstance users in Vancouver, Canada. Public Health Rep. 2016;131(3):491-499. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27252569.
  69. Weisberg DF, Gordon KS, Barry DT, et al. Long-term prescription of opioids and/or benzodiazepines and mortality among HIV-infected and uninfected patients. J Acquir Immune Defic Syndr. 2015;69(2):223-233. Available at: https://pubmed.ncbi.nlm.nih.gov/26009831.
  70. Newville H, Roley J, Sorensen JL. Prescription medication misuse among HIV-infected individuals taking antiretroviral therapy. J Subst Abuse Treat. 2015;48(1):56-61. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25245428.
  71. Motta-Ochoa R, Bertrand K, Arruda N, Jutras-Aswad D, Roy E. “I love having benzos after my coke shot”: the use of psychotropic medication among cocaine users in downtown Montreal. Int J Drug Policy. 2017;49:15-23. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28826127.
  72. Bruce RD, Altice FL, Friedland GH. Pharmacokinetic drug interactions between drugs of abuse and antiretroviral medications: implications and management for clinical practice. Expert Rev Clin Pharmacol. 2008;1(1):115-127. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24410515.
  73. Pacek LR, Towe SL, Hobkirk AL, Nash D, Goodwin RD. Frequency of cannabis use and medical cannabis use among persons living with HIV in the United States: findings from a nationally representative sample. AIDS Educ Prev. 2018;30(2):169-181. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29688777.
  74. Drug Enforcement Administration Diversion Control Division. Special report: synthetic cannabinoids and synthetic cathinones reported in NFLIS, 2013–2015. 2016. Available at: https://www.nflis.deadiversion.usdoj.gov/publicationsRedesign.xhtml?jfwid=lPT2hJ_tGoVr XHIAqd96yZVI_la5j234yi1CIVVq:4.
  75. Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S. A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila). 2016;54(1):1-13. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26567470.
  76. Lake S, Kerr T, Capler R, Shoveller J, Montaner J, Milloy MJ. High-intensity cannabis use and HIV clinical outcomes among HIV-positive people who use illicit drugs in Vancouver, Canada. Int J Drug Policy. 2017;42:63-70. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28336000.
  77. Lorenz DR, Dutta A, Mukerji SS, Holman A, Uno H, Gabuzda D. Marijuana use impacts midlife cardiovascular events in HIV-infected men. Clin Infect Dis. 2017;65(4):626-635. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28449059.
  78. Clayton HB, Lowry R, Ashley C, Wolkin A, Grant AM. Health risk behaviors with synthetic cannabinoids versus marijuana. Pediatrics. 2017;139(4). Available at: https://www.ncbi.nlm.nih.gov/pubmed/28289138.
  79. Sinha S, McCaul ME, Hutton HE, et al. Marijuana use and HIV treatment outcomes among PWH receiving care at an urban HIV clinic. J Subst Abuse Treat. 2017;82:102-106. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29021107.
  80. Gates PJ, Sabioni P, Copeland J, Le Foll B, Gowing L. Psychosocial interventions for cannabis use disorder. Cochrane Database Syst Rev. 2016(5):CD005336. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27149547.
  81. Stephens RS, Roffman RA, Curtin L. Comparison of extended versus brief treatments for marijuana use. J Consult Clin Psychol. 2000;68(5):898-908. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11068976.
  82. Copeland J, Swift W, Roffman R, Stephens R. A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder. J Subst Abuse Treat. 2001;21(2):55-64; discussion 65-56. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11551733.
  83. Daskalopoulou M, Rodger A, Phillips AN, et al. Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV. 2014;1(1):e22-31. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26423813.
  84. Inciardi JA, Surratt HL, Kurtz SP, Cicero TJ. Mechanisms of prescription drug diversion among drug-involved club- and street-based populations. Pain Med. 2007;8(2):171-183. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17305688.
  85. Bracchi M, Stuart D, Castles R, Khoo S, Back D, Boffito M. Increasing use of ‘party drugs’ in people living with HIV on antiretrovirals: a concern for patient safety. AIDS. 2015;29(13):1585-1592. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26372268.
  86. Colfax G, Guzman R. Club drugs and HIV infection: a review. Clin Infect Dis. 2006;42(10):1463-1469. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16619161.

  87. Papaseit E, Vázquez A, Pérez-Mañá C, et al. Surviving life-threatening MDMA (3,4- methylenedioxymethamphetamine, ecstasy) toxicity caused by ritonavir (RTV). Intensive Care Med. 2012;38(7):1239-1240. Available at: https://pubmed.ncbi.nlm.nih.gov/22460853.

