Cannabis use and HIV antiretroviral therapy adherence and HIV-related symptoms

The Impact of Cannabis Use on Cognition in People with HIV: Evidence of Function-Dependent Effects and Mechanisms from Clinical and Preclinical Studies

PURPOSE OF REVIEW

Cannabis may have beneficial anti-inflammatory effects in people with HIV (PWH); however, given this population's high burden of persisting neurocognitive impairment (NCI), clinicians are concerned they may be particularly vulnerable to the deleterious effects of cannabis on cognition. Here, we present a systematic scoping review of clinical and preclinical studies evaluating the effects of cannabinoid exposure on cognition in HIV.

RECENT FINDINGS

Results revealed little evidence to support a harmful impact of cannabis use on cognition in HIV, with few eligible preclinical data existing. Furthermore, the beneficial/harmful effects of cannabis use observed on cognition were function-dependent and confounded by several factors (e.g., age, frequency of use). Results are discussed alongside potential mechanisms of cannabis effects on cognition in HIV (e.g., anti-inflammatory), and considerations are outlined for screening PWH that may benefit from cannabis interventions. We further highlight the value of accelerating research discoveries in this area by utilizing translatable cross-species tasks to facilitate comparisons across human and animal work.

Main Partner Relationships and the HIV Care Cascade: Examining the Predictive Utility of Sexual Agreements, Partner Concordance, and Drug Use Among Sexual Minority Men Living With HIV in the USA

BACKGROUND

The past 15 years have seen increasing attention to relationship factors among sexual minority male (SMM) couples at high risk for HIV infection. Research has largely focused on HIV prevention outcomes. Outcomes relevant to SMM living with HIV have received relatively less attention.

PURPOSE

This study evaluated associations between relational covariates (relationship status, sexual agreements, and seroconcordance) and HIV care cascade outcomes (having a current antiretroviral therapy [ART] prescription, ART adherence, viral load (VL) testing, and VL detectability) above and beyond cannabis and stimulant drug use.

METHODS

Adult SMM (n = 36,874) living with HIV in the USA were recruited between November 1, 2017 and March 15, 2020 through social networking applications. They completed a cross-sectional survey online.

RESULTS

Nonmonogamous SMM with serodiscordant partners were most likely to have an ART prescription. Those with seroconcordant partners (regardless of sexual agreements) were least likely to be adherent. While relational covariates were not associated with VL testing, SMM in nonmonogamous relationships with serodiscordant partners were significantly more likely to have an undetectable VL. Those in monogamous relationships with seroconcordant partners were significantly less likely to have an undetectable VL.

CONCLUSIONS

SMM with seroconcordant partners and monogamous sexual agreements may experience diminished interpersonal motivation for HIV care engagement. HIV care cascade retention messages that emphasize the prevention of onward transmission may have limited relevance for these SMM. Novel intervention strategies are needed to enhance HIV care outcomes in this population, ideally ones that incorporate attention to drug use.

Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Accelerated aging in people living with HIV: The neuroimmune feedback model

People living with HIV (PLWH) experience earlier onset of aging-related comorbidities compared to their counterparts without HIV. This paper lays out a theoretical model to explain why PLWH experience accelerated aging. Briefly, the model is structured as follows. PLWH experience disproportionately heavy burdens of psychosocial stress across the life course. This psychosocial stress increases risks for depressive symptoms and problematic substance use. Depressive symptoms and problematic substance use interfere with long-term adherence to antiretroviral therapy (ART). Lower ART adherence, in turn, exacerbates the elevated systemic inflammation stemming from HIV infection. This inflammation increases risks for aging-related comorbidities. Systemic inflammation also reduces connectivity in the brain's central executive network (CEN), a large-scale brain network that is critical for coping with stressful circumstances. This reduced capacity for coping with stress leads to further increases in depressive symptoms and problematic substance use. Together, these changes form a neuroimmune feedback loop that amplifies the impact of psychosocial stress on aging-related comorbidities. In this paper, I review the existing evidence relevant to this model and highlight directions for future research.

