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The Longitudinal Effects of Non-injection Substance Use on Sustained HIV Viral Load Undetectability Among MSM and Heterosexual Men in Brazil and Thailand: The Role of ART Adherence and Depressive Symptoms (HPTN 063)

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  • Yale School of Public Health
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Abstract and Figures

The effect of non-injection substance use on HIV viral load (VL) is understudied in international settings. Data are from HPTN063, a longitudinal observational study of HIV-infected individuals in Brazil, Thailand, and Zambia, with focus on men with VL data (Brazil = 146; Thailand = 159). Generalized linear mixed models (GLMM) assessed whether non-injection substance use (stimulants, cannabis, alcohol, polysubstance) was associated with VL undetectability. ART adherence and depressive symptoms were examined as mediators of the association. In Thailand, substance use was not significantly associated with VL undetectability or ART adherence, but alcohol misuse among MSM was associated with increased odds of depression (AOR = 2.75; 95% CI 1.20, 6.32, p = 0.02). In Brazil, alcohol misuse by MSM was associated with decreased odds of undetectable VL (AOR = 0.34; 95% CI 0.13, 0.92, p = 0.03). Polysubstance use by heterosexual men in Brazil was associated with decreased odds of ART adherence (AOR = 0.25; 95% CI 0.08, 0.78, p = 0.02). VL suppression appears attainable among non-injection substance users. Substance use interventions among HIV-positive men should address depression, adherence, and VL undetectability.
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Vol.:(0123456789)
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AIDS and Behavior (2019) 23:649–660
https://doi.org/10.1007/s10461-019-02415-w
ORIGINAL PAPER
The Longitudinal Eects ofNon‑injection Substance Use onSustained
HIV Viral Load Undetectability Among MSM andHeterosexual Men
inBrazil andThailand: The Role ofART Adherence andDepressive
Symptoms (HPTN 063)
KiyomiTsuyuki1 · StevenJ.Shoptaw2· YusufRansome3· GordonChau4· CarlosE.Rodriguez‑Diaz5·
RuthK.Friedman6· KriengkraiSrithanaviboonchai7,8· SueLi4· MatthewJ.Mimiaga9· KennethH.Mayer10·
StevenA.Safren11
Published online: 6 February 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
The effect of non-injection substance use on HIV viral load (VL) is understudied in international settings. Data are from
HPTN063, a longitudinal observational study of HIV-infected individuals in Brazil, Thailand, and Zambia, with focus on
men with VL data (Brazil = 146; Thailand = 159). Generalized linear mixed models (GLMM) assessed whether non-injection
substance use (stimulants, cannabis, alcohol, polysubstance) was associated with VL undetectability. ART adherence and
depressive symptoms were examined as mediators of the association. In Thailand, substance use was not significantly asso-
ciated with VL undetectability or ART adherence, but alcohol misuse among MSM was associated with increased odds of
depression (AOR = 2.75; 95% CI 1.20, 6.32, p = 0.02). In Brazil, alcohol misuse by MSM was associated with decreased
odds of undetectable VL (AOR = 0.34; 95% CI 0.13, 0.92, p = 0.03). Polysubstance use by heterosexual men in Brazil was
associated with decreased odds of ART adherence (AOR = 0.25; 95% CI 0.08, 0.78, p = 0.02). VL suppression appears attain-
able among non-injection substance users. Substance use interventions among HIV-positive men should address depression,
adherence, and VL undetectability.
Keywords Substance use· HIV· Depression· Adherence· Undetectable viral load
* Kiyomi Tsuyuki
ktsuyuki@gmail.com
1 Division ofInfectious Diseases andGlobal Public Health,
Department ofMedicine, University ofCalifornia, San
Diego (UCSD), 9500 Gilman Drive, MC 0507, La Jolla,
SanDiego, CA92093-0507, USA
2 David Geffen School ofMedicine, Department ofFamily
Medicine, University ofCalifornia, Los Angeles (UCLA),
LosAngeles, CA, USA
3 Harvard T.H. Chan School ofPublic Health, Boston, MA,
USA
4 Statistical Center forHIV/AIDS Research andPrevention
(SCHARP), Fred Hutchinson Cancer Research Center,
Seattle, WA, USA
5 University ofPuerto Rico, Medical Sciences Campus,
SanJuan, PuertoRico
6 Instituto de Pesquisa Clinica Evandro Chagas, RiodeJaneiro,
Brazil
7 Faculty ofMedicine, Chiang Mai University, Muang District,
ChiangMai, Thailand
8 Research Institute forHealth Sciences, Chiang Mai
University, Muang District, ChiangMai, Thailand
9 Center forHealth Equity Research, Brown University,
Providence, RI, USA
10 The Fenway Institute, Fenway Health, Boston, MA, USA
11 Department ofPsychology, University ofMiami,
CoralGables, FL, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Polysubstance use was defined as the current use of two or more of these substances (i.e., alcohol, cannabis, heroin, cocaine, methamphetamine, heroin, and hallucinogens). Tobacco use was not included in the definition of polysubstance use, consistent with prior work among PWH [18,36,37]. ...
