SDOH Domains at Risk Correlated With Substance Use in People With HIV

Social drivers of health (SDOH) were correlated with substance use and polysubstance use in people living with HIV (PWH) according to a new study published in Open Forum Infectious Diseases.¹ Addressing both individual and environmental challenges in PWH can help to mitigate both substance use and the SDOH in this population.

Drug use is common in PWH, with 1 in 8 people who inject drugs reporting that they live with HIV.² Mental health conditions have been linked to substance use, including anxiety disorders and depression. This is especially true in PWH who face stigma for their condition. Although substance use has been studied in PWH, this study aimed to look outside of its link to medication adherence and instead to focus on its link to SDOH domains at risk and the presence of mental health symptom domains in PWH.

The Case Western Reserve University Center for Excellence on the Impact of Substance Use on HIV, based in Cleveland, Ohio, was used for baseline data. The center included a cohort of individuals with and at risk of HIV who did or did not use substances, and all participants in the cohort were aged 18 years or older and able to give informed consent. Use of marijuana, methamphetamine, sedatives, cocaine, opioids, and hallucinogens was considered substance use for this study. Those who had used substances had a baseline visit and visits after 6 and 12 months before annual visits; those without substance use only had a baseline visit. Individuals were excluded if they did not have HIV.

People with HIV had higher odds of several SDOH domains at risk, including low income and mental health issues | Image credit: Stanislau_V - stock.adobe.com

All participants completed an SDOH questionnaire; the Adverse Childhood Experiences questionnaire; the NIDA-Modified Alcohol, Smoking, and Substance Involvement Screening Test; the PTSD (post-traumatic stress disorder) Checklist Civilian; and the DSM-5 Cross-Cutting Symptom Measure at baseline. All SDOH and substance use were self-reported.

A total of 171 PWH were recruited between May 2022 and October 2024; 79% were PWH with substance use, and 21% acted as controls. A total of 50% reported polysubstance use. The mean (SD) age of those with single substance use was 49 (14) years compared with 52 (12) years in polysubstance users and 57 (13) years in the controls. A total of 75% were male at birth. All participants had prescriptions for antiretroviral therapy. Participants in the polysubstance (70%) and single-substance (61%) groups were more likely to have income below poverty level compared with the controls (42%).

All groups had similar rates of lack of internet access (31%), intimate partner violence (15%), and being at risk financially (12%). PWH who used substances were more likely to be at risk of housing instability (P = 0.05), food insecurity (P < 0.01), transportation needs (P < 0.01), and utilities (P < 0.01). Polysubstance users were more at risk for housing insecurity compared with controls (48% vs 25%); polysubstance (adjusted OR [AOR], 2.22; 95% CI, 0.84-5.84) and single substance use (AOR, 1.48; 95% CI, 0.56-3.93) also had higher odds of housing instability. Polysubstance and single substance users were more likely to have increased risk of transportation issues (31% and 29% vs 8%), utility issues (43% and 38% vs 14%), and food insecurity (64% and 60% vs 35%) compared with controls. PWH with polysubstance use had the highest number of total SDOH domains at risk (3.3 [2]) compared with controls (2 [1.7]) and single substance users (2.9 [2.2]).

Those with polysubstance abuse had higher odds of depression symptoms (AOR, 2.89; 95% CI, 1.00-8.31), mania (AOR, 4.6; 95% CI, 1.17-18.10), and anxiety (AOR, 1.67; 95% CI, 0.56-4.97) compared with controls; single substance users had higher odds of depression (AOR, 3.36; 95% CI, 1.17-9.62), mania (AOR, 3.82; 95% CI, 0.97-15.08), and anxiety (AOR, 3.12; 95% CI, 1.08-9.00). PWH with polysubstance and single-substance use were also more likely to have sleep problems and a history of childhood trauma when compared with controls.

There were some limits to this study. Causality could not be established due to the cross-sectional design of the study. All potential confounders could not be taken into account due to limited power. The effect of individual substances on the outcome could not be determined due to the number of substances included. The SDOH were. Not ranked by their impact on the participant’s quality of life. Severity of mental health and contributions to SDOH were not assessed for the study. This study was done at a single location and may not be generalizable.

The authors concluded that HIV and substance use are connected through their social contexts. “The intersections of health, behavioral, and social factors highlight the importance of utilizing holistic, integrated, person-centered care models to more effective address the individual and environmental complexities present within this population,” the authors wrote.

References

1. Avery A, Bitar Y, Hussey D, Hileman CO. Evaluating connections between polysubstance use, social drivers of health, and mental health symptoms in people with HIV. Open Forum Infect Dis. 2025;12(4):ofaf172. doi:10.1093/ofid/ofaf172
2. People who inject drugs. World Health Organization. Accessed April 29, 2025. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/populations/people-who-inject-drugs