  88. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths – United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419- 1427. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30605448.
  89. Bruce RD, Merlin J, Lum PJ, et al. 2017 HIV Medicine Association of Infectious Diseases Society of America clinical practice guideline for the management of chronic pain in patients living with human immunodeficiency virus. Clin Infect Dis. 2017;65(10):1601-1606. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29091230.
  90. Khatri UG, Viner K, Perrone J. Lethal fentanyl and cocaine intoxication. N Engl J Med. 2018;379(18):1782. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30380395.
  91. LaRue L, Twillman RK, Dawson E, et al. Rate of fentanyl positivity among urine drug test results positive for cocaine or methamphetamine. JAMA Netw Open. 2019;2(4):e192851. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31026029.
  92. Hoots BE, Finlayson TJ, Broz D, Paz-Bailey G, NHBS Study Group. Antiretroviral Therapy Use Among HIV-Infected People Who Inject Drugs-20 Cities, United States, 2009-2015. J Acquir Immune Defic Syndr. 2017;75 Suppl 3:S392-S396. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28604444.
  93. Lesko CR, Tong W, Moore RD, Lau B. Retention, antiretroviral therapy use and viral suppression by history of injection drug use among HIV-infected patients in an urban HIV clinical cohort. AIDS Behav. 2017;21(4):1016-1024. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27752872.
  94. Altice FL, Bruce RD, Lucas GM, et al. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study. J Acquir Immune Defic Syndr. 2011;56 Suppl 1:S22-32. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21317590.
  95. Cook RR, Jaworski EN, Hoffman KA, et al. Treatment initiation, substance use trajectories, and the social determinants of health in persons living with HIV seeking medication for opioid use disorder. Subst Abus. 2023;44(4):301-312. Available at: https://pubmed.ncbi.nlm.nih.gov/37842910.
  96. Kresina TF, Bruce RD, McCance-Katz EF. Medication assisted treatment in the treatment of drug abuse and dependence in HIV/AIDS infected drug users. Curr HIV Res. 2009;7(4):354-364. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19601770.
  97. Woody GE, Bruce D, Korthuis PT, et al. HIV risk reduction with buprenorphine-naloxone or methadone: findings from a randomized trial. J Acquir Immune Defic Syndr. 2014;66(3):288-293. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24751432.
  98. Schottenfeld RS, Chawarski MC, Mazlan M. Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo- controlled trial. Lancet. 2008;371(9631):2192-2200. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18586174.
  99. Kirchmayer U, Davoli M, Verster AD, Amato L, Ferri A, Perucci CA. A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence. Addiction. 2002;97(10):1241-1249. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12359026.
  100. Zhu DT, Friedman J, Bourgois P, Montero F, Tamang S. The emerging fentanyl-xylazine syndemic in the USA: challenges and future directions. Lancet. 2023;402(10416):1949-1952. Available at: https://pubmed.ncbi.nlm.nih.gov/37634523.
  101. Centers for Disease Control and Prevention. Illicitly manufactured fentanyl–involved overdose deaths with detected xylazine — United States, January 2019–June 2022. Morbidity and Mortality Weekly Report. June 30, 2023. Available at: https://www.cdc.gov/mmwr/volumes/72/wr/mm7226a4.htm?s_cid=mm7226a4_w.
  102. Drug Enforcement Administration. The growing threat of xylazine and its mixture with illicit drugs. October 2022. Available at: https://www.dea.gov/sites/default/files/2022- 12/The%20Growing%20Threat%20of%20Xylazine%20and%20its%20Mixture%20with%20 Illicit%20Drugs.pdf.
  103. The White House: Office of National Drug Control Policy. Fentanyl adulterated or associated with xylazine response plan. July 2023. Available at: https://www.whitehouse.gov/wp- content/uploads/2023/07/FENTANYL-ADULTERATED-OR-ASSOCIATED-WITH- XYLAZINE-EMERGING-THREAT-RESPONSE-PLAN-Report-July-2023.pdf.
  104. Veilleux-Lemieux D, Castel A, Carrier D, Beaudry F, Vachon P. Pharmacokinetics of ketamine and xylazine in young and old Sprague-Dawley rats. J Am Assoc Lab Anim Sci. 2013;52(5):567-570. Available at: https://pubmed.ncbi.nlm.nih.gov/24041212.
  105. Centers for Disease Control and Prevention. Drug overdose deaths involving xylazine: United States, 2018–2021. June 2023. Available at: https://blogs.cdc.gov/nchs/2023/06/30/7408.
  106. Hartzler B, Dombrowski JC, Crane HM, et al. Prevalence and predictors of substance use disorders among HIV care enrollees in the United States. AIDS Behav. 2017;21(4):1138- 1148. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27738780.
  107. Mimiaga MJ, Reisner SL, Grasso C, et al. Substance use among HIV-infected patients engaged in primary care in the United States: findings from the Centers for AIDS Research Network of Integrated Clinical Systems cohort. Am J Public Health. 2013;103(8):1457-1467. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23763417.
  108. Rosen MI, Black AC, Arnsten JH, et al. Association between use of specific drugs and antiretroviral adherence: findings from MACH 14. AIDS Behav. 2013;17(1):142-147. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22246513.
  109. Vu NT, Maher L, Zablotska I. Amphetamine-type stimulants and HIV infection among men who have sex with men: implications on HIV research and prevention from a systematic review and meta-analysis. J Int AIDS Soc. 2015;18:19273. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25609214.
  110. Chitsaz E, Meyer JP, Krishnan A, et al. Contribution of substance use disorders on HIV treatment outcomes and antiretroviral medication adherence among HIV-infected persons entering jail. AIDS Behav. 2013;17 Suppl 2:S118-127. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23673792.
  111. Mediouni S, Marcondes MC, Miller C, McLaughlin JP, Valente ST. The cross-talk of HIV-1 Tat and methamphetamine in HIV-associated neurocognitive disorders. Front Microbiol. 2015;6:1164. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26557111.
  112. Tyagi M, Weber J, Bukrinsky M, Simon GL. The effects of cocaine on HIV transcription. J Neurovirol. 2016;22(3):261-274. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26572787.
  113. Dash S, Balasubramaniam M, Villalta F, Dash C, Pandhare J. Impact of cocaine abuse on HIV pathogenesis. Front Microbiol. 2015;6:1111. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26539167.
  114. Carrico AW, Flentje A, Kober K, et al. Recent stimulant use and leukocyte gene expression in methamphetamine users with treated HIV infection. Brain Behav Immun. 2018;71:108-115 Available at: https://www.ncbi.nlm.nih.gov/pubmed/29679637.
  115. Carrico AW, Cherenack EM, Roach ME, et al. Substance-associated elevations in monocyte activation among methamphetamine users with treated HIV infection. AIDS. 2018;32(6):767- 771. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29369159.
  116. Ross EJ, Williams RS, Viamonte M, et al. Overamped: stimulant use and HIV pathogenesis. Current HIV/AIDS Reports. 2023;20(6):321-332. Available at: https://doi.org/10.1007/s11904-023-00672-y.
  117. Lai HH, Kuo YC, Kuo CJ, et al. Methamphetamine use associated with non-adherence to antiretroviral treatment in men who have sex with men. Sci Rep. 2020;10(1):7131. Available at: https://pubmed.ncbi.nlm.nih.gov/32346081.
  118. Goodman-Meza D, Shoptaw S, Weiss RE, et al. Methamphetamine use drives decreases in viral suppression for people living with HIV released from a large municipal jail: results of the LINK LA clinical trial. Drug Alcohol Depend. 2019;202:178-184. Available at: https://pubmed.ncbi.nlm.nih.gov/31352308.
  119. Fulcher JA, Javanbakht M, Shover CL, et al. Comparative impact of methamphetamine and other drug use on viral suppression among sexual minority men on antiretroviral therapy. Drug Alcohol Depend. 2021;221:108622. Available at: https://pubmed.ncbi.nlm.nih.gov/33631545.
  120. Carrico AW, Hunt PW, Neilands TB, et al. Stimulant use and viral suppression in the era of universal antiretroviral therapy. J Acquir Immune Defic Syndr. 2019;80(1):89-93. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30272634.
  121. Jin H, Ogunbajo A, Mimiaga MJ, et al. Over the influence: the HIV care continuum among methamphetamine-using men who have sex with men. Drug Alcohol Depend. 2018;192:125-128. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30248558.
  122. Minozzi S, Cinquini M, Amato L, et al. Anticonvulsants for cocaine dependence. Cochrane Database Syst Rev. 2015(4):CD006754. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25882271.
  123. Minozzi S, Amato L, Pani PP, et al. Dopamine agonists for the treatment of cocaine dependence. Cochrane Database Syst Rev. 2015(5):CD003352. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26014366.
  124. Hayashi K, Wood E, Kerr T, et al. Factors associated with optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA non-detectability among HIV-positive crack cocaine users: a prospective cohort study. BMC Infect Dis. 2016;16(1):455. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27568002.
  125. Berg KM, Litwin A, Li X, Heo M, Arnsten JH. Directly observed antiretroviral therapy improves adherence and viral load in drug users attending methadone maintenance clinics: a randomized controlled trial. Drug Alcohol Depend. 2011;113(2-3):192-199. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20832196.
  126. Bruce RD. Addiction. The Neurology of AIDS. 2011; Chp. 7.9. Available at: https://doi.org/10.1093/med/9780195399349.003.0046.
  127. Trivedi MH, Walker R, Ling W, dela Cruz A. Buproprion and naltrexone in methamphetamine use disorder. N Engl J Med. 2021;384:140-153. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa2020214.
  128. Coffin PO, Santos GM, Hern J, et al. Effects of mirtazapine for methamphetamine use disorder among cisgender men and transgender women who have sex with men: a placebo- controlled randomized clinical trial. JAMA Psychiatry. 2020;77(3):246-255. Available at: https://pubmed.ncbi.nlm.nih.gov/31825466.
  129. Wechsberg WM, Golin C, El-Bassel N, Hopkins J, Zule W. Current interventions to reduce sexual risk behaviors and crack cocaine use among HIV-infected individuals. Curr HIV/AIDS Rep. 2012;9(4):385-393. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22872433.
  130. Carrico AW, Gomicronmez W, Jain J, et al. Randomized controlled trial of a positive affect intervention for methamphetamine users. Drug Alcohol Depend. 2018;192:8-15. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30195243.
  131. Burch AE, Rash CJ, Petry NM. Cocaine-using substance abuse treatment patients with and without HIV respond well to contingency management treatment. J Subst Abuse Treat. 2017;77:21-25. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28476266.
  132. Carrico AW, Neilands TB, Dilworth SE, et al. Randomized controlled trial of a positive affect intervention to reduce HIV viral load among sexual minority men who use methamphetamine. J Int AIDS Soc. 2019;22(12):e25436. Available at: https://pubmed.ncbi.nlm.nih.gov/31860172.
  133. Moore DJ, Pasipanodya EC, Umlauf A, et al. Individualized texting for adherence building (iTAB) for methamphetamine users living with HIV: a pilot randomized clinical trial. Drug Alcohol Depend. 2018;189:154-160. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29958127.
  134. Frazier EL, Sutton MY, Brooks JT, Shouse RL, Weiser J. Trends in cigarette smoking among adults with HIV compared with the general adult population, United States – 2009–2014. Prev Med. 2018;111:231-234. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29550303.
  135. Helleberg M, May MT, Ingle SM, et al. Smoking and life expectancy among HIV-infected individuals on antiretroviral therapy in Europe and North America. AIDS. 2015;29(2):221-229. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25426809.
  136. Reddy KP, Parker RA, Losina E, et al. Impact of cigarette smoking and smoking cessation on life expectancy among people with HIV: a US-based modeling study. J Infect Dis. 2016;214(11):1672-1681. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27815384.
  137. Petoumenos K, Worm S, Reiss P, et al. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study(*). HIV Med. 2011;12(7):412-421. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21251183.
  138. Vidrine DJ, Arduino RC, Gritz ER. The effects of smoking abstinence on symptom burden and quality of life among persons living with HIV/AIDS. AIDS Patient Care STDS. 2007;21(9):659-666. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17919093.
  139. Shepherd L, Ryom L, Law M, et al. Cessation of cigarette smoking and the impact on cancer incidence in human immunodeficiency virus-infected persons: the Data Collection on Adverse Events of Anti-HIV Drugs Study. Clin Infect Dis. 2019;68(4):650-657. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29912335.
  140. Mercie P, Arsandaux J, Katlama C, et al. Efficacy and safety of varenicline for smoking cessation in people living with HIV in France (ANRS 144 Inter-ACTIV): a randomised controlled phase 3 clinical trial. Lancet HIV. 2018;5(3):e126-e135. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29329763.
  141. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387(10037):2507-2520. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27116918.
  142. Ashare RL, Thompson M, Serrano K, et al. Placebo-controlled randomized clinical trial testing the efficacy and safety of varenicline for smokers with HIV. Drug Alcohol Depend. 2019;200:26-33. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31082665.
  143. Reddy KP, Kruse GR, Lee S, Shuter J, Rigotti NA. Tobacco use and treatment of tobacco dependence among people with human immunodeficiency virus: a practical guide for clinicians. Clin Infect Dis. 2022;75(3):525-533. Available at: https://pubmed.ncbi.nlm.nih.gov/34979543.
  144. Amodei N, Lamb RJ. The role of nicotine replacement therapy in early quitting success. Nicotine Tob Res. 2010;12(1):1-10. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19897526.
  145. Gonzales D, Rennard SI, Nides M, et al. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):47-55. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16820546.
  146. West R, Baker CL, Cappelleri JC, Bushmakin AG. Effect of varenicline and bupropion SR on craving, nicotine withdrawal symptoms, and rewarding effects of smoking during a quit attempt. Psychopharmacology (Berl). 2008;197(3):371-377. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18084743.
Key Considerations and Recommendations
  • Substance use disorders (SUDs) are prevalent among people with HIV and contribute to poor health outcomes; therefore, screening for SUDs should be a routine part of clinical care (AII).
  • The most commonly used substances among people with HIV include alcohol, benzodiazepines, cannabinoids, club drugs, opioids, stimulants (cocaine and methamphetamines), and tobacco.
  • Health care providers should be nonjudgmental when addressing substance use with their patients (AIII).
  • People with HIV and SUDs should be screened for additional mental health disorders (AII).
  • People with HIV and SUDs should be offered evidence-based pharmacotherapy (e.g., opioid agonist therapy, tobacco cessation treatment, alcohol use disorder treatment; see Table 16 below) as part of comprehensive HIV care in clinical settings (AI).
  • Ongoing substance use is not a contraindication to antiretroviral therapy (ART) (AI). People who use substances can achieve and maintain viral suppression with ART.
  • Substance use may increase the likelihood of risk-taking behaviors (e.g., risky sexual behaviors), the potential for drug-drug interactions, and the risk or severity of substance-associated toxicities (e.g., increased hepatotoxicity or an increased risk of overdose).
  • Selection of antiretroviral (ARV) regimens for individuals who practice unhealthy substance and alcohol use should take into account potential adherence barriers, comorbidities that could impact care (e.g., advanced liver disease from alcohol or hepatitis viruses), potential drug-drug interactions, and possible adverse events associated with the medications (AII).
  • ARV regimens with once-daily dosing of single-tablet regimens, high barriers to resistance, low hepatotoxicity, and low potential for drug-drug interactions are preferred (AIII).

Rating of Recommendations:  A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Background on Substance Use Disorders among People with HIV

It is estimated there were 1,788 drug induced deaths in Australia in 2021, excluding those caused by alcohol and tobacco1. There were 1,559 alcohol-induced deaths in Australia in 20212.

