"Nobody's Going to Say No to a Dollar": Exploring HIV Medication Diversion As a Survival Strategy amid Chronic Poverty Among Black and Latino People Living with HIV

Background/Purpose: Antiretroviral-therapy (ART) diversion, the sale or trade of prescribed HIV medications, is an under-researched but persistent phenomenon among people living with HIV (PLWH). While often framed as non-adherence, ART diversion may function as a survival strategy shaped by chronic poverty. Few studies have included the perspectives of those directly engaged in it. The present study explored how Black and Latino PLWH experiencing chronic poverty navigate ART diversion.

Methods: This study draws on qualitative interview data from two larger intervention studies involving Black and Latino PLWH (N=38) experiencing barriers to HIV care engagement. Although ART diversion was not a primary focus of either study, it was identified as an unexpected yet salient theme. Data were reanalyzed for the present study, focusing on ART diversion. Analyses were guided by the Intervention Innovations Team’s Integrated Conceptual Model (IIT-ICM), which integrates critical race theory, harm reduction, and self-determination theory. Data were co-coded using Dedoose. Analyses were inductive and employed a phenomenological approach.

Results: Participants were mostly cisgender men (74%), Black (84%), heterosexual (66%), with a mean age of 48 (SD=9) and had lived with HIV for an average of 18.7 years (SD=8). Nearly all reported prior ART use (97%), and most reported indicators of poverty, including food insecurity (85%), unstable housing (52%), regularly running out of funds for basic needs (48%), and current unemployment (90%). Substance use was also common, approximately half reported alcohol (57%), cannabis (52%), and cocaine (48%) use at moderate-to-high risk levels, and 76% reported past substance use treatment. Findings illustrate how Black and Latino PLWH understood and navigated ART diversion in relation to their health, economic, and overall well-being. Participants described ART diversion as a survival strategy shaped by intersecting systems of poverty, racism, criminalization, and structural neglect. ART functioned not only as HIV medication but also as a form of currency. Results are organized along three overarching categories: 1) Dynamics of ART diversion, including material survival strategies, substance use and economic survival, and exploitation; 2) Navigating ART management in the context of diversion, including stretching ART, provider scrutiny, and perceptions of long acting injectables (LAI); and 3) Transitioning away from ART diversion, including precarious stability, aging, and HIV survivorship.

Conclusions/Implications: Together, these results describe ART diversion as a contextually driven response to chronic poverty, survival needs, and the desire to maintain control over health, economic, and overall well-being. ART diversion among Black and Latino PLWH experiencing chronic poverty must be understood as rooted in economic survival and structural exclusion. Rather than criminalize it, HIV care systems should consider adopting structurally competent, harm reduction-informed approaches that address the material conditions driving diversion. Clinical implications include expanding legal, low-barrier financial incentive programs. Pharmacies and LAI programs should consider offering participant incentives that match or exceed the cash value of ART diversion to mitigate treatment disruption. Policy recommendations include investing in structural supports, such as increased access to housing and income assistance for PLWH. Interventions that prioritize both viral suppression and economic well-being are essential to advancing equity in HIV care.