Effects of acute Δ9-tetrahydrocannabinol on behavior and the endocannabinoid system in HIV-1 Tat transgenic female and male mice

Cannabis use is highly prevalent especially among people living with HIV (PLWH). Activation of the anti-inflammatory and neuroprotective endocannabinoid system by phytocannabinoids, i.e. Δ9-tetrahydrocannabinol (THC), has been proposed to reduce HIV symptoms. However, THC's effects on HIV-related memory deficits are unclear. Using HIV-1 Tat transgenic mice, the current study investigates acute THC effects on various behavioral outcomes and the endocannabinoid system. For the rodent tetrad model, THC doses (1, 3, 10 mg/kg) induced known antinociceptive effects, with Tat induction increasing antinociceptive THC effects at 3 and 10 mg/kg doses. Only minor or no effects were noted for acute THC on body temperature, locomotor activity, and coordination. Increased anxiety-like behavior was found for females compared to males, but acute THC had no effect on anxiety. Object recognition memory was diminished by acute THC in Tat(-) females but not Tat(+) females, without affecting males. The endocannabinoid system and related lipids were not affected by acute THC, except for THC-induced decreases in CB1R protein expression levels in the spinal cord of Tat(-) mice. Female sex and Tat induction was associated with elevated 2-AG, AEA, AA, CB1R, CB2R, FAAH and/or MAGL expression in various brain regions. Further, AEA levels in the prefrontal cortex of Tat(+) females were negatively associated with object recognition memory. Overall, findings indicate that acute THC exerts differential effects on antinociception and memory, dependent on sex and HIV Tat expression, potentially in relation to an altered endocannabinoid system, which may be of relevance in view of potential cannabis-based treatment options for PLWH.

Substance Use and Adherence to HIV Pre-Exposure Prophylaxis in Studies Enrolling Men Who Have Sex with Men and Transgender Women: A Systematic Review

Optimal adherence to pre-exposure prophylaxis (PrEP) is critical, but challenging. Men who have sex with men and transgender women have high rates of HIV incidence and substance use. Substance use is associated with reduced adherence to other medications, but associations between substance use and adherence to PrEP are less clear. Thus, the current review 1) systematically evaluates the measurement of substance use and PrEP adherence in studies examining both and 2) summarizes reported findings. Peer-reviewed articles published between 2010 - April 2021 examining associations between substance use and PrEP adherence were reviewed. Fifty studies met inclusion criteria. Assessment of substance use (i.e., mostly via self-reports at baseline) and PrEP adherence (i.e., often via tenofovir diphosphate [TFV-DP] concentration levels at follow-up) varied considerably across studies. Many studies used categorical variables (e.g., substance use: yes/no). Studies using TFV-DP levels defined adherence consistently (i.e., TFV-DP ≥ 700 fmol/punch), with slight variations. Qualitative studies (n = 10) indicated that substance use (mainly alcohol) is related to poorer PrEP adherence. While quantitative findings to date are equivocal for alcohol, there is a pattern of findings linking stimulant use with poorer PrEP adherence. This review reveals four methodological gaps, which can be addressed in future research by: 1) use of uniform benchmarks for substance use measures, 2) prospective assessment for substance use, 3) use of continuous outcome variables wherever possible, and 4) more extensive consideration of potential confounders. Addressing these methodological gaps may help us reach more definitive conclusions regarding associations between substance use and PrEP adherence.

Characterizing the Development of Research Landscapes in Substance Use and HIV/AIDS During 1990 to 2021

Mitigating the impacts of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) and substance use requires comprehensive and systematic thinking in designing interventions and developing policies. This study describes the growth of research publications from 1991 to 2021 in the Web of Science database and points out current research landscapes in the fields of HIV/AIDS and substance use. Latent Dirichlet Allocation was used for classifying 21 359 papers into corresponding topics. The most common topics were HIV transmission, HIV infection, quality of life and mental health of substance users, and the biomedical effect of substance use. Emerging research landscapes include vulnerabilities of people who inject drugs to HIV transmission and related health problems. This study found a lack of research on health services, interdisciplinary and inter-sectoral in combination with clinical evaluation and treatment services. Future investment and implementation of HIV/AIDS and substance use programs should focus on research of health services and clinical evaluation, especially context-specific interventions.

Effects of drug and hazardous alcohol use on having a detectable HIV viral load: An adherence mediation analysis

Objectives

People living with HIV (PWH) with substance or alcohol use often have unsuppressed plasma HIV viral loads (pVL). The degree to which substance and alcohol use effects on HIV viral suppression are mediated through medication nonadherence is incompletely understood.

Methods

We included PWH prescribed antiretroviral therapy and receiving care at an academic HIV clinic between 2014 and 2018 who completed both patient-reported outcomes (PRO) questionnaires and had subsequent pVL measurements. Measures included assessments of alcohol use (AUDIT-C), drug use (NIDA-ASSIST), and self-reported adherence measured using four different methods. Substances found in bivariate analysis to predict detectable pVL were modeled separately for mediation effects through adherence. We report natural direct (NDE) and indirect effect (NIE), marginal total effect (MTE), and percentage mediated.