Reference 1: https://ndarc.med.unsw.edu.au/resource-analytics/trends-drug-induced-deaths-australia-2002-2021

Reference 2: https://www.aihw.gov.au/reports-data/behaviours-risk-factors/alcohol/overview

Current Australian guidelines recommend to reduce the risk of harm from alcohol-related disease or injury, healthy men and women should drink no more than 10 standard drinks a week and no more than 4 standard drinks on any one day

Ref: https://www.health.gov.au/topics/alcohol/about-alcohol/how-much-alcohol-is-safe-to-drink#guidelines-to-reduce-your-risk

Ending the HIV epidemic requires addressing substance use among people with HIV, which poses a barrier to optimal engagement in the HIV care continuum. Ongoing substance use may prevent an individual from being tested for HIV, initiating antiretroviral therapy (ART), or adhering to ART, and it may increase the frequency of behaviors that put a person at risk for HIV transmission. Substance use may increase the likelihood of risk-taking behaviors (e.g., risky sexual behaviors, needle sharing, and injection of substances), the potential for drug-drug interactions, and the risk or severity of substance-related toxicities (e.g., increased hepatotoxicity and increased risk of overdose). In the United States, the death toll for drug overdose (70,237 deaths in 2017)1 now far exceeds the death toll for HIV (15,807 deaths in 2016).2 As the drug overdose epidemic continues to expand, health care providers need a basic understanding of how to screen for and treat substance use disorders (SUDs) in people with HIV in clinical settings.3 Substance use exists on a continuum from episodic use to a SUD with its concomitant negative consequences. Research on alcohol consumption has defined a threshold at which consumption does not reach a diagnosis of SUD, but where the level of consumption is nonetheless hazardous to the person. This level of consumption has been defined as “hazardous drinking.” A comparable category does not exist for other substances. The prevalence of substance use and SUDs is higher among people with HIV than among the general public,4 and polysubstance use is common. This section will focus on the most commonly used substances among people with HIV: alcohol, benzodiazepines, cannabinoids, club drugs,5 opioids, stimulants (cocaine and methamphetamines), and tobacco.  People with HIV may use more than one substance and may not be ready to consider reducing the use of substances or seeking treatment for SUDs. Polysubstance use occurs for multiple reasons, including to improve the euphoria associated with use (e.g., use of cocaine and heroin mixtures called “speedballs”) and to reduce the adverse effects of a particular substance (e.g., the use of alcohol or benzodiazepines to reduce the anxiety caused by cocaine use). Substance Use and Sexual Risk Taking A growing body of literature describes the intersection of substance use and sexual risk taking (“chemsex”). This research highlights the impact of substance use on sexual risk behaviors; although no precise definition of “chemsex” exists, studies have investigated the use of many different substances used to enhance sexual pleasure, decrease inhibitions related to particular sexual acts, and combat low self-esteem. In a retrospective study in a London sexual health clinic, individuals who disclosed substance use (463 of 1,734 patients) had higher odds of acquiring new HIV infection, bacterial sexually transmitted infections (STIs), and/or hepatitis C virus (HCV).6 A much larger analysis using the European Men Who Have Sex with Men (MSM) Internet Survey, which collected data from 16,065 United Kingdom–based respondents, found that MSM who reported using methamphetamines or gamma-hydroxybutyrate (GHB) during the previous year were more likely to have gonorrhea infection than MSM who did not use these drugs, with odds ratios of 1.92 and 2.23, respectively.7 These data emphasize the need to screen patients for substance use and STIs in clinical settings. Screening for Substance Use Disorders

Australian clinicians can access Australian screening tools for substance use disorders here: https://aodscreening.flinders.edu.au/screening

Screening for SUDs should be incorporated into the routine clinical care of all people with HIV. The following questions can be used to screen for drug or alcohol use: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” and “How many times in the past year have you had X or more drinks in a day?” (X is five for men and four for women).8 Data are lacking on the appropriate threshold for alcohol use among transgender individuals, so until data clarify the risks, providers should use the more conservative threshold of four drinks. Individuals with liver disease, including active HCV infection, should not consume alcohol. A positive response at least one time on either screen should prompt additional screening with other short yet effective screening tools (see the Screening and Assessment Tools Chart from the National Institute on Drug Abuse). These tools can identify substance use and guide decisions on appropriate treatment interventions. Currently, not enough data exist to determine how often patients should be screened for SUDs; however, given the potential negative impact that SUDs may have on people with HIV, it is advisable to ask these questions during every clinical visit. 

Health care providers should be nonjudgmental when discussing substance use with their patients. Patients who experience stigma or who feel judged may not trust the health care provider’s recommendations, may avoid returning to see that provider again, and may consequently have poorer health outcomes.9 Language is one way in which stigma is communicated, and words such as “addict” and “dirty urine” convey a negative connotation. The Office of National Drug Control Policy (ONDCP), American Medical Association, American Society of Addiction Medicine, International Society of Addiction Journal Editors, and others have recommended the adoption of clinical, non-stigmatizing language for substance use, as described in the “Changing the Language of Addiction“ report from ONDCP.

Co-Occurring Mental Illness

Many people who use substances have co-occurring mental health disorders, including a history of trauma that may drive or exacerbate their substance use. Conversely, ongoing use of substances can place individuals at risk of trauma, such as sexual assault and sexual exploitation, which may further exacerbate their substance use.6, 10 People with SUDs should undergo evaluation and treatment for concurrent mental health disorders using standardized screening instruments (e.g., the Patient Health Questionnaire-2 [PHQ-2] for depression). Where applicable, clinicians should use available behavioral and pharmacological interventions to address mental health concerns, because recommending that patients stop their substance use without providing treatment for underlying mental health conditions has very limited efficacy.11 

Several behavioral interventions have shown promise in randomized trials. Motivational interviewing, cognitive behavioral therapy, or a combination of the two have led to decreases in stimulant use, decreases in risky sexual behaviors, and improved adherence to ART.12 Contingency management, a behavioral intervention that provides rewards for abstinence, has been shown to be effective in decreasing stimulant use among people with HIV, but whether decreases in stimulant use are sustained over time is less clear.13

Selecting, Initiating, and Maintaining Antiretroviral Therapy

Opioid Agonist treatment with buprenorphine has expanded in Australia to include the long-acting depot buprenorphine formulation. Dosage is given weekly or monthly. Refer to NSW Clinical Guidelines for the use of depot buprenorphine in th treatment of opioid dependence.

Ongoing substance use is not a contraindication to having ART prescribed. Indeed, ART reduces the risk of HIV transmission to sexual partners and to individuals who share drug paraphernalia. These clinical, community, and individual benefits should encourage health care providers to initiate ART in people with HIV who use substances and those with SUDs.

When selecting antiretroviral (ARV) regimens for individuals who use substances, clinicians should consider potential barriers to adherence (see Adherence to the Continuum of Care), co-morbidities that could impact care (e.g., advanced liver disease from alcohol or HCV), potential drug-drug interactions, and possible adverse events that are associated with the medications. Providers should discuss adherence with their patients during multiple, nonjudgmental evaluations. In general, the use of simplified ARV regimens should be considered to aid ART adherence. Regimens for people with SUDs should be easy to take, such as a once-daily, single-tablet regimen,14 and should have a high barrier to resistance or a low risk of hepatotoxicity. Adherence counseling should highlight the benefits of ART use, irrespective of concurrent substance use. Additionally, a reduction in substance use may improve adherence to ART.15

The development of long-acting injectable (LAI) antiretrovirals provides additional options for patients on ART. The combination of injectable cabotegravir (CAB) and rilpivirine (RPV) is an optimization option for patients who demonstrate retention in HIV care and who are virologically suppressed on oral therapy (see Optimizing Antiretroviral Therapy in the Setting of Virologic Suppression). Current research on these medications is limited to individuals with expected good adherence and an ability to achieve virologic suppression on oral therapy prior to starting LAIs. To date, little research has examined the use of these medications to support individuals struggling with adherence. Specifically, data on the use of CAB and RPV to improve medication adherence for people who actively use substances or have SUDs are lacking. LAI anti-psychotics have been studied in people with schizophrenia and SUDs. Starr and colleagues, for example, found fewer treatment failures using a once-a-month injectable paliperidone when compared to an oral anti-psychotic regimen.16 The use of LAIs, however, presents unique concerns in people with HIV and SUDs, given the potential for the emergence of HIV drug resistance in the case of reduced adherence to or a delay in receiving scheduled injections. 

The following factors should be considered when contemplating the use of LAIs in people with HIV and SUDs: 

  • As with all treatment conversations, providers should discuss adherence with their patients during multiple, nonjudgmental evaluations. 
  • Providers and people with HIV should consider the impact of using LAIs in the context of current or past substance use behaviors. Although some people may welcome or even prefer LAIs,17 one qualitative study highlighted that some people who either currently inject or previously injected substances may find that LAIs are a trigger for the injection of illicit substances.18
  • Studies utilizing LAIs have included individuals with good adherence before starting the LAIs, but this should not exclude people with SUDs who are struggling with adherence from being considered for LAIs. Rather, the clinical team should consider what additional support may be needed to help people with SUDs be successful with LAIs. Some people with HIV may benefit from the administration of LAI in conjunction with methadone for the treatment of opioid use disorder, given anticipated adherence with methadone clinic visits. Case management, patient navigators, and/or peer navigators should be considered to help patients return for follow-up injections.
  • Given the often unpredictable lifestyles of people with SUDs, clinical care teams should be flexible in scheduling patients for injections or accommodating walk-ins for injections.
  • Patients with hepatitis B virus (HBV) have not been studied with CAB and RPV because these patients would need oral agents for HBV treatment. People with HIV should be screened for HBV infection and vaccinated before consideration of CAB/RPV, if not already immune or infected.
  • Depressive disorders have been associated with CAB and RPV, so patients with SUD should be screened for depressive disorders and treated for depression if indicated. If depressive disorders worsen while on CAB and RPV, patients should be reevaluated to determine whether continued therapy with this regimen is advisable.

Importantly, multiple knowledge gaps exist regarding the use of LAIs among people with HIV and SUDs. The results from the ongoing Long-Acting Therapy to Improve Treatment Success in Daily LifE (LATITUDE) Study (NCT 03635788) will provide needed information on using LAIs among people with HIV and SUDs who have struggled with ART adherence.19 Additional research is needed to determine optimal methods to support ART adherence (including LAI adherence) among people with HIV and SUDs. These research studies will need to take into consideration the combination of various interventions (e.g., peer support, case management, pharmacotherapy for SUDs, etc.) and the appropriate individual interventions needed to support overall ART adherence.

Commonly Used Substances and Their Impact on HIV and Antiretroviral Therapy

Health care providers should have a basic understanding of evidence-based treatments for different substances, including alcohol, benzodiazepines, cannabinoids, club drugs, opioids, stimulants (cocaine and methamphetamines), and tobacco. The sections below discuss the impact of these substances on people with HIV and how these substances affect ART use.

