Substance Use Disorders and HIV

Last Updated: July 10, 2019; Last Reviewed: July 10, 2019

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). Persons with HIV and SUDs should be screened for additional mental health disorders (AII). Persons with HIV and SUDs should be offered evidenced-based pharmacotherapy (e.g., opioid agonist therapy, tobacco cessation treatment, alcohol use disorder treatment; see Table 13) as part of comprehensive HIV care in HIV clinical settings (AI). Ongoing substance use is not a contraindication to antiretroviral therapy (ART) (AI). Persons 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 ART regimens for individuals who practice unhealthy substance and alcohol use should take potential adherence barriers, comorbidities which 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 into account (AII). ART 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

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).
Persons with HIV and SUDs should be screened for additional mental health disorders (AII).
Persons with HIV and SUDs should be offered evidenced-based pharmacotherapy (e.g., opioid agonist therapy, tobacco cessation treatment, alcohol use disorder treatment; see Table 13) as part of comprehensive HIV care in HIV clinical settings (AI).
Ongoing substance use is not a contraindication to antiretroviral therapy (ART) (AI). Persons 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 ART regimens for individuals who practice unhealthy substance and alcohol use should take potential adherence barriers, comorbidities which 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 into account (AII).
ART 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

Medication	Dose and Recommendations	Potential Interaction with ARV Drugs	Comments
Acamprosate	666 mg PO three times a day or 333 mg PO three times a day for patients with CrCl 30–50 mL/min	No significant interaction with ARV drugs expected.	Contraindicated in patients with CrCl <30 mL/min.
Disulfiram	250 mg PO once daily	Use with caution when prescribing an ARV oral solution that contains ethanol and/or propylene glycol (e.g., FPV, LPV/r, RTV).	Counsel patients regarding disulfiram reaction when taken with alcohol; symptoms for the reaction may include flushing, tachycardia, nausea, vomiting, or hypotension.
Naltrexone	50–100 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 alcohol use disorder.
Key: ARV = antiretroviral; CrCl = creatinine clearance; CYP = cytochrome P; FDA = Food and Drug Administration; FPV = fosamprenavir; LPV/r = lopinavir/ritonavir; OUD = opioid use disorder; OTP = opioid treatment program; PO = orally; RTV = ritonavir; SR = sustained release

Medication	Dose and Recommendations	Potential Interaction with ARV Drugs	Comments
Buprenorphine	Individualize buprenorphine dosing based on a patient’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 patient is using the appropriate technique for sublingual administration before adjusting the dose, as improper administration will result in poor absorption and low drug levels.
Methadone	Individualize dose. Patients 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 only be prescribed for OUD by a licensed OTP.
Naltrexone	50–100 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 to placebo after transition from prison to community.
Key: ARV = antiretroviral; CrCl = creatinine clearance; CYP = cytochrome P; FDA = Food and Drug Administration; FPV = fosamprenavir; LPV/r = lopinavir/ritonavir; OUD = opioid use disorder; OTP = opioid treatment program; PO = orally; RTV = ritonavir; SR = sustained release

Medication	Dose and Recommendations	Potential Interaction with ARV Drugs	Comments
Nicotine Replacement Therapy	There are a wide variety of FDA-approved nicotine replacement products. All formulations are effective.	No significant interaction with ARV drugs expected.	Work with the patient to identify the route of delivery that the patient will use and find most helpful.
Bupropion	Start at 150 mg PO daily for three days, then increase to either 150 mg twice daily or 300 mg once daily (only use 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.	Tobacco quit date should ideally be 1 week after starting therapy.
Varenicline	Titrate dose based on tolerability until desired effect is achieved. The goal is to reach a dose of 1 mg PO twice daily. Requires dose adjustment in patients with CrCl <30 mL/min.	No significant interaction with ARV drugs expected.	Tobacco quit date should ideally be 1 week after starting therapy.
Key: ARV = antiretroviral; CrCl = creatinine clearance; CYP = cytochrome P; FDA = Food and Drug Administration; FPV = fosamprenavir; LPV/r = lopinavir/ritonavir; OUD = opioid use disorder; OTP = opioid treatment program; PO = orally; RTV = ritonavir; SR = sustained release