Results

Among 3125 PWH who met eligibility criteria, 25.8% reported hazardous alcohol use, 27.1% cannabis, 13.1% amphetamines, 1.9% inhalants, 5.3% cocaine, 4.5% sedative-hypnotics, 2.9% opioids, and 2.3% hallucinogens. Excellent adherence was reported by 58% of PWH, and 10% had detectable pVL. Except for sedatives, using other substances was significantly associated with worse adherence. Bivariate predictors of detectable pVL were [OR (95% CI)]: amphetamine use 2.4 (1.8-3.2) and opioid use 2.3 (1.3-4.0). The percent of marginal total effect mediated by nonadherence varied by substance: 36% for amphetamine use, 27% for opioid use, and 39% for polysubstance use.

Conclusion

Use of amphetamines, opioids, and multiple substances predicted detectable pVL. Up to 40% of their effects were mediated by self-reported nonadherence. Confirmation using longitudinal measurement models will strengthen causal inference from this cross-sectional analysis.

Disentangling Medicinal and Recreational cannabis Use Among People Living with HIV: An Ecological Momentary Assessment Study

This study examined the feasibility of using ecological momentary assessment (EMA) to disentangle medicinal cannabis use (MCU) from recreational cannabis use (RCU) among people living HIV (PLWH). Over a 14-day period, PLWH (N = 29) who engaged in both MCU and RCU completed a smartphone-based survey before and after every cannabis use event assessing general motivation for cannabis use (MCU-only, RCU-only, or mixed MCU/RCU), cannabis use behavior, and several antecedents and outcomes of cannabis use. A total of 739 pre-cannabis surveys were completed; 590 (80%) of the prompted post-cannabis surveys were completed. Motives for cannabis use were reported as MCU-only on 24%, RCU-only on 30%, and mixed MCU/RCU on 46% of pre-cannabis surveys. Mixed effects models examined within-person differences across MCU-only, RCU-only, and mixed MCU/RCU events. Results showed that relative to RCU-only events, MCU-only events were more likely to involve symptom management and drug substitution motives, physical and sleep-related symptoms, solitary cannabis use, and use of cannabis oils and sprays; MCU-only events were less likely to involve relaxation, happiness, and wellness motives, cannabis flower use, and positive cannabis consequences. Differences between mixed MCU/RCU and RCU-only events were similar, except that mixed MCU/RCU events were additionally associated with stress reduction motives and symptoms of anxiety and depression. Findings support the feasibility of partially disentangling MCU and RCU behavior among PLWH who engage in concurrent MCU and RCU. This study highlights the need for more EMA studies isolating MCU from RCU to inform ongoing changes to cannabis policies.

Role of the gut-brain axis in HIV and drug abuse-mediated neuroinflammation

Drug abuse and related disorders are a global public health crisis affecting millions, but to date, limited treatment options are available. Abused drugs include but are not limited to opioids, cocaine, nicotine, methamphetamine, and alcohol. Drug abuse and human immunodeficiency virus-1/acquired immune deficiency syndrome (HIV-1/AIDS) are inextricably linked. Extensive research has been done to understand the effect of prolonged drug use on neuronal signaling networks and gut microbiota. Recently, there has been rising interest in exploring the interactions between the central nervous system and the gut microbiome. This review summarizes the existing research that points toward the potential role of the gut microbiome in the pathogenesis of HIV-1-linked drug abuse and subsequent neuroinflammation and neurodegenerative disorders. Preclinical data about gut dysbiosis as a consequence of drug abuse in the context of HIV-1 has been discussed in detail, along with its implications in various neurodegenerative disorders. Understanding this interplay will help elucidate the etiology and progression of drug abuse-induced neurodegenerative disorders. This will consequently be beneficial in developing possible interventions and therapeutic options for these drug abuse-related disorders.

Cannabis and complementary/alternative self-treatment approaches for symptom management among African American persons living with HIV

Persons living with HIV (PLWH) experience symptoms from disease progression and side effects of antiretroviral treatment. This study examines in African American PLWH (N = 259) commonly-endorsed symptoms, types and self-rated efficacy of therapies for symptom alleviation. Analyses were stratified by gender (n = 178 males, n = 81 females) and cannabis use typology: non-users (n = 90), mostly recreational use (n = 46), mixed recreational/therapeutic use (n = 51), or mostly therapeutic use (n = 72). Females reported greater severity for pain, fatigue, depression, weight change and tingling in extremities, but there were no gender differences for ratings of poor sleep, anxiety, poor appetite, or headache. Both marijuana (used therapeutically by females more than males) and medication(s) were among the 3 top methods for managing pain, poor sleep, anxiety, and headache. Marijuana was most often used for poor appetite, and medications for depression. Perceived efficacy of self-treatment approaches was moderately good. Among African American PLWH, symptom severity was higher for females and for therapeutic users of cannabis. Marijuana and medicine were often used to self-treat symptoms, but many participants did nothing. These results highlight the need for careful evaluation and management of symptoms in this underserved population.

