Background: Alcohol and drug use are associated with worse outcomes for persons with HIV in high-income settings, but effects of drug and alcohol use on the HIV care cascade in sub-Saharan Africa are not known.
Methods: We evaluated the association between drug and alcohol use and ART initiation, retention in care, and virologic suppression (HIV RNA < 200 copies/mm³) in a longitudinal cohort of 2375 HIV-infected adults attending an urban clinic outside Durban, South Africa (2013-2017). At the time of HIV testing/enrollment, participants self-reported alcohol use (any or none within the past 30 days) and drug use (any or none within the past 30 days, by type of drug). ART initiation was captured from chart abstraction and viral load (VL) tested at 6 and 12 months after initiation. Persons without a recorded VL measurement were presumed non-suppressed. We used multivariate logistic regression to evaluate the odds ratios for each outcome, controlling for age, sex, anxiety, depression, and socioeconomic status.
Results: 502 (50%) men and 281 (33%) women reported any alcohol use in the previous 30 days at baseline. 127 (5%) reported marijuana and 31 (1%) any other drug use in the previous 30 days. Overall, 1925 (81%) participants initiated ART, 1851 (78%) were retained in HIV care at 12 months, and 1272 (55%) achieved VL suppression. Alcohol use was associated with lower odds of initiating ART (aOR 0.81, 95%CI 0.65-1.03, p=0.08), significantly lower odds of being retained in care at 12 months (aOR 0.64, 95%CI 0.51- 0.79, p< 0.001), and lower odds of VL suppression (aOR 0.94, 0.78-1.13, p=0.53) (not statistically significant). Baseline drug use was not associated with any HIV outcome. No further intensity-of-use data were available among persons endorsing any drug or alcohol use in 30 days prior to enrollment.
Conclusions: Self-reported alcohol use was common and drug use rare in this cohort of HIV-infected South Africans. Alcohol use was associated with increased risk of poor HIV outcomes. Research quantifying alcohol and drug use to determine the relationship between heavy/frequent alcohol use, drug use, VL suppression, and death is needed to best target interventions to reduce harms from alcohol and drug use.