Screening and Ongoing Assessment for Substance Abuse in HIV

Guideline and Commentary

Barbara Chaffee, MD, MPH


April 05, 2011

In This Article

Substance Abuse in HIV: Expert Commentary

In the early 1990s, on the door of a bar in a small city where HIV was not yet common, there was among the scribbled graffiti the phrase "Sex for coke -- call Linda." The words and their location (a bar) summarized how the HIV epidemic would grow through sex, drug and alcohol use, and sex in exchange for drugs. In the past 30 years of the HIV epidemic, great progress has been made in treatment but not nearly so much progress in prevention, and drug and alcohol use are key culprits.

Problematic drug and alcohol use and abuse are associated with many medical problems, perhaps none so much as HIV/AIDS. A person who is drinking heavily is more likely than his/her sober peers to practice unsafe sex and therefore is at increased risk of acquiring and spreading HIV infection.

HIV infection is passed by sexual contact, blood exposure, and from mother to child. Because mood-altering drugs including alcohol are frequently associated with unsafe sex and/or needle sharing, the prevalence of problematic drug and alcohol use is high among patients with HIV/AIDS. This drug and alcohol use then further increases the risk for transmission of HIV infection. In addition to increasing the risk for transmission, alcohol has a direct toxic effect on the immune system lowering the CD4 count and increasing the HIV viral load.(1)

Once infected, a substance-using patient is less likely to adhere to antiretroviral medications correctly, thus increasing the risk for viral resistance. This sequence of events applies to alcohol and all forms of drug use. Fortunately, needle exchange programs and information about cleaning needles have reduced the rate of new infections due to needle sharing, but people with drug and alcohol misuse problems remain a population at increased risk for HIV.

Clinicians caring for patients with HIV/AIDS therefore need to screen all HIV/AIDS patients for ongoing or recurrent drug and alcohol use and abuse. There are many screening tools that can help identify these problems. None of these tools is perfect, and the most important element of a good history is probably the manner by which the clinician asks the questions: a nonjudgmental tone and body language being key.

An anonymous wit has said that an alcoholic is a patient who drinks more than the doctor. A better definition is that an alcoholic is someone whose use of alcohol causes medical, social, or legal problems, and that person is unable to change his/her use in reaction to these problems. Motivating patients to accept treatment of their drug and alcohol dependence is not easy and often takes a long time; making the diagnosis and helping patients accept the diagnosis is the first step.

Clinicians need to convey empathy and to remember that the patient who minimizes or denies his/her drug or alcohol use may do so due to struggles with his/her loss of control. If the clinician scolds or lectures the patient then the patient will be less likely to reveal the true extent of his/her use, but if the tone is sympathetic then the patient is more likely to accept a referral for treatment of the substance use.


  1. Hahn JA, Samet JH. Alcohol and HIV disease progression: weighing the evidence. Curr HIV/AIDS Rep. 2010;7:226-233.


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