Differential Effects of Substance Use on HIV Outcomes: A Longitudinal Analysis Among People Living with HIV

Background and Purpose: People living with HIV (PLWH) who use substances face persistent barriers to care, including reduced treatment adherence and worse clinical outcomes. While prior research has shown general associations between substance use and HIV-related health, less is known about how specific substances differentially affect self-management, adherence, and symptom burden over time. As public health systems seek to tailor interventions for high-risk populations, identifying substance-specific risks is critical. This study conducted a secondary data analysis of a randomized controlled trial (RCT) that evaluated a behavioral intervention for PLWH in two U.S. cities disproportionately affected by the HIV epidemic—New York City and Birmingham, Alabama. The current study aimed to examine whether baseline use of distinct substance classes predicted HIV-related outcomes at 6 and 12 months, including adherence self-efficacy, self-reported adherence, HIV self-management, and symptom distress. We hypothesized that greater use of specific substances would predict poorer outcomes.

Methods: Participants were recruited from HIV clinical and community-based settings using purposive sampling. They completed surveys at baseline, 6 months, and 12 months. Measures included the WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), the HIV Treatment Adherence Self-Efficacy Scale (ASES), a validated single-item visual analogue scale (VAS) of self-reported medication adherence, the HIV Symptom Distress Module (SDM), and the HIV Self-Management Scale. Linear and ordinal regression models were fit on multiply imputed datasets using chained equations, adjusting for intervention assignment, site, and sociodemographic characteristics (age, gender identity, sex assigned at birth, race, sexual orientation, education level, and annual income).

Results: The sample (N = 300) had a mean age of 48.1 years (SD = 11.7); 74.7% identified as Black/African American; 44.4% identified as women, and 6.7% identified as transgender, queer, or another gender identity; over half (51%) earned less than $10,000 annually, and 28% had less than a high school education. Results revealed that baseline cocaine use predicted lower self-reported adherence at 6 months (β = –5.03, p = .018), and methamphetamine use predicted poorer HIV self-management at 12 months (β = –2.92, p = .025). Inhalant use was associated with higher HIV symptom distress at 6 months (β = 8.33, p = .015), while hallucinogen use predicted lower adherence self-efficacy at 12 months (β = –20.26, p = .039).

Conclusions and Implications: Findings underscore the clinical significance of substance-specific effects on HIV outcomes. Cocaine, methamphetamine, inhalants, and hallucinogens were each uniquely associated with poorer adherence to health management later on. These results support the need for tailored risk assessments and integrated behavioral health interventions that address specific patterns of substance use among PLWH. Incorporating nuanced substance use profiles into HIV care may improve long-term health outcomes, particularly for underserved communities facing intersecting structural and behavioral health disparities.