Substance use disorder in PLHIV

Clinical description

• People who inject drugs are at high risk of acquiring and transmitting HIV, Hepatitis B, C and

other blood borne diseases.

• Alcohol and substance abuse are likely to affect ART adherence and retention.
• Liver damage from alcohol is a major risk factor for drug toxicity (DTG, INH, ATV/r, etc.) and a

contraindication for starting TPT.

Screening for substance use disorder (SUD)

• Screen all PLHIV with history/physical examination suggestive of substance abuse using the DSM-

5 screening criteria (see Table 13 below).

• Ask initial questions to quickly assess for potential risk using the recommended single-item alcohol

and drug screening questions.

• SUD is confirmed if a patient has significant impairment or distress from their pattern of drug use

and had 2 or more of the DSM-5 symptoms in the last 12 months.

• Refer all patients with SUD for an in-depth assessment and management to a mental health clinic.

Table 13: DSM-5 Substance use disorder criteria Which of these criteria apply in the last year? 1 Taking the substance in larger amounts or for longer than you're meant to.

2 Wanting to cut down or stop using the substance but not managing to.

3 Spending a lot of time getting, using, or recovering from use of the substance.

4 Cravings and urges to use the substance.

5 Not managing to do what you should at work, home, or school because of substance use.

6 Continuing to use, even when it causes problems in relationships.

7 Giving up important social, occupational, or recreational activities because of substance use.

8 Using substances again and again, even when it puts you in danger.

9 Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.

10 Needing more of the substance to get the effect you want (tolerance).

11 Development of withdrawal symptoms, which can be relieved by taking more of the substance.

Total Score Syringe (needle) exchange program for people who inject drugs (PWID)

• Enrol PWID for harm reduction and HIV prevention services at Drop-in Centres (DICs)
• Record age, sex, residential area and group members in an improvised register
• Ascertain HIV status of all group members

o Link HIV negative members to combined HIV prevention services e.g., PrEP o Link HIV positive members to ART

• Link PWID with mental health experts for counselling and opiate substitution therapy
• Dispense single-use syringes in exchange for used syringes in DICs