Substance abuse is the excessive use of a substance, such as drugs or alcohol, which results in clinical and functional impairments.
This loss of function can include detriments to professional, academic, and social interactions 1. Ongoing substance abuse can cause severe health problems over time, even in previously healthy individuals. These health complications include increased disease risk, difficulty in detecting and diagnosing certain disease states, a reduced inherent ability to recover from certain diseases, and a decrease in the effectiveness of various treatments.
With regard to HIV and AIDS, substance abuse plays a significant factor in infection and disease progression. Although HIV/AIDS can affect anyone, the risk of infection is significantly higher in patients suffering from substance abuse, whether the risk is of direct exposure through needles or increased likelihood of high risk behavior due to loss of judgment. Substance abuse is of primary concern to HIV/AIDS by promoting actions which increase the initial risk of infection. Furthermore, some abused substances can also influence disease progression and interfere with the effectiveness of treatment.
HIV (human immunodeficiency virus) is a virus that is transmitted in bodily fluids, often by sharing a used needle or having sexual intercourse with an infected individual.
When a person becomes exposed to HIV, the virus infects the patient’s white blood cells, particularly CD4+ T cells 2.
These T cells are crucial players in a healthy body’s ability to mount an appropriate immune response to infections – their loss results in markedly diminished immune functioning.
After this time, the disease enters the chronic stage of HIV infection which may last for several years. With effective treatment this stage can be extended to several decades in some patients. During this stage, the virus continues to replicate and stimulate an immune response. This chronic response may be due in part to an increased, system-wide bacterial load resulting from the decreased vigilance of a weakened immune system 3. The immune system actively attempts to replenish the lost T cells, which also subsequently become infected by the virus. This chronic immune and T cell activation causes additional strain on the immune system as the body loses the ability to maintain a sufficient supply of T cells.
The heightened activation of T cells can be used as a predictor for disease progression toward AIDS 4. Once there are no longer enough T cells to mount an immune response, a patient crosses below an immunological threshold and is considered to have developed acquired immunodeficiency syndrome (AIDS). Because of the association of the virus (HIV) with the late stage disease (AIDS), this guide will refer to the virus itself as HIV and to the whole disease as HIV/AIDS.
The diminished immune function puts HIV/AIDS patients at a greater risk of infection with many opportunistic diseases that would not otherwise affect a healthy individual. HIV/AIDS also places these patients at a higher risk of increased disease severity when they are exposed to any illness. The risk of these additional infections varies by the individual and where they live. For example, HIV/AIDS patients in poor nations face an increased risk of tuberculosis (TB), making TB a leading cause of death for HIV/AIDS patients in those areas 6. TB is generally not considered to be a major problem in most developed countries, but HIV/AIDS patients are highly susceptible to infection. Patients who care for cats and come in contact with cat litter or cat feces face an increased risk of toxoplasmosis. Toxoplasma gondii is a common protozoan parasite, and many healthy people are exposed to it regularly. Although exposure to Toxoplasma normally only results in a mild reaction, it can be harmful to pregnant women and it can be fatal to individuals with weakened immune systems 7.
In some cases these cancer risks are due to other factors commonly associated with HIV/AIDS. For example, smoking is more common among HIV/AIDS patients, and the increased smoking rate among HIV/AIDS patients may account for much of the increased incidence of lung cancer among that population. However, other cancers appear to be more common as a result of HIV infection and disease progression. Because HIV primarily targets immune cells, HIV/AIDS can lead to lymphoma, which is a cancer of the white blood cells. Another cancer common in HIV/AIDS patients and rare in uninfected people is Kaposi’s sarcoma. This cancer affects blood vessels and causes the characteristic reddish lesions that have often been associated with AIDS patients. Other cancers, including Hodgkin disease and testicular seminoma also appear to occur at a higher frequency in HIV/AIDS patients as a result of decreased immune function 8.
