Skip to main content

Substance use and the HIV care continuum: important advances

The HIV care continuum identifies five stages of HIV medical care: (1) HIV diagnosis, (2) linkage to HIV care, (3) engagement and retention in HIV care, (4) treatment with antiretroviral therapy (ART), and (5) achievement of HIV viral suppression—all of which are essential to effectively treat and prevent the spread of HIV. Most recent estimates indicate that in the United States, 85% of people living with HIV are diagnosed, 62% are linked to care, and only 49% achieve HIV viral suppression [1]. People who use drugs and alcohol are particularly likely to experience gaps in each stage of the HIV care continuum. While antiretroviral therapy has dramatically improved the life expectancy for people living with HIV, important disparities remain among people with substance use that threaten individual and public health [2]. Screening for and treating substance use may close these gaps in outcomes and help achieve the UNAIDS 90-90-90 goal of 90% diagnosis, 90% ART treatment, and 90% HIV viral suppression by 2020 [3].

Addiction Science and Clinical Practice’s special thematic series, “Substance Use and the HIV Care Continuum,” sponsored by the National Institute on Drug Abuse (NIDA) Clinical Trials Network, focuses on publications that advance understanding of how identifying and treating substance use contributes to the HIV care continuum in U.S. and international settings. The series includes original research on the adverse effects of alcohol, drugs and structural barriers on the HIV care continuum, novel strategies for improving engagement in HIV treatment, and protocols for three recently implemented major clinical trials to improve engagement and retention in HIV care. The authors adhere to recent recommendations for using less stigmatizing, patient-centered terms when referring to substance use [4, 5].

While progress has been made toward the UNAIDS 90-90-90 goals, challenges remain. In an observational study of people using drugs in Oakland, California, Lambdin et al. [6], reported that criminal justice involvement was associated with increased rates of HIV and hepatitis C testing but did not result in improved treatment engagement. Those who reported receiving substance use disorder treatment, however, were more likely to engage in HIV care than those not receiving treatment. In Pretoria, South Africa, women who reported recent physical assault were more likely to be newly diagnosed with HIV, and those using opiates or cocaine were less likely to receive antiretroviral therapy [7]. Similarly, female entertainment and sex workers in Thailand who used methamphetamines were less likely to be retained in care at 12 months [8].

Alcohol is often overlooked as a potentially detrimental contributor to adverse HIV outcomes. Cook et al. [9] carefully examined the role of alcohol, demonstrating that people with HIV who report heavy drinking experienced increased odds of failing to achieve sustained HIV viral suppression.

Systems issues must also be addressed to close HIV care continuum gaps for people who use drugs. Qualitative interviews with public health and HIV service providers in Connecticut identified the need to increase mental health and substance use services and peer navigation/case management services and the need to decrease service agency stigma as key barriers and potential facilitators for improving HIV testing, engagement, and treatment [10]. Idrisov et al. [11] reported no association between individual injection use histories and HIV outcomes, suggesting that systems issues may also prove a dominating contributor to HIV outcomes in Russia, obscuring individual factors.

The special series highlights several areas of progress toward interventions to overcome such barriers. Contingency management, the strategy of rewarding people for desired behaviors, was a key component of Project HOPE, a NIDA Clinical Trials Network study that used peer navigators to link hospitalized patients with untreated HIV and substance use disorders to HIV treatment. Providing monetary incentives to attend peer navigator sessions increased visit attendance and HIV viral suppression at 6 months [12]. Similar strategies might be tested in outpatient HIV clinics where the prevalence of substance use disorders remains high.

Integration of HIV care and addiction treatment might also improve HIV outcomes. Mburu et al. [13] used a peer-led community-based approach to increase HIV testing and treatment services in Cambodia. Simeone et al. [14] found 93% retention and HIV viral suppression among patients receiving integrated methadone and HIV primary care in an opioid treatment program—much higher than when HIV primary care was delivered off-site. Similarly, in-depth interviews with HIV providers and patients in Tanzania endorsed a preference for integrating HIV care in methadone treatment settings [15]. Additional implementation and comparative effectiveness studies are urgently needed to increase understanding of optimal approaches for integrating HIV and substance use treatment, both in clinical and non-clinical settings (e.g. AIDS service organizations). Integrating treatment approaches such as buprenorphine into general healthcare settings help to change a medical culture that has long stigmatized people with substance use disorders in the U.S. and other countries [16].

Novel study protocols and a feasibility trial published in the special series report the design of promising interventions to improve HIV treatment and engagement. Westergaard et al. [17] reported that a peer navigation intervention with a smartphone application to aid in care coordination was acceptable and feasible to HIV-infected patients for improving visit attendance and ART adherence. Other trials aim to address systems improvement interventions. Claborn et al. [18] describes a randomized trial of a tablet-based mobile platform to improve care coordination between HIV and substance use providers. Garner et al. [19] describe protocols for two multi-site, cluster randomized trials: one testing the Addiction Technology Transfer Center change quality improvement strategy with or without an organizational change intervention in AIDS service organizations, and a second trial of motivational interviewing training for AIDS service organization staff versus usual care [20]. Both trials study intervention effects on client treatment engagement and HIV outcomes.

Taken together, these publications advance the science of interventions to improve engagement in the HIV care continuum for people with substance use disorders and point to the need for additional research. Many community-based settings with high HIV prevalence, such as some substance use disorder treatment facilities and office-based buprenorphine providers, still do not routinely test for HIV [21]. Implementation trials to promote testing in these settings would likely increase the proportion of people living with HIV who know their diagnosis. Substance use in rural settings continues to grow, with risk of HIV and hepatitis C outbreaks in areas with limited treatment resources. Studies to engage HIV testing and treatment retention among people using drugs in rural settings are urgently needed. Correctional settings also offer opportunities to initiate treatment for substance use and relapse prevention interventions that increase the likelihood of engaging in HIV treatment and achieving HIV viral suppression.