Alcohol
Epidemiology

Alcohol consumption is common among people with HIV. Recent estimates indicate that >50% of people with HIV in the United States consume any amount of alcohol (range, 54%–67%).20, 21 Among a sample of people with HIV across seven university-based HIV clinics in the United States, 27% of people screened positive for unhealthy alcohol use as determined by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C).21 Unhealthy alcohol use includes a spectrum of consumption, including risky or hazardous use, heavy episodic use (binge drinking), and alcohol use disorder (AUD).22

Risk-Taking Behaviors, the HIV Care Continuum, and Comorbidities

Unhealthy alcohol use has been linked to HIV acquisition, because it can increase the frequency of behaviors that put a person at risk for sexual transmission of HIV.23-25 In a meta-analysis of 27 studies, any alcohol use, unhealthy alcohol use, and alcohol use in sexual contexts all were associated with condomless sex among people with HIV.24 

In addition, unhealthy alcohol use has been associated with interruptions in all steps of the HIV care continuum, including lower adherence to ART.26, 27 Studies have demonstrated both temporal and dose-related relationships between alcohol use and adherence, where ART is more likely to be missed on a given drinking day and the day after drinking, with a stronger association on heavy (binge) drinking days.28-30 The negative impact of unhealthy alcohol use on ART adherence is likely multifactorial and driven by the effects of intoxication, ARV regimen complexity, and patient perceptions of adverse interactions between alcohol and ARV drugs.31-33 Studies also have demonstrated an association between unhealthy alcohol use and the loss of durable viral suppression,34, 35 greater time spent with a viral load >1,500 copies/mL after ART initiation,36 increased risk of viral rebound, lower retention in care,37, 38 and increased mortality.39-41 Unhealthy alcohol use alone (hazardous or AUD) and in combination with other common comorbidities, including viral hepatitis coinfection, can hasten liver fibrosis progression in people with HIV.42, 43 Finally, in general medical populations, unhealthy alcohol use complicates the management of diabetes mellitus, hypertension, mental health disorders, other substance use, and other chronic diseases, and it increases the risk for pneumonia, osteoporosis, a number of cancers (e.g., liver, head and neck, and breast cancers), and tuberculosis.

Management of Unhealthy Alcohol Use

Australian clinicians can refer to the Guidelines for the Treatment of Alcohol Problems.

Ongoing alcohol use is not a contraindication for a person to receive ART. However, treatment for unhealthy alcohol use may improve HIV treatment outcomes. Behavioral treatments for unhealthy alcohol use among people with HIV demonstrate a small but significant reduction in alcohol use44 (see additional resources for alcohol management from the National Institute on Alcohol Abuse and Alcoholism and the Substance Abuse and Mental Health Services Administration [SAMHSA]). Pharmacotherapy also can reduce alcohol use among people with HIV. The Food and Drug Administration (FDA) has approved three pharmacotherapies for AUD: naltrexone, disulfiram, and acamprosate (see Table 16 below). 

Clinical trials have demonstrated the efficacy of naltrexone in reducing the number of heavy drinking days among those with HIV and among the general population. Naltrexone appears to be safe to use in people with HIV,45, 46 and it is not associated with significant drug-drug interactions or irreversible hepatotoxicity. However, it is not recommended for individuals with decompensated liver disease and should be used with caution in individuals with elevated transaminase levels. Use of naltrexone in people with HIV and AUD can improve HIV treatment outcomes. In a randomized placebo-controlled trial of 100 prisoners with HIV who met the criteria for AUD, individuals who were provided depot naltrexone upon release from prison were more likely to achieve viral suppression at 6 months than the placebo group (56.7% versus 30.3%).46

Data on the use of disulfiram and acamprosate among people with HIV are lacking. Notably, integrating treatment for AUD with treatment for HIV has been shown to increase the number of patients who receive alcohol treatment medication, counseling, and formal outpatient alcohol treatment services. Integrating these treatments also may improve the likelihood that a patient will achieve viral suppression on ART. A randomized controlled trial of 128 individuals with HIV and AUD compared an integrated stepped-care model of alcohol treatment in Veterans Administration HIV clinics to treatment as usual. At the end of treatment (24 weeks), integrated stepped care resulted in more participants’ receiving pharmacotherapy for AUD and participating in counseling. Although differences in alcohol use and viral suppression were not seen at 24 weeks, at 52 weeks, integrated stepped care was associated significantly with an increased number of alcohol-abstinent days, a decrease in the number of drinks per drinking day, and a decreased number of heavy drinking episodes. In addition, the patients in the stepped care group had increased odds of achieving viral suppression (odds ratio [OR] 5.58; 95% confidence interval [CI], 1.11–27.99).47

Liver cirrhosis—whether related to chronic heavy alcohol use, viral hepatitis, or nonalcoholic fatty liver disease—can result in altered metabolism of ARV drugs. For those who have hepatic impairment due to alcohol-related liver disease, ART dosing should follow the recommendations in Appendix B, Table 11, which are based on Child-Pugh classifications.

Benzodiazepines
Epidemiology

A specific epidemiologic data on the prevalence of benzodiazepine use among people with HIV are limited, the use of benzodiazepines can impact both morbidity and mortality. Benzodiazepines cause anterograde amnesia, defined as difficulty recalling events after taking the medication. Individuals do not develop tolerance to this neurocognitive effect, and long-term use of benzodiazepines may result in impairment of neurocognitive functioning.48 

Risk-Taking Behaviors and the HIV Care Continuum

People who inject drugs and who also use benzodiazepines engage in riskier behaviors than people who inject drugs but do not use benzodiazepines; these behaviors may include paying for sex, sharing injection equipment with more people, and performing more frequent injections.49 A cohort of 2,802 people who injected drugs was followed from 1996 to 2013. During that time, benzodiazepines were the substances with the greatest association with mortality.50 The long-term neurocognitive impact of benzodiazepines on ART adherence among people with HIV is unclear, but prescribing a memory-impairing medication to people with HIV who are prone to neurocognitive impairments from other causes may increase the risk of poor ART adherence.51 Benzodiazepines also are used illicitly to counteract the negative side effects of stimulants, such as cocaine and methamphetamine.52 

Management of Benzodiazepine Use

Repeated use of benzodiazepines can result in physiologic dependence and life-threatening withdrawal in some patients. When feasible, individuals who chronically take benzodiazepines should be slowly tapered off the benzodiazepines under the supervision of an experienced clinician. Different benzodiazepines have different potencies (e.g., alprazolam is more potent than diazepam) and, therefore, require different tapers in terms of length and graduated decrease in dosage.

Benzodiazepine and Antiretroviral Drug Interactions

Several pharmacological interactions with ARV drugs also have been described. For example, some benzodiazepines are cytochrome P (CYP) 3A4 substrates; thus, when these benzodiazepines are used with a ritonavir-boosted or cobicistat-boosted ARV drug, their half-lives and concentrations can increase significantly, leading to enhanced and prolonged sedating effects. See Drug-Drug Interactions for available data on benzodiazepine-related interactions.53 

Cannabis and Cannabinoids
Epidemiology

Both medical and recreational cannabis (marijuana) use are prevalent among people with HIV.54 Cannabis belongs to a class of compounds that activate cannabinoid receptors. This class, known as cannabinoids, also includes synthetic compounds, such as K2. In recent years, cannabinoids have become more popular. In 2009, two cannabinoids were reported to the National Forensic Laboratory Information System. By 2015, 84 compounds had been reported.55 These compounds most commonly cause tachycardia, agitation, and nausea, but they have a wide range of psychiatric effects, including psychosis and paranoia.56 

Risk-Taking Behaviors and the HIV Care Continuum

Cannabis has not been shown to negatively impact adherence to ART or a patient’s ability to achieve viral suppression. In one study, among 874 people with HIV, daily cannabis use did not predict lower odds of ART use or achieving an undetectable HIV RNA level, except when combined with binge drinking.57 Data from the Multicenter AIDS Cohort Study have supported the idea that marijuana use does not predict problems with adherence to ART or achieving viral suppression.58 In some cases, however, cannabinoids have been listed as the cause of death in overdoses. While data are lacking among adults with HIV, the nationally representative 2015 Youth Risk Behavior Survey (which includes data from 15,624 adolescent students in Grades 9 to 12) found that students who had ever used synthetic cannabinoids engaged in riskier activities, including sex, than students who only used marijuana.59 While the available data suggest that the use of marijuana is not associated with decreased adherence to ART,60 data are lacking on the impact of synthetic cannabinoids on ART adherence. Finally, with the growing use of synthetic cannabinoids, there is concern that fentanyl could be added to these products, which may increase the risk of opioid overdose.

Management of Cannabinoid Use

Patients can be referred to cannabis management tools for support in minimise or ceasing use.

Because of the aforementioned concerns regarding cannabinoid use, particularly the variety of compounds and neuropsychiatric effects, people with HIV should be discouraged from using cannabinoids until more data are available. No pharmacological treatment exists for cannabinoid use disorder; however, behavioral health treatment may be effective for some patients.61-63 

Club Drugs
Epidemiology

Club drugs are recreational substances that have euphoric or hallucinogenic effects or that are used to enhance sexual experiences.5 The use of multiple club drugs or other drugs simultaneously is common. Although these substances are used by many different people with HIV, the majority of data come from MSM with HIV. Use of club drugs in this population has been shown to negatively impact HIV treatment.64 Club drugs include methylenedioxymethamphetamine (MDMA), GHB, ketamine, benzodiazepines (see the benzodiazepine section above), and other drugs that are used to enhance sexual experiences (e.g., mephedrone, inhaled nitrates [poppers], and phosphodiesterase-5 inhibitors [PDE5] for erectile dysfunction). Survey data from users of club drugs also have revealed that efavirenz is purchased by people without HIV for its intoxicating effects.65 

Risk-Taking Behaviors and the HIV Care Continuum

Club drugs have disinhibitory effects. Using club drugs increases the likelihood that a person will engage in high-risk sexual practices, which can increase the risk of HIV transmission. In addition, these disinhibitory effects can lead to poor ART adherence.53, 64, 66 

Management of Club Drug Use

Treatment strategies for club drug use have not been well studied in controlled trials.67 No recommended pharmacotherapies exist at this time, and the most common strategy for treating patients who use club drugs is to employ the behavioral interventions that are used for other drug use disorders.

Club Drug and Antiretroviral Drug Interactions

MDMA, GHB, ketamine, and methamphetamine all have the potential to interact with ARV drugs because they are metabolized, at least in part, by the CYP450 system.53, 66 Overdoses secondary to interactions between club drugs (i.e., MDMA or GHB) and protease inhibitor–based ART have been reported.53 For instance, using PDE5 or ketamine concurrently with potent CYP3A4 inhibitors, such as ritonavir or cobicistat, can lead to potentiation of the effects of these substances.64 

Cocaine

See the discussion in the section on stimulants below.

Opioids
Epidemiology

Australian clinicians can refer to RACGP Evidence-based guidance for opioids in pain management.

Naloxone is available in all states and territories with a prescription. Under the national Take Home Naloxone program, naloxone will be available free of charge and without a prescription across all participating pharmacies in Australia. Naloxone is also available over the counter from non-participating Take Home Naloxone program pharmacies for a fee.  