Other complications experienced in a conjunction with HIV/AIDS include severe weight loss and kidney disease. The weight loss experienced in AIDS patients is referred to as wasting syndrome and is marked by a greater than ten percent loss of body weight. This weight loss is often attributed to a loss of muscle mass and may be associated with diarrhea and extreme weakness. Kidney disease associated with HIV infection is referred to as HIV-associated nephropathy. This form of kidney disease is characterized by glomerular lesions in the kidneys. Prior to the introduction of antiretroviral therapies, HIV-associated nephropathy often led to kidney failure and the need for life-sustaining dialysis.
Indirect risks are changes in behavior that increase the chance that someone would be exposed to the virus. The abuse of alcohol and other non-injection drugs is associated with an increased risk of HIV infection 9. Many drugs, including alcohol, reduce inhibitions and impair judgment. As a result, alcohol may make risky behavior more likely, such as unprotected sex and sex with multiple partners. In cases such as this, the use of alcohol is not directly related to HIV/AIDS risk, but the actions as a result of substance abuse can lead to increased risk. This is true for nearly all substance abuse. Anything that impairs judgment also increases risk.
This is extremely important for HIV/AIDS patients because their immune systems are already weakened by the disease. Further weakening the immune system increases the risk of additional infections while also raising the chance that HIV replication may increase. Even with proper medication, such as antiretroviral therapy (ART), maintaining the best immune function possible is important to preventing disease progression. HIV patients who are heavy drinkers have diminished effectiveness of antiretroviral therapies. Specifically, heavy drinkers are two to four times less likely to achieve a positive response while undergoing antiretroviral therapies 11.
Excessive alcohol consumption can lead to liver damage, cirrhosis, and eventually culminate in end stage liver failure. Because of the liver damage associated with ethanol consumption, alcohol is particularly problematic for other conditions that also affect the liver. This is the case for HIV/AIDS patients, given the hepatic consequences of HIV itself combined with the impact that HIV/AIDS pharmaceutical treatment can have on the liver.
As mentioned, many HIV/AIDS patients also suffer from other infections that affect the liver, such as hepatitis 12. HIV infection can exacerbate the liver damage caused by these other diseases. Many drugs used to treat HIV, such as antiretroviral drugs, carry a risk of liver toxicity. Because treatment of HIV takes priority over many other medical issues, patients will often receive treatment even in the presence of prior liver damage. Because it is so important to continue to treat HIV infection, it is also important to minimize any additional risks of liver damage.Alcohol is not the only substance that can be abused. Any chemical that changes the way the mind or body functions is defined as a drug. Substance abuse includes the use of illicit drugs, such as the misuse of prescription drugs or the use of recreational or illegal drugs. Drugs that have not been approved by a physician for medical use are characterized as recreational or illegal drugs. This text focuses on the drugs that are used by people with HIV and AIDS and how those drugs can negatively impact their health and prognosis.
Different drugs have different effects depending on the individual, with many well document negative health consequences for the general population. It follows that drug use can have detrimental effects on HIV/AIDS patients. These effects range from increased risk of contracting HIV, as described above, to decreased effectiveness of medications and treatment.
The rate of smoking is two to three times higher in HIV-positive adults than in the general population. This is of significant concern for HIV/AIDS patients due to the increased risk of various diseases related to smoking, and how that risk is affected by being HIV-positive.
Because HIV weakens the immune system, HIV/AIDS patients who smoke have an increased risk of mouth, throat, and lung infections. In particular, HIV/AIDS sufferers who smoke are more likely to contract pneumonia, such as bacterial or Pneumocystis carinii pneumonia (of note, this particular pneumonia is commonly abbreviated as ‘PCP’; not to be confused with the dissociative drug phencyclidine) 13. Furthermore, HIV/AIDS patients who contract this illness are far more likely to require hospitalization for treatment. Pneumocystis is an opportunistic pathogen that does not normally cause disease but, in immunocompromised individuals and HIV/AIDS patients, it can lead to a potentially life-threatening infection. Other diseases of the respiratory tract include a candidal, or yeast infection of the mouth referred to as thrush or leukoplakia 14, which is characterized by white sores in the mouth. Smoking can potentially produce an oral environment even more conducive to the development of these lesions.