Closing gaps in the HIV care continuum requires the development and testing of new interventions directed at people who use drugs, and improved implementation strategies for the interventions that are already known to work. As the HIV epidemic matures, it provides an important framework for translating health improvements for other chronic conditions, such as treatment of substance use disorders and chronic hepatitis C. Lessons learned from interventions to improve engagement in the HIV care continuum across diverse settings may serve as models to address the care continuum for these and other conditions.


  1. Centers for Disease Control and Prevention. Understanding the HIV care continuum. CDC Fact Sheet; (2017).

  2. Samji H, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS ONE. 2013;8(12):e81355.

    Article  PubMed  PubMed Central  Google Scholar 

  3. UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic. 2014, Joint United Nations Programme on HIV/AIDS: Geneva, Switzerland.

  4. Wakeman SE. Medications for addiction treatment: changing language to improve care. J Addict Med. 2017;11(1):1–2.

    Article  PubMed  Google Scholar 

  5. Kelly JF, Wakeman SE, Saitz R. Stop talking ‘dirty’: clinicians, language, and quality of care for the leading cause of preventable death in the United States. Am J Med. 2015;128(1):8–9.

    Article  PubMed  Google Scholar 

  6. Lambdin BH, et al. Associations of criminal justice and substance use treatment involvement with HIV/HCV testing and the HIV treatment cascade among people who use drugs in Oakland, California. Addict Sci Clin Pract. 2017;12(1):13.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Wechsberg WM, et al. Seek, test, treat: substance-using women in the HIV treatment cascade in South Africa. Addict Sci Clin Pract. 2017;12(1):12.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Muth S, et al. HIV treatment cascade among female entertainment and sex workers in Cambodia: impact of amphetamine use and an HIV prevention program. Addict Sci Clin Pract. 2017;12(1):20.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Cook RL, et al. Alcohol consumption patterns and HIV viral suppression among persons receiving HIV care in Florida: an observational study. Addict Sci Clin Pract. 2017;12(1):22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Grau LE, et al. Barriers and facilitators of the HIV care continuum in Southern New England for people with drug or alcohol use and living with HIV/AIDS: perspectives of HIV surveillance experts and service providers. Addict Sci Clin Pract. 2017;12(1):24.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Idrisov B, et al. Role of substance use in HIV care cascade outcomes among people who inject drugs in Russia. Addict Sci Clin Pract. 2017;12(1):30.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Stitzer M, et al. Enhancing patient navigation to improve intervention session attendance and viral load suppression of persons with HIV and substance use: a secondary post hoc analysis of the Project HOPE study. Addict Sci Clin Pract. 2017;12(1):16.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Mburu G, et al. Patterns of HIV testing, drug use, and sexual behaviors in people who use drugs: findings from a community-based outreach program in Phnom Penh, Cambodia. Addict Sci Clin Pract. 2017;12(1):27.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Simeone C, Shapiro B, Lum PJ. Integrated HIV care is associated with improved engagement in treatment in an urban methadone clinic. Addict Sci Clin Pract. 2017;12(1):19.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Cooke A, et al. Convenience without disclosure: a formative research study of a proposed integrated methadone and antiretroviral therapy service delivery model in Dar es Salaam, Tanzania. Addict Sci Clin Pract. 2017;12(1):23.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Velez CM, et al. “It’s been an experience, a life learning experience”: a qualitative study of hospitalized patients with substance use disorders. J Gen Intern Med. 2017;32(3):296–303.

    Article  PubMed  Google Scholar 

  17. Westergaard RP, et al. Acceptability of a mobile health intervention to enhance HIV care coordination for patients with substance use disorders. Addict Sci Clin Pract. 2017;12(1):11.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Claborn K, et al. Mobile technology intervention to improve care coordination between HIV and substance use treatment providers: development, training, and evaluation protocol. Addict Sci Clin Pract. 2017;12(1):8.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Garner BR, et al. Testing the implementation and sustainment facilitation (ISF) strategy as an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy: study protocol for a cluster randomized trial. Addict Sci Clin Pract. 2017;12(1):32.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Garner BR, et al. Testing the effectiveness of a motivational interviewing-based brief intervention for substance use as an adjunct to usual care in community-based AIDS service organizations: study protocol for a multisite randomized controlled trial. Addict Sci Clin Pract. 2017;12(1):31.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Knudsen HK, et al. A mixed methods study of HIV-related services in buprenorphine treatment. Subst Abuse Treat Prev Policy. 2017;12(1):37.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Authors’ contributions

PTK and EJE served as co-editors for the special series. PTK drafted the editorial and EJE critically reviewed it. Both authors read and approved the final manuscript.


The special series received support from the National Institutes of Health, National Institute on Drug Abuse, Clinical Trials Network. Dr. Korthuis’s time is supported by the National Institutes of Health, National Institute on Drug Abuse (UG3DA044831, UG1DA015815, R01DA037441). Dr. Edelman’s time is supported by the National Institutes of Health, National Institute on Drug Abuse (R01DA04071, R01DA041067, UG1DA015831) and National Institute on Alcohol Abuse and Alcoholism (U01AA020795, U01AA020790).

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Not applicable.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author information

Authors and Affiliations


Corresponding author

Correspondence to P. Todd Korthuis.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Korthuis, P.T., Edelman, E.J. Substance use and the HIV care continuum: important advances. Addict Sci Clin Pract 13, 13 (2018).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: