Substance Abuse and HIV: What's the Link?

Medically Reviewed by Jonathan E. Kaplan, MD on April 11, 2022
6 min read

Substance abuse, or an unhealthy pattern of alcohol or other drug use, can harm your health if you have HIV. It can also lead to risky behaviors that could make you more likely to get HIV or pass the disease on to someone else.

Doctors consider the use of recreational drugs and misuse of alcohol and other medications as substance abuse. This can include:

Drugs of abuse, like opioids (including prescription opioids like hydrocodone and illegal drugs like heroin), methamphetamine (meth), crack cocaine, and inhalants (such as poppers). Other commonly used drugs include benzodiazepines, cannabinoids, tobacco, and club drugs, like ecstasy (MDMA), GHB (gamma hydroxybutyrate), ketamine, rohypnol or “roofies,” and LSD.

Prescription and over-the-counter medications. Some of these drugs have stimulants in them. If misused, they can be harmful.

Overuse of alcohol. If you consume too much alcohol, or binge drink, you’ll be more likely to engage in risky behavior.

When you drink alcohol or use drugs, they affect your brain. Because these substances make it harder to think clearly, you might make risky decisions. These could include:

  • If you have unprotected anal or vaginal sex (sex without a condom or proper medication to prevent HIV, like pre-exposure prophylaxis or “PrEP”)
  • If you have sex with multiple partners
  • If you inject drugs and share needles, syringes, or other injection tools (such as cookers)

These actions can put you at risk for HIV.

Anal sex. You can get HIV if you have anal sex with a person who has HIV. Anal sex has the highest risk of HIV transmission, compared to other forms of sex.

If you’re the receiving partner (or the bottom), your risk for HIV is higher than the insertive partner (or the top). This is because your rectal lining is thin and could allow for HIV to enter your body.

But if you’re on top, you could still get the virus. HIV can enter your body through the small hole on the tip of your penis (called the urethra). The virus can also enter through your foreskin (if you aren’t circumcised) or any scratches, small cuts, or sores you have on your penis.

Vaginal sex. You can also get HIV from vaginal sex if you have unprotected intercourse with someone who has the virus. But it’s less risky than receptive anal sex.

HIV can enter your body through the tissue around your vagina and cervix. If you have a penis, you can also get HIV if you have vaginal sex. Fluid and blood from the vagina can carry HIV. This can pass through your penis’s urethra, foreskin, or any wounds or sores on your penis.

It’s important to never share needles, syringes, or other things you might use to inject drugs. These can have other people’s blood on them. If their blood carries HIV, you could get the virus if you use the same tools.

If you have HIV, risky behavior from alcohol and drug abuse can also make you more likely to spread the virus to others.

Antiretroviral therapy (ART) is a treatment for HIV. It can’t cure HIV, but it can help you live longer and healthier with the virus.

ART stops HIV from multiplying. This lowers your viral load, or the amount of HIV in your body. If you have less HIV in your body, your immune system has a better chance to recover and make more healthy cells that fight infection.

It also lowers the risk of HIV transmission. This means that with ART, you’ll be less likely to give someone else the virus. You have almost no risk of sexual transmission with HIV-negative partners if your viral load is at an undetectable level. An undetectable level is when the level of HIV in your blood is too low for a viral load test to catch.

But current substance abuse can affect your HIV treatment. Drug or alcohol misuse can affect how well ART works to keep your viral load low. If you abuse substances, you’re also less likely to stick to your HIV treatment routine. These things can make you more likely to spread HIV to an HIV-negative partner during sex.

Substance abuse can also harm your own health, especially if you have HIV. If you misuse alcohol and drugs, they can:

Weaken your immune system. HIV harms your immune system. This can make it harder for your body to fight off certain cancers or infections. If you use drugs and alcohol, they can damage your immune system even more. This can lead to a worsened HIV infection.

Harm your liver. When your liver breaks down chemicals in alcohol or drugs, it creates unhealthy substances, called toxins. Your liver helps rid your blood of these. Drug and alcohol misuse can harm your liver. They make it harder for your body to remove the harmful chemicals. If these build up in your body, they can lead to liver disease.

Interact with HIV medications. Some recreational drugs can affect how well your HIV medications work. This can put you more at risk for harmful side effects. It’s possible to overdose because of interactions between some HIV medications and drugs like ecstasy or GHB.

Make it hard to take HIV drugs. If you have HIV, you probably take a mix of HIV medications, or an HIV treatment regimen. These medicines help you stay healthy. But drug and alcohol abuse can make it harder to stay on track with a medication routine each day. If you skip HIV medication doses, your HIV will multiply and harm your immune system.

Experts have also found that drug use and addiction can make your viral load go up, make your disease get worse faster, and cause more people to die due to AIDS (even among people who are on ART).

Overall, more people with HIV use drugs and alcohol or have substance use disorders than HIV-negative groups.

The death toll for drug overdoses is now much higher than the death toll for HIV in the United States. Since overdoses continue to happen throughout the country, it’s important for health care providers to understand how to treat substance abuse in people with HIV.

If you have a substance use disorder, it’s important that your doctor is aware. Your care team should use a non-judgmental approach as they help you treat HIV.

When your doctor decides on an HIV treatment plan for you, they should:

  • Consider a treatment that takes into account drug interactions, barriers to your treatment plan, and any potential adverse effects with other medications or substances
  • Talk about the importance of sticking to your plan and the benefits of ART so that your viral load stays low
  • Suggest simplified treatment plans like an easy-to-take, once-a-day pill
  • Create plans that have a low chance of harming your liver and a high barrier to resistance (which means that the medication isn’t as likely to become ineffective due to mutations)

While they treat your HIV, your doctor can also help you overcome substance abuse. Treatment for drug or alcohol misuse isn’t a one-size-fits-all. You and your care team will need to work together to find a solution that works for you. Alongside your HIV treatment, you might consider substance abuse care that includes:

  • Medication
  • Behavioral counseling
  • Medical devices that can treat your withdrawal symptoms
  • Treatment of other mental health problems (like depression or anxiety)
  • Long-term care to avoid a relapse