Importance: HIV diagnosis, linkage and retention in care, and adherence to antiretroviral therapy (ART) are steps in the care continuum enabling consistent viral suppression (VS) for people living with HIV. Achieving VS is known to extend life expectancy and prevent further transmission. While people living with HIV (PLWH) receive consistent ART and achieve viral suppression during incarceration, many when in the community struggle with substance use which often serves as a barrier to HIV care and is a reason for incarceration.
Objective: To examine the association between substance use prior to entry in LINK LA participants with ART adherence and HIV viral suppression upon entry into Los Angeles county jail.
Design, Setting, and Participants: LINK LA was a randomized clinical trial conducted from December 2012 through October 2016 among 356 people with HIV being released from LA county jail. For the present study, we conducted a cross-sectional analysis of baseline data collected for the trial. All participants were (1) 18 years or older; (2) either men or transgender women diagnosed with HIV; (3) English speaking; and (4) residing in LA County. Statistical analysis consisted of: (1) descriptive analysis of dependent variables, independent variables and covariates (sociodemographics and clinical variables); (2) bivariate associations between dependent and independent variables, as well as between dependent variables and covariates; (3) multivariable regression models to assess the associations of ART adherence and viral suppression.
Main Outcomes: (1) Adherence to ART within 30 days prior to jail entry; (2) HIV viral suppression upon entry into jail (<75 copies/mL)
Results: Among the 356 participants all diagnosed with HIV, methamphetamines (58%), marijuana (54%), binge alcohol (5+ drinks in a sitting; 25%), and cocaine (incl. crack; 17%) were the most commonly used substances within the study group. Whites and Hispanics used methamphetamines at distinctly higher rates relative to Black (Whites 73%; Hispanic 69%; Blacks 40%) while cocaine use was more prevalent in Blacks relative to Whites (Blacks 26%; Whites 6%). More broadly, Blacks had the lowest rates of hard drug use (heroin, crack, cocaine, methamphetamines, and/or oxycodone or other opiates) when compared to Hispanics and Whites (White 79%; Hispanic 75%; Black 63%). Hard drug was negatively associated adherence to ART within 30 days prior to entering LACJ (b= -20.6; SE= 5.4; P <0.001). Similarly, methamphetamine use by itself showed a negative association with ART adherence (b= -15.6; SE= 5.45; P= 0.0048). Moreover, low income (<$10k) was associated with a lower likelihood of HIV viral suppression (OR= 0.53; 95% Cl 0.33-0.83; P= 0.0087).
Conclusion and Relevance: Substance use prior to jail entry was prevalent with methamphetamines being the predominant hard drug, used most by Hispanics and Whites, while cocaine was most frequently used by Blacks. Despite having lower rates of hard drug use overall, Blacks had lower levels of ART adherence and VL suppression. Of note, those reporting low income also had a lower likelihood of achieving viral suppression however, low income did not explain the worse outcomes for Blacks. Together these findings suggest the need to better understand and address Blacks’ non-financial barriers to obtaining effective treatment for HIV.