Alcohol, Smoking, Recreational Drug Use and Association With Virological Outcomes Among People Living With HIV

Cross-Sectional and Longitudinal Analyses

Timothy P. W. Jones; Fiona C. Lampe; Alejandro Arenas-Pinto; Colette Smith; Jeff McDonnell; Lewis Haddow; Margaret Johnson; Elaney Yousef; Monica Lascar; Anna Maria Geretti; Lorraine Sherr; Simon Collins; Andrew N. Phillips; Alison J. Rodger


HIV Medicine. 2022;23(3):209-226. 

In This Article

Abstract and Introduction


Objectives: There is increasing evidence to suggest that people living with HIV (PLWH) have significant morbidity from alcohol, recreational drug use and cigarette smoking. Our aim was to report associations of these factors with antiretroviral therapy (ART) non-adherence, viral non-suppression and subsequent viral rebound in PLWH.

Methods: The Antiretroviral Sexual Transmission Risk and Attitudes (ASTRA) study recruited PLWH attending eight outpatient clinics in England between February 2011 and December 2012. Data included self-reported excessive drinking (estimated consumption of > 20 units of alcohol/week), alcohol dependency (CAGE score ≥ 2 with current alcohol consumption), recreational drug use (including injection drug use in the past 3 months), and smoking status. Among participants established on ART, cross-sectional associations with ART non-adherence [missing ≥2 consecutive days of ART on ≥2 occasions in the past three months] and viral-non suppression [viral load (VL) > 50 copies/mL] were assessed using logistic regression. In participants from one centre, longitudinal associations with subsequent viral rebound (first VL > 200 copies/mL) in those on ART with VL ≤ 50 copies/mL at baseline were assessed using Cox regression during a 7-year follow-up.

Results: Among 3258 PLWH, 2248 (69.0%) were men who have sex with men, 373 (11.4%) were heterosexual men, and 637 (19.6%) were women. A CAGE score ≥ 2 was found in 568 (17.6%) participants, 325 (10.1%) drank > 20 units/week, 1011 (31.5%) currently smoked, 1242 (38.1%) used recreational drugs and 74 (2.3%) reported injection drug use. In each case, prevalence was much more common among men than among women. Among 2459 people on ART who started at least 6 months previously, a CAGE score ≥ 2, drinking > 20 units per week, current smoking, injection and non-injection drug use were all associated with ART non-adherence. After adjusting for demographic and socioeconomic factors, CAGE score ≥ 2 [adjusted odds ratio (aOR) = 1.52, 95% confidence interval (CI): 1.09–2.13], current smoking (aOR = 1.58, 95% CI: 1.10–2.17) and injection drug use (aOR = 2.11, 95% CI: 1.00–4.47) were associated with viral non-suppression. During follow-up of a subset of 592 people virally suppressed at recruitment, a CAGE score ≥ 2 [adjusted hazard ratio (aHR) = 1.66, 95% CI: 1.03–2.74], use of 3 or more non-injection drugs (aHR = 1.82, 95% CI: 1.12–3.57) and injection drug use (aHR = 2.73, 95% CI: 1.08–6.89) were associated with viral rebound.

Conclusions: Screening and treatment for alcohol, cigarette and drug use should be integrated into HIV outpatient clinics, while clinicians should be alert to the potential for poorer virological outcomes.


Effective antiretroviral therapy (ART) and increased HIV testing have dramatically increased survival in people living with HIV (PLWH). However, lifestyle factors such as alcohol consumption, smoking and recreational drug use may have an impact on adherence to ART and HIV outcomes as well as increasing risk of non-HIV-related morbidity. Previous questionnaire studies have suggested that alcohol, smoking and recreational drug use are prevalent in PLWH.[1–7]

The WHO attribute 5.9% of global deaths to alcohol consumption.[8] There is evidence that alcohol intake may have a greater impact on the mortality and morbidity of PLWH compared with the general population, although the causes for this remain unclear.[9] While there is evidence that higher alcohol consumption is associated with ART non-adherence among PLWH,[1] the impact of alcohol on virological outcomes of ART per se is less clear. Although several studies reported a positive association between high alcohol intake and viral load rebound,[2,5,10–13] others have not found significant associations.[1,14,15] Lack of consistent definitions of what constitutes hazardous or harmful alcohol use, the potential for non-linear associations with amount of alcohol and, in some cases, small sample sizes have hampered interpretation of this literature.

Reduced adherence to ART and higher viral loads have likewise been associated with cigarette smoking[16] and use of recreational drugs, including 'chemsex'.[4] There is evidence that PLWH who smoke are particularly susceptible to lung damage from smoking, with those stable on treatment expected (based on modelling analysis) to lose more years to smoking than to HIV.[17] Although people who inject drugs are known to have poor health outcomes, the effects of non-injected recreational drug use in PLWH is less clear, although recent studies suggest that this may also have a negative impact on adherence.[3,18] In combination, these findings may indicate that adverse lifestyle factors have significant implications for increased morbidity in PLWH, as well as potential implications for HIV treatment outcomes and onward transmission in PLWH on ART.

Much of the literature has focused on PLWH already identified as high risk for alcohol and drug use disorders.[19] Furthermore, few studies have reported on the use of drugs, alcohol, smoking and the association with virological outcomes among PLWH in the UK. Different societal views and practices make unselected country-specific data invaluable in measuring the impact of such lifestyle factors and in guiding the public health response. The aim of this study was to use data from the Antiretroviral Sexual Transmission Risk and Attitudes (ASTRA) study[20] to report levels of alcohol, smoking and recreational drug use among PLWH in England, to assess associations with demographic socioeconomic, health and HIV-related factors, and to examine the associations with ART non-adherence, viral non-suppression and subsequent virological rebound over a 7-year period.