A list of pharmacies and other sites participating in the national Take Home Naloxone program can be found on the Pharmacy Programs Administrator Website.

Opioids remain a significant concern for people with HIV, both for the acquisition of HIV and as major contributors to morbidity and mortality. Overdose involving opioids is the leading cause of accidental death in the United States.68 The appropriate use of opioids while caring for people with HIV and chronic pain is an important component of combating the opioid epidemic, but this subject is beyond the scope of this section. Please refer to additional resources, such as those from the Centers for Disease Control and Prevention (CDC) and the Infectious Diseases Society of America.69 To combat the opioid overdose epidemic, health care providers should prescribe naloxone for opioid overdose prevention for all patients who are using opioids beyond the short-term treatment of acute pain.3 

Risk-Taking Behaviors and the HIV Care Continuum

Many people who use opioids start by using opioid tablets (e.g., oxycodone) that are ingested orally or crushed and sniffed. Once tolerance develops, some individuals move from sniffing the crushed tablets to injecting heroin purchased on the streets. This transition from sniffing to injecting dramatically increases the risk of HIV and HCV infection. 

Low-cost heroin is often a mix of heroin and higher potency synthetic opioids, such as fentanyl.68 Methamphetamines and cocaine also have been combined with fentanyl but at a lower rate than heroin.70, 71 With the growing use of synthetic cannabinoids, there is concern that fentanyl could be added to these as well. In all instances where fentanyl or other high-potency opioids are added to other drugs, the risk of overdose increases.

Although treatment for an opioid use disorder can improve HIV treatment outcomes, it is not a prerequisite for treating HIV, as some patients are able to adhere successfully to ART despite ongoing opioid use. Although ART coverage among people with HIV who injected drugs increased from 58% to 71% between 2009 and 2015, additional work is needed to improve ART coverage in this population.72 Data from the Johns Hopkins HIV Clinical Cohort (2001–2012) demonstrated that in the early years of the cohort, people who injected drugs were less likely to be retained in care; however, this gap in retention had closed by 2012, and people who injected drugs and noninjectors had similar probabilities of being on ART and having a suppressed viral load during the later years of the cohort.73 

Management of Opioid Use

Oral naltrexone is briefly included in both National1 and State2 Opioid Treatment Guidelines. However, in current Australian clinical practice it is rarely used for relapse prevention. It also requires the patient receiving treatment to be abstinent from opioids which can be challenging. Naltrexone is currently available on the PBS for the treatment of Alcohol use Disorder. Sustained release and implant preparations of naltrexone are currently not registered in Australia and remain experimental3.

Ref1. https://www.health.gov.au/sites/default/files/national-guidelines-for-medication-assisted-treatment-of-opioid-dependence.pdf

Ref2. https://www.health.nsw.gov.au/aod/Pages/nsw-clinical-guidelines-opioid.aspx

Ref3. http://www.atoda.org.au/wp-content/uploads/ANCDnaltrexonepositionstatement.pdf

Australian state and territory governments have different legislative requirements to prescribe Opioid Agonist Treatment in Australia. Most require accreditation and training to prescribe. You can find the requirements by jurisdiction below:

FDA has approved three medications for the treatment of opioid use disorder that can help decrease or eliminate opioid use, reduce the risks of morbidity and mortality that are associated with opioid use, and improve HIV treatment success. These medications, collectively termed medication-assisted treatment (MAT), include buprenorphine, methadone, and naltrexone (see Table 16 below). Buprenorphine and methadone are opioid agonists (the use of these drugs is termed opioid agonist therapy [OAT]), whereas naltrexone is an opioid-antagonist or “blocker.” Both buprenorphine and naltrexone can be prescribed in the setting of routine HIV clinical care.74 Prescribing buprenorphine requires specific training and licensure (known as an X-waiver; see the SAMHSA website for more information). Methadone must be prescribed through a licensed opioid treatment program (OTP). An OTP directory also can be found on the SAMHSA website.

Use of buprenorphine or methadone can lead to reductions in risky behaviors associated with HIV transmission, psychosocial and medical morbidity related to opioid use disorder, and criminal behaviors. People who are receiving treatment for opioid use are already engaging with the health care system; therefore, they are more likely to initiate treatment for HIV and to be adherent to their ARV regimens. Both buprenorphine and methadone are cost-effective interventions at the societal level.75 Methadone has better retention in SUD treatment than either buprenorphine or naltrexone, and it should be considered for individuals who do not achieve successful outcomes with buprenorphine or naltrexone.76 Buprenorphine has a lower risk of overdose than methadone. In addition, it can be prescribed in primary care offices. Patients who are taking buprenorphine have significantly better retention in treatment than those who are taking daily oral naltrexone.77 Although several randomized, controlled clinical trials have demonstrated efficacy for naltrexone when treating opioid use disorder, subsequent study results have been disappointing; one meta-analysis revealed that oral naltrexone was equivalent to placebo.78 To address the adherence challenges with naltrexone, a depot formulation was created for monthly administration. This preparation has the potential to improve adherence; however, studies that compare opioid agonists, such as buprenorphine and methadone, to depot naltrexone as treatments for opioid use disorder have not been conducted. In a randomized, placebo-controlled trial in people with both HIV and opioid use disorder, participants who received at least three doses of depot naltrexone before discharge from prison achieved longer periods of continuous abstinence after transitioning from prison to the community than those who received either placebo or two or less doses of depot naltrexone.46 On the basis of these data, methadone or buprenorphine generally are used as first-line agents for the treatment of opioid use disorder. Depot naltrexone is used as an alternative treatment for people who have been released recently from correctional facilities when other options are not available.

Important pharmacokinetic interactions between these medications (particularly methadone) and certain ARV drugs are listed in Drug-Drug Interactions. 

Stimulants
Epidemiology

Cocaine and methamphetamine are powerful stimulants that have been associated with multiple detrimental effects to people with HIV, including accelerated disease progression, poor ART adherence, and lack of viral suppression. Cocaine powder is snorted or injected, whereas the free-base form (crack) is smoked. Methamphetamines can be taken orally or rectally, injected, or smoked. Cocaine and methamphetamine commonly are used with other substances, including alcohol, and can be combined with fentanyl, which increases the risk of overdose.70, 71 Individuals who use stimulants experience a sense of euphoria and may have heightened sexual desire and arousal. This can lead to disinhibited sexual behaviors, increasing the risk of HIV transmission. 

The prevalence of stimulant use among people with HIV has been estimated to be 5% to 15% across multiple studies.79-81 Methamphetamine use is more common among MSM,82 and increased rates of cocaine use have been observed among ethnic and racial minorities and persons with a history of incarceration.83 

Risk-Taking Behaviors and the HIV Care Continuum

Multiple negative health consequences of stimulant use are observed among people with HIV, including rapid development of dependence and adverse effects on multiple organ systems, particularly the central nervous and cardiovascular systems. Stimulant use is associated with neurocognitive impairment,84 delirium, seizures, hemorrhagic strokes, and mental health disturbances, including anxiety, psychosis, and paranoia.

Stimulant use may lead independently to HIV disease progression even among people who are taking ART and have achieved viral suppression. Research to identify the cellular mechanisms responsible for this is ongoing, but increased viral replication, direct effects on the immune system that lead to declines in CD4 T lymphocyte cell count, enhanced immune activation, and disruption of the blood-brain barrier, facilitating HIV entry into the brain, have been implicated.85-88 Stimulant use has been associated with poor HIV continuum of care outcomes, including suboptimal rates of ART adherence, retention in care, and viral suppression. Lack of viral suppression, combined with the increased likelihood of risky sexual behaviors that occur under the influence of stimulants, poses a threat to the HIV treatment-as-prevention paradigm.89 

Management of Stimulant Use

Clinicians should discuss peer-based services with people with HIV who use stimulants and want to minimise or cease. These may not be appropriate for people with HIV with complex or regular substance use but should be discussed with the individual.

Several pharmacologic and behavioral interventions for stimulant dependence have been investigated, and some trials have included people with HIV. The results of pharmacologic interventions generally have been disappointing. No FDA-approved pharmacotherapy for cocaine use disorder currently exists, despite research on multiple drug classes, including antidepressants, antipsychotics, anticonvulsants, and dopaminergic medications (e.g., disulfiram).90, 91 Among people with HIV who use crack and opioids, MAT for opioid use disorder may improve ART adherence and viral suppression.92, 93 Limited evidence indicates that some pharmacologic interventions (e.g., methylphenidate, modafinil, bupropion, naltrexone)94 can reduce methamphetamine use or cravings. A double-blind, placebo-controlled trial of extended-release injectable naltrexone plus oral extended-release buproprion in adults with moderate or severe methamphetamine use disorder demonstrated a higher response of urine samples free of methamphetamines compared to placebo (weighted average response of 13.6% with naltrexone-buproprion and 2.5% with placebo, P < 0.001); however, the overall response rate was low.95 No recommended pharmacotherapy exists to treat stimulant use disorder in people with HIV. 

Several behavioral interventions have shown promise in randomized trials. People with HIV who received motivational interviewing sessions, cognitive behavioral therapy, or a combination of the two decreased their stimulant use and improved their adherence to ART, and they were less likely to engage in risky sexual behaviors.12 Contingency management has been shown to be effective in decreasing stimulant use among people with HIV, but the sustained effects on the reduction of stimulant use and improvements in ART adherence are less clear.13, 80, 96 Technology-based interventions, such as text messaging, may have a role in supporting ART adherence and decreasing methamphetamine use among people with HIV, but further research is needed.97 People with HIV who use stimulants benefit most from multidimensional interventions that target substance use, ART adherence, and risky sexual behaviors.12 

Despite the challenges discussed above, people with HIV who use stimulants can achieve viral suppression with ART98 and should be prescribed ART even if stimulant use is ongoing. 