Cannabis Use Is Associated With Decreased Antiretroviral Therapy Adherence Among Older Adults With HIV

Background

Conflicting evidence exists on the impact of cannabis use on antiretroviral therapy (ART) adherence among people with human immunodeficiency virus (PWH). We leveraged data collected among older PWH to characterize longitudinal associations between cannabis use and ART adherence.

Methods

AIDS Clinical Trials Group (ACTG) A5322 study participants were categorized as <100% (≥1 missed dose in past 7 days) or 100% (no missed doses) ART adherent. Participants self-reported current (past month), intermittent (past year but not past month), and no cannabis (in past year) use at each study visit. Generalized linear models using generalized estimating equations were fit and inverse probability weighting was used to adjust for time-varying confounders and loss to follow-up.

Results

Among 1011 participants (median age, 51 years), 18% reported current, 6% intermittent, and 76% no cannabis use at baseline; 88% reported 100% ART adherence. Current cannabis users were more likely to be <100% adherent than nonusers (adjusted risk ratio [aRR], 1.53 [95% CI, 1.11-2.10]). There was no association between ART adherence and current versus intermittent (aRR, 1.39 [95% CI, .85-2.28]) or intermittent versus no cannabis use (aRR, 1.04 [95% CI, .62-1.73]).

Conclusions

Among a cohort of older PWH, current cannabis users had a higher risk of <100% ART adherence compared to nonusers. These findings have important clinical implications as suboptimal ART adherence is associated with ART drug resistance, virologic failure, and elevated risk for mortality. Further research is needed to elucidate the mechanisms by which cannabis use decreases ART adherence in older PWH and to advance the development of more efficacious methods to mitigate nonadherence in this vulnerable population.

"You Almost Feel Out of Touch [For Saying] … 'Oh, and by the way, Stop Smoking.'" A Qualitative Exploration of Provider Perspectives About Discussing Tobacco and Cannabis Use With 18-24-Year-Old Young Adults With HIV

Background: Youth with HIV (YWH) aged 18-24 are overburdened by tobacco, with half also using cannabis recreationally. Increasing tobacco cessation necessitates exploring providers' approaches to cessation. Methods: Grounded in social cognitive theory, we explored cognitive, socioenvironmental, and behavioral factors impacting providers' approaches to tobacco use among recreational cannabis users. Virtual interviews were conducted among healthcare providers caring for YWH in Washington (legalized cannabis), Massachusetts (legalized cannabis), and Alabama (cannabis not legal). Interviews were transcribed and analyzed via deductive and exploratory, thematic approaches using NVivo 12 Plus. Results: Twelve providers participated; 80% were subspecialist physicians. All providers (N = 12) reported discussing tobacco use; none reported discussing tobacco use in conjunction with cannabis use. Identified themes included competing demands including cannabis co-use, prioritization of social determinants of health, and need for youth-tailored tools. Conclusions: YWH disproportionately use tobacco and recreational cannabis. Optimizing clinical visits to identify opportunities to address tobacco is crucial.

Marijuana Use and Health Outcomes in Persons Living With HIV: Protocol for the Marijuana Associated Planning and Long-term Effects (MAPLE) Longitudinal Cohort Study

BACKGROUND

Marijuana use is common in persons with HIV, but there is limited evidence of its relationship with potential health benefits or harms.

OBJECTIVE

The Marijuana Associated Planning and Long-term Effects (MAPLE) study was designed to evaluate the impact of marijuana use on HIV-related health outcomes, cognitive function, and systemic inflammation.

METHODS

The MAPLE study is a longitudinal cohort study of participants living with HIV who were recruited from 3 locations in Florida and were either current marijuana users or never regular marijuana users. At enrollment, participants completed questionnaires that included detailed marijuana use assessments, underwent interviewer-administered neurocognitive assessments, and provided blood and urine samples. Ongoing follow-ups included brief telephone assessments (every 3 months), detailed questionnaires (annually), repeated blood and urine samples (2 years), and linkage to medical records and statewide HIV surveillance data. Supplemental measures related to intracellular RNA, COVID-19, Alzheimer disease, and the gut microbiome were added after study initiation.