... This can lead to HIV disease advancement through biological mechanisms such as lowering CD4+ T-cell count and promoting viral replication, thus aiding in the progression of HIV infection and community transmission [53]. Further research can extend our work on the polysubstance-ART adherence relationship by examining the extent to which these effects are additive or multiplicative [37]. ...
... Importantly, PSU was associated with ART non-adherence, contributing to the growing body of literature on PSU among PWH [19,37]. These findings suggest possible intervention strategies. ...
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... Furthermore, AU has been found to increase the risk of hepatotoxicity associated with ART [13,119]. Nonetheless, several studies have found no association between SU and poor TA [12,29,101,102,113,118,[120][121][122][123][124]. ...
... SU has also been associated with TF as evidenced by virologic failure (VF) in Brazil [37,99,113,119,120,125], Guatemala [16], Peru [15,121], and a multinational study [122]. In Brazil, PLWH with a detectable VL had 1.76 times higher chance of AU [120], while DU increased risk of a detectable VL by 3 times [119]. ...
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This scoping review aims to explore the interplay between substance use (SU) and HIV in Latin America (LA). Database searches yielded 3481 references; 196 were included. HIV prevalence among people who used substances (PWUS) ranged from 2.8–15.2%. SU definitions were variable throughout studies, and thus data were not easily comparable. In 2019, only 2% of new HIV infections were attributed to injection drug use (IDU) in LA. Factors associated with HIV among PWUS included being female, IDU and homelessness, and PWUS were likely to engage in risky sexual behaviors, start antiretroviral treatment late, have poor adherence, have treatment failure, be lost to follow-up, have comorbidities, and experience higher mortality rates and lower quality of life, as has been reported in PLWH with SU in other regions. Five intervention studies were identified, and only one was effective at reducing HIV incidence in PWUS. Interventions in other regions have varying success depending on context-specific characteristics, highlighting the need to conduct more research in the LA region. Though progress has been made in establishing SU as a major concern in people living with HIV (PLWH), much more is yet to be done to reduce the burden of HIV and SU in LA.
... However, an analysis of adult PLHIV in South Korea did find patients with depression were more likely to frequently miss clinical appointments and have a higher cumulative time lost to follow-up per month compared to patients without depression [44]. Among HIV-positive heterosexual men and MSM in Thailand, non-injection substance use was associated with a lower likelihood of having an undetectable viral load [45], but a study of predominantly male adult PLHIV in care at community and hospital-based ART clinics in Vietnam found no association between mental health symptoms and virologic suppression [46]. Despite a high burden of depression and substance use, and the potential for negative impacts on HIV clinical outcomes, there remain substantial gaps in access to mental health and substance use related care for adult PLHIV in the region, and fragmented integration of related services within HIV clinical settings. ...
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Despite the mental health and substance use burden among people living with HIV (PLHIV) in the Asia–Pacific, data on their associations with HIV clinical outcomes are limited. This cross-sectional study of PLHIV at five sites assessed depression and substance use using PHQ-9 and ASSIST. Among 864 participants, 88% were male, median age was 39 years, 97% were on ART, 67% had an HIV viral load available and < 1000 copies/mL, 19% had moderate-to-severe depressive symptoms, and 80% had ever used at least one substance. Younger age, lower income, and suboptimal ART adherence were associated with moderate-to-severe depressive symptoms. Moderate-to-high risk substance use, found in 62% of users, was associated with younger age, being male, previous stressors, and suboptimal adherence. Our findings highlight the need for improved access to mental health and substance use services in HIV clinical settings.
... [23][24][25][26][27][28][29][30][31] Other studies have linked psychological predictors and substance use, although not their additive effects, to viral nonsupression and worse HIV clinical outcomes. [32][33][34][35][36][37][38][39][40][41] In the treatment as prevention (TasP) era, consistent adherence to ART effectively suppresses HIV RNA, minimizing transmission to seronegative partners. [42][43][44] Connecting PLWH to care and achieving ART adherence are key to the UNAIDS 95-95-95 treatment target and the US government's Ending the HIV Epidemic strategy. ...
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... ART nonadherence, uncontrolled viral load or biobehavioural transmission risk behaviour) [35][36][37][38][39][40][41][42][43]. Other studies have linked psychosocial variables (notably, depression) and substance use (notably, stimulants), though not their additive effects, to elevated viral load and worse HIV clinical outcomes [9,[44][45][46][47][48][49][50][51][52]. To our knowledge, no prior analysis has quantified the impact of co-occurring syndemic conditions among PLWH on HIV transmission, estimated or otherwise. ...
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