Tobacco
Epidemiology

The prevalence of tobacco smoking among people with HIV in the United States is approximately twice that of the general population (33.6% versus 16.8%).99 Prevalence is even higher among specific subgroups, including those who use alcohol and/or other drugs, those who have concurrent mental health disorders, and those of a lower socioeconomic status. Although smoking rates are declining overall in the United States, people with HIV are less likely to quit smoking than people in the general population.99 

Associated Risks of Tobacco Use and HIV Infection

With respect to substance use and HIV, tobacco smoking is the biggest threat to health-related gains achieved through ART. Among individuals with viral suppression on ART, more years of life may be lost from continued smoking than from HIV infection itself.100, 101 Tobacco smoking among people with HIV is associated with an increased risk of numerous health conditions, including lung cancer and other smoking-related cancers, cardiovascular disease, and pulmonary disease. In a sample of 17,995 people with HIV on ART in Europe and North America, individuals who smoked had nearly twice the mortality of those who did not (mortality rate ratio 1.94; 95% CI, 1.56–2.41) with significant mortality attributed to cardiovascular disease and non-AIDS-related malignancy.100 Importantly, tobacco cessation reduces the incidence of cardiovascular disease and smoking-related cancers (although definitive data on lung cancer are not available) and improves quality of life.102-104 

Managing Tobacco Use

Australian clinicians should refer to RACGP Supporting smoking cessation: A guide for health professionals.

To maximize the survival benefits of ART, clinicians should consider using evidence-based behavioral and pharmacological105-107 cessation strategies when treating patients with HIV who smoke tobacco (see the tools and recommendations provided by the CDC and the U.S. Preventive Services Task Force). These include (but are not limited to) advising the patient to quit smoking, using the five A’s, employing motivational interviewing, and referring the patient to a tobacco quitline. Pharmacotherapies for smoking cessation (nicotine replacement therapy, bupropion, and varenicline) have few clinically significant interactions with ARV drugs and can lead to enormous reductions in morbidity and mortality if the person is able to stop smoking. Nicotine replacement is efficacious;108 however, bupropion doubles rates of smoking cessation compared with nicotine replacement therapy.109 Varenicline is a partial nicotine receptor agonist. In comparative studies, varenicline was more effective than bupropion in smoking cessation.109, 110 Clinical trials among people with HIV have found varenicline to be both effective and safe.105, 107 In a recent randomized controlled trial among 179 individuals with HIV who were randomized to receive 12 weeks of behavioral counseling and either varenicline or placebo, varenicline use led to an increase in the percentage of participants who achieved a 7-day abstinence period at 12 weeks (28.1% versus 12.1%, OR 4.5; 95% CI, 1.83–11.2) and produced higher continuous abstinence between weeks 9 and 12 (23.6% versus 10%, OR 4.65; 95% CI, 1.71–12.67) compared to placebo.107 Although significant between-group differences were not observed after 24 weeks, these data support the use of varenicline among people with HIV. Varenicline should be used in combination with relapse prevention strategies and other measures for long-term tobacco cessation.

Table 16:

Opioid Agonist treatment with buprenorphine has expanded in Australia to include the long-acting depot buprenorphine formulation. Dosage is given weekly or monthly. Refer to NSW Clinical Guidelines for the use of depot buprenorphine in th treatment of opioid dependence.

Depot formulation is NOT TGA approved in Australia.

Oral naltrexone is briefly included in both National1 and State2 Opioid Treatment Guidelines. However, in current Australian clinical practice it is rarely used for relapse prevention. It also requires the patient receiving treatment to be abstinent from opioids which can be challenging. Naltrexone is currently available on the PBS for the treatment of Alcohol use Disorder. Sustained release and implant preparations of naltrexone are currently not registered in Australia and remain experimental.

Ref1. https://www.health.gov.au/sites/default/files/national-guidelines-for-medication-assisted-treatment-of-opioid-dependence.pdf

Ref2. https://www.health.nsw.gov.au/aod/Pages/nsw-clinical-guidelines-opioid.aspx

Acamprosate and Bupropion are subsidised by the PBS in Australia for Nicotine Dependence.

In Australia, disulfiram is formulated in tablets of 200mg, with the recommended dose being 200- 400mg (1-2 tablets/day orally). Some patients can continue to drink on 200-400 mg without significant aversive effects, and the dose should be increased. The maintenance dosage should generally not exceed 600 mg a day.

Disulfiram not subsidised by the PBS in Australia.

Naltrexone is subsidised by the PBS in Australia for Alcohol Dependence.

Opioid Agonists Treatments (OAT) will be subsidised by the PBS in Australia from the 1st of July 2023.

Table 15. Medications for Treatment of Substance Use Disorders
Medication
Dose and Recommendations
Potential Interaction with ARV Drugs
Comments
Alcohol Use Disorder
Acamprosate666 mg PO three times a day
or
333 mg PO three times a day for people with CrCl 30–50 mL/min		No significant interaction with ARV drugs expected.Contraindicated in people with CrCl <30 mL/min
Disulfiram250 mg PO once dailyUse with caution when prescribing an ARV oral solution that contains ethanol and/or propylene glycol
(e.g., FPV, LPV/r, RTV).
Counsel people regarding disulfiram reaction when taken with alcohol; symptoms for the reaction may include flushing, tachycardia, nausea, vomiting, or hypotension.
Naltrexone50–100 mg PO once daily

Depot formulation is a fixed-dose monthly injection.		No significant interaction with ARV drugs expected.Has the greatest efficacy of all FDA-approved medications for AUD.
Opioid Use Disorder
BuprenorphineIndividualize buprenorphine dosing based on the person’s opioid use. The dose range is 4–24 mg sublingually.

Dosing is once daily or twice daily.
Potential interaction with ARV drugs that are CYP inhibitors or inducers. See Drug-Drug Interactions for further recommendations.Buprenorphine has 90% first- pass hepatic metabolism. Verify that the person is using the appropriate technique for sublingual administration before adjusting the dose, because improper administration will result in poor absorption and low drug levels.
MethadoneIndividualize the dose. People who receive higher doses (>100 mg) are more likely to remain in treatment.Potential interaction with ARV drugs that are CYP inhibitors or inducers. See Drug-Drug Interactions for further recommendations.QTc prolongation is a concern at higher doses. Methadone can be prescribed for OUD only by a licensed OTP.
Naltrexone50–100 mg PO once daily

Depot formulation is a fixed-dose monthly injection.		No significant interaction with ARV drugs expected.Longer time of continuous abstinence in those who received depot formulation naltrexone compared with placebo after transition from prison to community.
Nicotine Use Disorder
Nicotine Replacement TherapyThe FDA has approved a wide variety of nicotine replacement products. All formulations are effective.No significant interaction with ARV drugs expected.Work with the person to identify the route of delivery that they will use and find most helpful.
BupropionStart at 150 mg PO daily for 3 days, then increase to either 150 mg twice daily or 300 mg once daily (use only formulations that are approved for once-daily dosing).Concentration may be reduced when used with ARV drugs that are CYP2D6 inducers. See Drug-Drug Interactions for further recommendations.For optimal results, tobacco quit date should occur 1 week after starting therapy.
VareniclineTitrate the dose based on tolerability until the desired effect is achieved. The goal is to reach a dose of 1 mg PO twice daily.
Requires dose adjustment in people with CrCl
<30 mL/min.
No significant interaction with ARV drugs expected.Tobacco quit date ideally should be 1 week after starting therapy.