Other debilitating and potentially life-threatening diseases which disproportionately affect HIV-positive smokers include heart disease, stroke, cancer, and chronic obstructive pulmonary disease (COPD). HIV and HIV treatment also increases the risks of some of certain conditions that are associated with smoking, such as osteoporosis, stroke, and heart attacks 15. While smoking or HIV/AIDS alone may lead to many of these conditions, HIV/AIDS patients have a greater risk of these conditions if they smoke, further diminishing quality of life.
As mentioned above, illicit drug use affects HIV risk, HIV/AIDS complications, HIV/AIDS treatment efficacy, and long-term HIV/AIDS prognosis. Illicit drug users have increased risk of contracting HIV through the use of used needles, shared injection supplies, contaminated injection drugs, and reduced judgment leading to a heightened chance of high risk behavior.
For illicit drug users who have HIV/AIDS, the complications due to the illicit drugs and the conditions associated with their use lead to poor treatment. Illicit drug users with HIV are less likely to have access to effective treatment options. This lack of treatment options comes in the form of relatively few accommodating rehabilitation services to address the illicit drug use as well as limited access to clinics and antiretroviral therapies to treat their HIV.
Along with the increased risk of contracting HIV, the impaired judgment and mental effects of illicit
Many illicit drugs are associated with HIV infection and AIDS by being commonly found within the same populations. Due to the risk of being exposed to HIV by drug injection, all injection drugs can be linked to directly to HIV/AIDS. Non-injection drugs are more likely to be associated HIV transmission by increasing the likelihood of risky behavior such as unprotected sex or sex with multiple partners. Illicit drugs also reduce the effectiveness of HIV/AIDS treatment by interfering with the ability of a patient to seek treatment and taking focus and attention off of maintaining a successful treatment regimen.
Injection drugs most commonly associated with HIV/AIDS include heroin, a depressant opioid, and cocaine, a stimulant. Various forms of amphetamine can also be abused via an intravenous route of administration. Although these are associated with HIV risk, these drugs are all floridly addictive and, without addiction treatment, it is likely that drug use of this type will continue throughout any possible HIV/AIDS treatment. It is not known whether any of these drugs directly interfere with antiretroviral therapies.
Marijuana, other stimulants, and street or club drugs (e.g., ketamine, methamphetamine, amyl nitrate) are strongly associated with sexual transmission of HIV. This is particularly true of amphetamine and amyl nitrate (poppers) which may be used to enhance sexual pleasure. As with other illicit drugs, anything that decreases the adherence to therapy for HIV/AIDS patients decrease the effectiveness of treatment and ultimately diminishes quality of life.
As mentioned above, illicit drug use can interfere with treatment of HIV/AIDS. Although illicit drugs may not interact directly with many antiretroviral treatments, the use of illicit drugs can interfere with treatment schedules.
The legal consequences of illegal drug use may also pose a barrier to treatment of HIV/AIDS. Individuals who are concerned about possible punishments for illegal drugs are less likely to come forward for treatment. This fear of stepping forward decreases the likelihood of a person seeking treatment and increases the chances that HIV may be passed to other people. This environment creates a cycle where people are more likely to engage in risky behavior as a result of their drug use and they are more likely to remain in their environment out of a fear of punishment. Furthermore, some medical providers are more reluctant to provide equal services to someone who is actively abusing illicit drugs since it is unlikely that the patient will be able to adhere to an effective and successful treatment regimen.
In some cases, the use of illicit drugs or the medications used for recovery from illicit drug use may increase the risk of side effects from antiretroviral therapies. The medications used to aid recovery from addition to illicit drugs do not typically interfere with the efficacy of HIV/AIDS treatments.
Methadone is a common treatment option for opioid addiction. It is safe for use with antiretroviral therapies, although there are slight interactions. In particular, antiretroviral medications may lead to a decrease therapeutic methadone levels in patients. For this reason, these patients may require higher doses of methadone for effective treatment.
The good news is that HIV therapies are effective in drug users. Substance abuse can lead to an increased risk of HIV exposure, reduce an individual’s ability to get treatment and follow a treatment schedule, and lead to potential complications. However, despite these issues, HIV medications can remain effective in drug users. Illicit drug use should not pose a barrier to HIV/AIDS treatment. Furthermore, the knowledge of existing drug use shouldn’t prompt negative clinician bias against treatment.
Methamphetamine use is associated with risk of HIV infection, but it can also exacerbate symptoms associated with HIV/AIDS. Methamphetamine and HIV/AIDS both carry risks of neurological symptoms, and these symptoms are compounded in HIV-positive patients who abuse methamphetamines. A study examined the cognitive impairment among control patients, HIV-positive individuals, methamphetamine users, and HIV-positive methamphetamine users 16. This study found that either methamphetamine or HIV caused cognitive impairment when compared to the control group, but the cognitive impairment was significantly worse in the HIV-positive methamphetamine users. This indicates that the use of methamphetamines may accelerate the cognitive decline associated with HIV infection.
An active HIV infection is often measured by the number of active viral particles. Even in cases where the viral load is equal between cocaine users and control patients, the CD4 T cell population was reduced in the cocaine users 18. While adherence to treatment is always a concern in the context of illicit drug use, adherence to antiretroviral therapy is not sufficient to manage HIV in the context of cocaine use. These studies indicate that treatment for substance abuse is a necessary part of an effective HIV treatment program.
Substance abuse is associated with increased risk of contracting HIV and a reduced effectiveness of HIV/AIDS treatment. In many cases, substance abuse is a causal factor for HIV infection. For some illicit drugs, including methamphetamine and cocaine, drug use can have adverse consequences on HIV and other disease progression. Illicit drug users are at increased risk of contracting HIV through unprotected sex or through shared supplies for injection drugs. Complications range from pulmonary infections in smokers to lapses in medications for illicit drug users.
Several effective treatments for substance abuse exist. Many of these treatments can be given alongside antiretroviral therapies for the treatment of HIV/AIDS. Even without the complications of HIV/AIDS, substance abuse is a leading cause of death and emergency room visits 19. Effective substance abuse programs and treatments make this a preventable illness with multiple treatment options available.
Ongoing substance abuse can lead to organ damage 20, exacerbating the damage caused by HIV/AIDS. In some cases, the damage can also lead to increased risk of various infections or cancers, which are particularly dangerous for HIV/AIDS patients.
Termination of substance abuse can be a painful and debilitating process. For patients suffering from other diseases, such as HIV/AIDS, the process can be even more difficult. It is important to seek treatment immediately to reduce the associated risks and to receive help in controlling substance abuse. Although various medications can help the process and reduce cravings, withdrawal from illicit drugs or alcohol can lead to intense cravings, fever, sweating, nausea, vomiting, and pain throughout the body. For some types of substance abuse—including that of alcohol and benzodiazepines—the process
of withdrawal can be quite severe and, even, life threatening. With medically supervised or medically assisted addiction treatment, the early stages can be managed at a care facility, where physicians can monitor a patient’s progress and help manage their withdrawal symptoms. Getting help through the withdrawal process can make the process easier and also lead to additional opportunities for long-term mental health care to reduce the risk of relapse.
Substance abuse and HIV/AIDS are very difficult and complex diseases. The combination of these factors can increase risks of many dangerous infections and cancers and can complicate treatment options. Each condition requires intensive treatments in order to properly manage them, and the association of substance abuse with HIV/AIDS makes those treatments that much more difficult. Effective treatment of substance abuse is critical in all individuals and can lead to an improved quality of life. For anyone suffering from either of these conditions, the best option is too seek out qualified medical care and effective professional substance abuse treatment.
