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The overlap of substance use disorders, mental illness, and cognitive impairment is well known. Ryan White HIV/AIDS Program grantees and providers have a wealth of experience in delivering HIV care and treatment to people suffering from these conditions.

Substance Use Disorders

More than one-third of all AIDS cases in the United States are directly or indirectly attributed to injection drug use (IDU).116 Buprenorphine/naloxone is a valuable tool for clinicians who are treating opioid-dependent patients, since qualified physicians can administer it in the context of HIV primary care. A Health Resources and Services Administration (HRSA)-funded demonstration project at Ryan White clinics reported that administering buprenorphine reduced opioid use, increased initiation of ART, and improved certain quality of care indicators (e.g. Hepatitis A and pneumococcal vaccination, CD4 and viral load monitoring, injection drug use risk reduction counseling, and HIV clinic visits).117,118,119 (A monograph on best practices from the project can be found as a PDF here.)

Polypathology is common among current and former IDUs as they age, especially if they are HIV-positive. Among the general population, up to 13 percent of adults ages 25 and over are estimated to have two or fewer of the following: arthritis, cancer, diabetes, hypertension, heart disease, obstructive pulmonary disease, and psychiatric disorders; 3 percent to 5 percent of the population have three or more of these conditions, and prevalence of polypathology increases with age.120 In contrast, 61 percent of HIV-positive current and former IDUs had two or more of the following conditions: diabetes, obstructive lung disease, liver disease, anemia, obesity, kidney dysfunction, and hypertension; and approximately 30 percent had at least three conditions—a rate that is 6 to 10 times greater than that of the general population (and significantly higher than a matched group of HIV-negative current and former IDUs).121

Alcohol use is prevalent among PLWHA; rates of heavy drinking are twice as high among HIV-positive people versus the general population.122 Problem drinking is associated with poor adherence to antiretroviral therapy; detectable HIV RNA (viral load);  and low CD4 cell count.123,124,125 Clinicians can use screening questionnaires, such as the CAGE and AUDIT-C, to identify patients with dangerous alcohol intake.


Depression is more common among HIV-positive people than the general population, and rates of depression among PLWHA increase with aging.126,127,128 Depression worsens adherence to ART, but adherence can be improved by treatment with a selective serotonin reuptake inhibitor (SSRI).129 “We don’t even think about patient education taking longer with older patients. We have to go slowly. My brain doesn’t work as well as it did 30 years ago, and neither do theirs,” says Weyer.

Cognitive Impairment

Older PLWHA are more likely to have cognitive impairment than their HIV-negative peers; deficits in attention, memory, executive function, and speed of information processing have been reported in several studies.130,131,132 People over 50 years of age are three times more likely to be adherent to ART than their younger counterparts, but they are also more likely to experience cognitive impairment, which more than doubles the risk for poor adherence.133,134,135

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