References

  1. HIV.gov. U.S. Statistics. 2019. Available at: https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics.
  2. Centers for Disease Control and Prevention. Drug Overdose Deaths. 2018. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html. 
  3. Bowman S, Eiserman J, Beletsky L, Stancliff S, Bruce RD. Reducing the health consequences of opioid addiction in primary care. Am J Med. 2013;126(7):565-571. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23664112.
  4. Shiau S, Arpadi SM, Yin MT, Martins SS. Patterns of drug use and HIV infection among adults in a nationally representative sample. Addict Behav. 2017;68:39-44. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28088742.
  5. National Institute on Drug Abuse. Club Drugs. Available at: https://www.drugabuse.gov/drugs-abuse/club-drugs.
  6. Pakianathan M, Whittaker W, Lee MJ, et al. Chemsex and new HIV diagnosis in gay, bisexual and other men who have sex with men attending sexual health clinics. HIV Med. 2018. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29790254.
  7. Kohli M, Hickson F, Free C, Reid D, Weatherburn P. Cross-sectional analysis of chemsex drug use and gonorrhoea diagnosis among men who have sex with men in the UK. Sex Health. 2019. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30760386.
  8. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155-1160. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20625025.
  9. Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr. 2001;28(1):47-58. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11579277.
  10. Marinetti L, Montgomery MA. The Use of GHB to Facilitate Sexual Assault. Forensic Sci Rev. 2010;22(1):41-59. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26242455.
  11. Basu S, Chwastiak LA, Bruce RD. Clinical management of depression and anxiety in HIV-infected adults. AIDS. 2005;19(18):2057-2067. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16284454.
  12. Wechsberg WM, Golin C, El-Bassel N, Hopkins J, Zule W. Current interventions to reduce sexual risk behaviors and crack cocaine use among HIV-infected individuals. Curr HIV/AIDS Rep. 2012;9(4):385-393. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22872433.
  13. Carrico AW, Gomicronmez W, Jain J, et al. Randomized controlled trial of a positive affect intervention for methamphetamine users. Drug Alcohol Depend. 2018;192:8-15. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30195243.
  14. Griffith DC, Farmer C, Gebo KA, et al. Uptake and virological outcomes of single- versus multi-tablet antiretroviral regimens among treatment-naive youth in the HIV Research Network. HIV Med. 2019;20(2):169-174. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30561888.
  15. Feldman MB, Kepler KL, Irvine MK, Thomas JA. Associations between drug use patterns and viral load suppression among HIV-positive individuals who use support services in New York City. Drug Alcohol Depend. 2019;197:15-21. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30743195.
  16. Starr HL, Bermak J, Mao L, Rodriguez S, Alphs L. Comparison of long-acting and oral antipsychotic treatment effects in patients with schizophrenia, comorbid substance abuse, and a history of recent incarceration: An exploratory analysis of the PRIDE study. Schizophr Res. 2018;194:39-46. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28601497.
  17. Williams J, Sayles HR, Meza JL, et al. Long-acting parenteral nanoformulated antiretroviral therapy: interest and attitudes of HIV-infected patients. Nanomedicine (Lond). 2013;8(11):1807-1813. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23611617.
  18. Philbin MM, Parish C, Bergen S, et al. A Qualitative Exploration of Women’s Interest in Long-Acting Injectable Antiretroviral Therapy Across Six Cities in the Women’s Interagency HIV Study: Intersections with Current and Past Injectable Medication and Substance Use. AIDS Patient Care and STDs. 2021;35(1). Available at: https://www.liebertpub.com/doi/10.1089/apc.2020.0164.
  19. ClinicalTrials.gov. The LATITUDE Study: Long-Acting Therapy to Improve Treatment Success in Daily Life. 2020. Available at: https://www.clinicaltrials.gov/ct2/show/NCT03635788.
  20. Williams EC, Joo YS, Lipira L, Glass JE. Psychosocial stressors and alcohol use, severity, and treatment receipt across human immunodeficiency virus (HIV) status in a nationally representative sample of US residents. Subst Abus. 2017;38(3):269-277. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27925867.
  21. Crane HM, McCaul ME, Chander G, et al. Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment. AIDS Behav. 2017;21(7):1914-1925. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28285434.
  22. Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352(6):596-607. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15703424.
  23. Scott-Sheldon LA, Carey KB, Cunningham K, Johnson BT, Carey MP, Team MR. Alcohol Use Predicts Sexual Decision-Making: A Systematic Review and Meta-Analysis of the Experimental Literature. AIDS Behav. 2016;20 Suppl 1:S19-39. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26080689.
  24. Shuper PA, Joharchi N, Monti PM, Loutfy M, Rehm J. Acute Alcohol Consumption Directly Increases HIV Transmission Risk: A Randomized Controlled Experiment. J Acquir Immune Defic Syndr. 2017;76(5):493-500. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28930769.
  25. Rehm J, Shield KD, Joharchi N, Shuper PA. Alcohol consumption and the intention to engage in unprotected sex: systematic review and meta-analysis of experimental studies. Addiction. 2012;107(1):51-59. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22151318.
  26. Williams EC, McGinnis KA, Edelman EJ, et al. Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare. AIDS Behav. 2019;23(1):140-151. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29995206.
  27. Vagenas P, Azar MM, Copenhaver MM, Springer SA, Molina PE, Altice FL. The Impact of Alcohol Use and Related Disorders on the HIV Continuum of Care: a Systematic Review : Alcohol and the HIV Continuum of Care. Curr HIV/AIDS Rep. 2015;12(4):421-436. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26412084.
  28. Braithwaite RS, McGinnis KA, Conigliaro J, et al. A temporal and dose-response association between alcohol consumption and medication adherence among veterans in care. Alcohol Clin Exp Res. 2005;29(7):1190-1197. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16046874.
  29. Braithwaite RS, Bryant KJ. Influence of alcohol consumption on adherence to and toxicity of antiretroviral therapy and survival. Alcohol Res Health. 2010;33(3):280-287. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23584069.
  30. Parsons JT, Rosof E, Mustanski B. Patient-related factors predicting HIV medication adherence among men and women with alcohol problems. J Health Psychol. 2007;12(2):357-370. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17284499.
  31. Kalichman SC, Grebler T, Amaral CM, et al. Viral suppression and antiretroviral medication adherence among alcohol using HIV-positive adults. Int J Behav Med. 2014;21(5):811-820. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24085706.
  32. Pellowski JA, Kalichman SC, Kalichman MO, Cherry C. Alcohol-antiretroviral therapy interactive toxicity beliefs and daily medication adherence and alcohol use among people living with HIV. AIDS Care. 2016;28(8):963-970. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26964014.
  33. Williams EC, Hahn JA, Saitz R, Bryant K, Lira MC, Samet JH. Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions. Alcohol Clin Exp Res. 2016;40(10):2056-2072. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27696523.
  34. Cook RL, Sereika SM, Hunt SC, Woodward WC, Erlen JA, Conigliaro J. Problem drinking and medication adherence among persons with HIV infection. J Gen Intern Med. 2001;16(2):83-88. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11251758.
  35. Kelso NE, Sheps DS, Cook RL. The association between alcohol use and cardiovascular disease among people living with HIV: a systematic review. Am J Drug Alcohol Abuse. 2015;41(6):479-488. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26286352.
  36. Lesko CR, Lau B, Chander G, Moore RD. Time Spent with HIV Viral Load > 1500 Copies/mL Among Persons Engaged in Continuity HIV Care in an Urban Clinic in the United States, 2010-2015. AIDS Behav. 2018;22(11):3443-3450. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29541913.
  37. Monroe AK, Lau B, Mugavero MJ, et al. Heavy Alcohol Use Is Associated With Worse Retention in HIV Care. J Acquir Immune Defic Syndr. 2016;73(4):419-425. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27243904.
  38. Ladak F, Socias E, Nolan S, et al. Substance use patterns and HIV-1 RNA viral load rebound among HIV-positive illicit drug users in a Canadian setting. Antivir Ther. 2019;24(1):19-25. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30230474.
  39. DeLorenze GN, Weisner C, Tsai AL, Satre DD, Quesenberry CP, Jr. Excess mortality among HIV-infected patients diagnosed with substance use dependence or abuse receiving care in a fully integrated medical care program. Alcohol Clin Exp Res. 2011;35(2):203-210. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21058961.
  40. Canan CE, Lau B, McCaul ME, Keruly J, Moore RD, Chander G. Effect of alcohol consumption on all-cause and liver-related mortality among HIV-infected individuals. HIV Med. 2017;18(5):332-341. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27679418.
  41. Eyawo O, McGinnis KA, Justice AC, et al. Alcohol and Mortality: Combining Self-Reported (AUDIT-C) and Biomarker Detected (PEth) Alcohol Measures Among HIV Infected and Uninfected. J Acquir Immune Defic Syndr. 2018;77(2):135-143. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29112041.
  42. Marcellin F, Roux P, Loko MA, et al. High levels of alcohol consumption increase the risk of advanced hepatic fibrosis in HIV/hepatitis C virus-coinfected patients: a sex-based analysis using transient elastography at enrollment in the HEPAVIH ANRS CO13 cohort. Clin Infect Dis. 2014;59(8):1190-1192. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25015913.
  43. Lim JK, Tate JP, Fultz SL, et al. Relationship between alcohol use categories and noninvasive markers of advanced hepatic fibrosis in HIV-infected, chronic hepatitis C virus-infected, and uninfected patients. Clin Infect Dis. 2014;58(10):1449-1458. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24569533.
  44. Scott-Sheldon LAJ, Carey KB, Johnson BT, Carey MP, Team MR. Behavioral Interventions Targeting Alcohol Use Among People Living with HIV/AIDS: A Systematic Review and Meta-Analysis. AIDS Behav. 2017;21(Suppl 2):126-143. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28831609.
  45. Edelman EJ, Moore BA, Holt SR, et al. Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial. AIDS Behav. 2019;23(1):211-221. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30073637.
  46. Springer SA, Di Paola A, Azar MM, et al. Extended-Release Naltrexone Improves Viral Suppression Among Incarcerated Persons Living With HIV With Opioid Use Disorders Transitioning to the Community: Results of a Double-Blind, Placebo-Controlled Randomized Trial. J Acquir Immune Defic Syndr. 2018;78(1):43-53. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29373393.
  47. Edelman EJ, Maisto SA, Hansen NB, et al. Integrated stepped alcohol treatment for patients with HIV and alcohol use disorder: a randomised controlled trial. Lancet HIV. 2019. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31109915.
  48. Barker MJ, Greenwood KM, Jackson M, Crowe SF. Cognitive effects of long-term benzodiazepine use: a meta-analysis. CNS Drugs. 2004;18(1):37-48. Available at: https://www.ncbi.nlm.nih.gov/pubmed/14731058.
  49. Darke S, Hall W, Ross M, Wodak A. Benzodiazepine use and HIV risk-taking behaviour among injecting drug users. Drug Alcohol Depend. 1992;31(1):31-36. Available at: https://www.ncbi.nlm.nih.gov/pubmed/1358587.
  50. Walton GR, Hayashi K, Bach P, et al. The Impact of Benzodiazepine Use on Mortality Among Polysubstance Users in Vancouver, Canada. Public Health Rep. 2016;131(3):491-499. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27252569.
  51. Newville H, Roley J, Sorensen JL. Prescription medication misuse among HIV-infected individuals taking antiretroviral therapy. J Subst Abuse Treat. 2015;48(1):56-61. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25245428.
  52. Motta-Ochoa R, Bertrand K, Arruda N, Jutras-Aswad D, Roy E. “I love having benzos after my coke shot”: The use of psychotropic medication among cocaine users in downtown Montreal. Int J Drug Policy. 2017;49:15-23. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28826127.
  53. Bruce RD, Altice FL, Friedland GH. Pharmacokinetic drug interactions between drugs of abuse and antiretroviral medications: implications and management for clinical practice. Expert Rev Clin Pharmacol. 2008;1(1):115-127. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24410515.
  54. Pacek LR, Towe SL, Hobkirk AL, Nash D, Goodwin RD. Frequency of Cannabis Use and Medical Cannabis Use Among Persons Living With HIV in the United States: Findings From a Nationally Representative Sample. AIDS Educ Prev. 2018;30(2):169-181. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29688777.
  55. Drug Enforcement Administration Diversion Control Division. Special Report: Synthetic Cannabinoids and Synthetic Cathinones Reported in NFLIS, 2013-2015. 2016. Available at: https://www.nflis.deadiversion.usdoj.gov/publicationsRedesign.xhtml. Accessed: May 30, 2019.
  56. Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S. A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila). 2016;54(1):1-13. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26567470.
  57. Lake S, Kerr T, Capler R, Shoveller J, Montaner J, Milloy MJ. High-intensity cannabis use and HIV clinical outcomes among HIV-positive people who use illicit drugs in Vancouver, Canada. Int J Drug Policy. 2017;42:63-70. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28336000.
  58. Lorenz DR, Dutta A, Mukerji SS, Holman A, Uno H, Gabuzda D. Marijuana Use Impacts Midlife Cardiovascular Events in HIV-Infected Men. Clin Infect Dis. 2017;65(4):626-635. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28449059.
  59. Clayton HB, Lowry R, Ashley C, Wolkin A, Grant AM. Health Risk Behaviors With Synthetic Cannabinoids Versus Marijuana. Pediatrics. 2017;139(4). Available at: https://www.ncbi.nlm.nih.gov/pubmed/28289138.
  60. Sinha S, McCaul ME, Hutton HE, et al. Marijuana use and HIV treatment outcomes among PWH receiving care at an urban HIV clinic. J Subst Abuse Treat. 2017;82:102-106. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29021107.
  61. Gates PJ, Sabioni P, Copeland J, Le Foll B, Gowing L. Psychosocial interventions for cannabis use disorder. Cochrane Database Syst Rev. 2016(5):CD005336. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27149547.
  62. Stephens RS, Roffman RA, Curtin L. Comparison of extended versus brief treatments for marijuana use. J Consult Clin Psychol. 2000;68(5):898-908. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11068976.
  63. Copeland J, Swift W, Roffman R, Stephens R. A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder. J Subst Abuse Treat. 2001;21(2):55-64; discussion 65-56. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11551733.
  64. Daskalopoulou M, Rodger A, Phillips AN, et al. Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV. 2014;1(1):e22-31. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26423813.
  65. Inciardi JA, Surratt HL, Kurtz SP, Cicero TJ. Mechanisms of prescription drug diversion among drug-involved club- and street-based populations. Pain Med. 2007;8(2):171-183. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17305688.
  66. Bracchi M, Stuart D, Castles R, Khoo S, Back D, Boffito M. Increasing use of ‘party drugs’ in people living with HIV on antiretrovirals: a concern for patient safety. AIDS. 2015;29(13):1585-1592. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26372268.
  67. Colfax G, Guzman R. Club drugs and HIV infection: a review. Clin Infect Dis. 2006;42(10):1463-1469. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16619161.
  68. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419-1427. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30605448.
  69. Bruce RD, Merlin J, Lum PJ, et al. 2017 HIV Medicine Association of Infectious Diseases Society of America Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With Human Immunodeficiency Virus. Clin Infect Dis. 2017;65(10):1601-1606. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29091230.
  70. Khatri UG, Viner K, Perrone J. Lethal Fentanyl and Cocaine Intoxication. N Engl J Med. 2018;379(18):1782. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30380395.
  71. LaRue L, Twillman RK, Dawson E, et al. Rate of Fentanyl Positivity Among Urine Drug Test Results Positive for Cocaine or Methamphetamine. JAMA Netw Open. 2019;2(4):e192851. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31026029.
  72. Hoots BE, Finlayson TJ, Broz D, Paz-Bailey G, Group NS. Antiretroviral Therapy Use Among HIV-Infected People Who Inject Drugs-20 Cities, United States, 2009-2015. J Acquir Immune Defic Syndr. 2017;75 Suppl 3:S392-S396. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28604444.
  73. Lesko CR, Tong W, Moore RD, Lau B. Retention, Antiretroviral Therapy Use and Viral Suppression by History of Injection Drug Use Among HIV-Infected Patients in an Urban HIV Clinical Cohort. AIDS Behav. 2017;21(4):1016-1024. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27752872.
  74. Altice FL, Bruce RD, Lucas GM, et al. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study. J Acquir Immune Defic Syndr. 2011;56 Suppl 1:S22-32. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21317590.
  75. Kresina TF, Bruce RD, McCance-Katz EF. Medication assisted treatment in the treatment of drug abuse and dependence in HIV/AIDS infected drug users. Curr HIV Res. 2009;7(4):354-364. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19601770.
  76. Woody GE, Bruce D, Korthuis PT, et al. HIV risk reduction with buprenorphine-naloxone or methadone: findings from a randomized trial. J Acquir Immune Defic Syndr. 2014;66(3):288-293. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24751432.
  77. Schottenfeld RS, Chawarski MC, Mazlan M. Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial. Lancet. 2008;371(9631):2192-2200. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18586174.
  78. Kirchmayer U, Davoli M, Verster AD, Amato L, Ferri A, Perucci CA. A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence. Addiction. 2002;97(10):1241-1249. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12359026.
  79. Hartzler B, Dombrowski JC, Crane HM, et al. Prevalence and Predictors of Substance Use Disorders Among HIV Care Enrollees in the United States. AIDS Behav. 2017;21(4):1138-1148. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27738780.
  80. Mimiaga MJ, Reisner SL, Grasso C, et al. Substance use among HIV-infected patients engaged in primary care in the United States: findings from the Centers for AIDS Research Network of Integrated Clinical Systems cohort. Am J Public Health. 2013;103(8):1457-1467. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23763417.
  81. Rosen MI, Black AC, Arnsten JH, et al. Association between use of specific drugs and antiretroviral adherence: findings from MACH 14. AIDS Behav. 2013;17(1):142-147. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22246513.
  82. Vu NT, Maher L, Zablotska I. Amphetamine-type stimulants and HIV infection among men who have sex with men: implications on HIV research and prevention from a systematic review and meta-analysis. J Int AIDS Soc. 2015;18:19273. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25609214.
  83. Chitsaz E, Meyer JP, Krishnan A, et al. Contribution of substance use disorders on HIV treatment outcomes and antiretroviral medication adherence among HIV-infected persons entering jail. AIDS Behav. 2013;17 Suppl 2:S118-127. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23673792.
  84. Mediouni S, Marcondes MC, Miller C, McLaughlin JP, Valente ST. The cross-talk of HIV-1 Tat and methamphetamine in HIV-associated neurocognitive disorders. Front Microbiol. 2015;6:1164. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26557111.
  85. Tyagi M, Weber J, Bukrinsky M, Simon GL. The effects of cocaine on HIV transcription. J Neurovirol. 2016;22(3):261-274. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26572787.
  86. Dash S, Balasubramaniam M, Villalta F, Dash C, Pandhare J. Impact of cocaine abuse on HIV pathogenesis. Front Microbiol. 2015;6:1111. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26539167.
  87. Carrico AW, Flentje A, Kober K, et al. Recent stimulant use and leukocyte gene expression in methamphetamine users with treated HIV infection. Brain Behav Immun. 2018;71:108-115. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29679637.
  88. Carrico AW, Cherenack EM, Roach ME, et al. Substance-associated elevations in monocyte activation among methamphetamine users with treated HIV infection. AIDS. 2018;32(6):767-771. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29369159.
  89. Jin H, Ogunbajo A, Mimiaga MJ, et al. Over the influence: The HIV care continuum among methamphetamine-using men who have sex with men. Drug Alcohol Depend. 2018;192:125-128. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30248558.
  90. Minozzi S, Cinquini M, Amato L, et al. Anticonvulsants for cocaine dependence. Cochrane Database Syst Rev. 2015(4):CD006754. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25882271.
  91. Minozzi S, Amato L, Pani PP, et al. Dopamine agonists for the treatment of cocaine dependence. Cochrane Database Syst Rev. 2015(5):CD003352. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26014366.
  92. Hayashi K, Wood E, Kerr T, et al. Factors associated with optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA non-detectability among HIV-positive crack cocaine users: a prospective cohort study. BMC Infect Dis. 2016;16(1):455. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27568002.
  93. Berg KM, Litwin A, Li X, Heo M, Arnsten JH. Directly observed antiretroviral therapy improves adherence and viral load in drug users attending methadone maintenance clinics: a randomized controlled trial. Drug Alcohol Depend. 2011;113(2-3):192-199. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20832196.
  94. Bruce R. Addiction In: Secondary Bruce R, ed^eds. Subsidiary Bruce R, trans. Secondary Addiction Vol. 3rd ed.: Oxford University Press; 2011.
  95. Trivedi MH, Walker R, Ling W, dela Cruz A. Buproprion and Naltrexone in Methamphetamine Use Disorder. N Engl J Med. 2021;384:140-153. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa2020214.
  96. Burch AE, Rash CJ, Petry NM. Cocaine-using substance abuse treatment patients with and without HIV respond well to contingency management treatment. J Subst Abuse Treat. 2017;77:21-25. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28476266.
  97. Moore DJ, Pasipanodya EC, Umlauf A, et al. Individualized texting for adherence building (iTAB) for methamphetamine users living with HIV: A pilot randomized clinical trial. Drug Alcohol Depend. 2018;189:154-160. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29958127.
  98. Carrico AW, Hunt PW, Neilands TB, et al. Stimulant Use and Viral Suppression in the Era of Universal Antiretroviral Therapy. J Acquir Immune Defic Syndr. 2019;80(1):89-93. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30272634.
  99. Frazier EL, Sutton MY, Brooks JT, Shouse RL, Weiser J. Trends in cigarette smoking among adults with HIV compared with the general adult population, United States – 2009-2014. Prev Med. 2018;111:231-234. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29550303.
  100. Helleberg M, May MT, Ingle SM, et al. Smoking and life expectancy among HIV-infected individuals on antiretroviral therapy in Europe and North America. AIDS. 2015;29(2):221-229. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25426809.
  101. Reddy KP, Parker RA, Losina E, et al. Impact of Cigarette Smoking and Smoking Cessation on Life Expectancy Among People With HIV: A US-Based Modeling Study. J Infect Dis. 2016;214(11):1672-1681. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27815384.
  102. Petoumenos K, Worm S, Reiss P, et al. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study(*). HIV Med. 2011;12(7):412-421. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21251183.
  103. Vidrine DJ, Arduino RC, Gritz ER. The effects of smoking abstinence on symptom burden and quality of life among persons living with HIV/AIDS. AIDS Patient Care STDS. 2007;21(9):659-666. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17919093.
  104. Shepherd L, Ryom L, Law M, et al. Cessation of Cigarette Smoking and the Impact on Cancer Incidence in Human Immunodeficiency Virus-infected Persons: The Data Collection on Adverse Events of Anti-HIV Drugs Study. Clin Infect Dis. 2019;68(4):650-657. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29912335.
  105. Mercie P, Arsandaux J, Katlama C, et al. Efficacy and safety of varenicline for smoking cessation in people living with HIV in France (ANRS 144 Inter-ACTIV): a randomised controlled phase 3 clinical trial. Lancet HIV. 2018;5(3):e126-e135. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29329763.
  106. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387(10037):2507-2520. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27116918.
  107. Ashare RL, Thompson M, Serrano K, et al. Placebo-controlled randomized clinical trial testing the efficacy and safety of varenicline for smokers with HIV. Drug Alcohol Depend. 2019;200:26-33. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31082665.
  108. Amodei N, Lamb RJ. The role of nicotine replacement therapy in early quitting success. Nicotine Tob Res. 2010;12(1):1-10. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19897526.
  109. Gonzales D, Rennard SI, Nides M, et al. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):47-55. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16820546.
  110. West R, Baker CL, Cappelleri JC, Bushmakin AG. Effect of varenicline and bupropion SR on craving, nicotine withdrawal symptoms, and rewarding effects of smoking during a quit attempt. Psychopharmacology (Berl). 2008;197(3):371-377. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18084743.

The ARV Guidelines with Australian commentary is administered by ASHM

The Australian Government Department of Health

While the Australian Department of Health provides financial support for the ARV Guidelines, the material contained in this resource should not be taken to represent the views of the Australian Department of Health.

Developing a sustainable HIV, Viral Hepatitis and Sexual Health Workforce

Information

About ASHMFeedback
Glossary of TermsPrivacy Policy
AcknowledgementsDisclosure Statements

Acknowledgement of Country

We pay our respects to the Aboriginal and Torres Strait Islander peoples of the past, present, and future, including the Gadigal peoples (Sydney office), the Turrbal and Jagera/Yuggera peoples (Brisbane office), and all First Nations people of the nations where we live and work.

ASHM Health | ABN 48 264 545 457 | CFN 17788 | Copyright © 2024 ASHM

Scroll to Top