RESULTS

The MAPLE study completed enrollment of 333 persons between 2018 and 2021. The majority of participants in the sample were ≥50 years of age (200/333, 60.1%), male (181/333, 54.4%), cisgender men (173/329, 52.6%), non-Hispanic Black (221/333, 66.4%), and self-reported marijuana users (260/333, 78.1%). Participant follow-up was completed in 2022, with annual updates to HIV surveillance data through at least 2027.

CONCLUSIONS

The MAPLE study is the largest cohort specifically designed to understand the use of marijuana and its effects on HIV-related outcomes. The study population has significant diversity across age, sex, gender, and race. The data will help clinicians and public health officials to better understand patterns of marijuana use associated with both positive and negative health outcomes, and may inform recommendations for future clinical trials related to medical marijuana and HIV.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37153.

Medical conditions of primary care patients with documented cannabis use and cannabis use disorder in electronic health records: a case control study from an academic health system in a medical marijuana state

BACKGROUND

Approximately 3.8% of adults worldwide have used cannabis in the past year. Understanding how cannabis use is associated with other health conditions is crucial for healthcare providers seeking to understand the needs of their patients, and for health policymakers. This paper analyzes the relationship between documented cannabis use disorders (CUD), cannabis use (CU) and other health diagnoses among primary care patients during a time when medical use of marijuana was permitted by state law in California, United States of America.

METHODS

The study utilized primary care electronic health record (EHR) data from an academic health system, using a case-control design to compare diagnoses among individuals with CUD/CU to those of matched controls, and those of individuals with CUD diagnoses with individuals who had CU otherwise documented. Associations of documented CU and CUD with general medical conditions and health conditions associated with cannabis use (both medical and behavioral) were analyzed using conditional logistic regression.

RESULTS

Of 1,047,463 patients with ambulatory encounters from 2013-2017, 729 (0.06%) had CUD diagnoses and 3,731 (0.36%) had CU documented in their EHR. Patients with documented CUD and CU patients had significantly (p < 0.01) higher odds of most medical and behavioral diagnoses analyzed. Compared to matched controls, CUD-documented patients had highest odds of other substance use disorders (OR = 21.44: 95% CI 9.43-48.73), any mental health disorder (OR = 6.99; 95% CI 5.03-9.70) social anxiety disorder (OR = 13.03; 95% CI 2.18-77.94), HIV/AIDS (OR = 7.88: 95% CI 2.58-24.08), post-traumatic stress disorder (OR = 7.74: 95% CI 2.66-22.51); depression (OR = 7.01: 95% CI 4,79-10.27), and bipolar disorder (OR = 6.49: 95% CI 2.90-14.52). Compared to matched controls, CU-documented patients had highest odds of other substance use disorders (OR = 3.64; 95% CI 2.53-5.25) and post-traumatic stress disorder (OR = 3.41; 95% CI 2.53-5.25). CUD-documented patients were significantly more likely than CU-documented patients to have HIV/AIDS (OR = 6.70; 95% CI 2.10-21.39), other substance use disorder (OR = 5.88; 95% CI 2.42-14.22), depression (OR = 2.85; 95% CI 1.90-4.26), and anxiety (OR = 2.19: 95% CI 1.57-3.05) diagnoses.

CONCLUSION

The prevalence of CUD and CU notation in EHR data from an academic health system was low, highlighting the need for improved screening in primary care. CUD and CU documentation were associated with increased risk for many health conditions, with the most elevated risk for behavioral health disorders and HIV/AIDS (among CUD-documented, but not CU-documented patients). Given the strong associations of CUD and CU documentation with health problems, it is important for healthcare providers to be prepared to identify CU and CUD, discuss the pros and cons of cannabis use with patients thoughtfully and empathically, and address cannabis-related comorbidities among these patients.

Self-Reported Cannabis Use and HIV Viral Control among Patients with HIV Engaged in Care: Results from a National Cohort Study

Background: The association between cannabis use and HIV-1 RNA (viral load) among people with HIV (PWH) engaged in care is unclear. Methods: We used data collected from 2002 to 2018 on PWH receiving antiretroviral therapy (ART) enrolled in the Veterans Aging Cohort Study. Generalized estimating equations were used to estimate associations between self-reported past-year cannabis use and detectable viral load (≥500 copies/mL), with and without adjustment for demographics, other substance use, and adherence. Results: Among 2515 participants, 97% were male, 66% were Black, the mean age was 50 years, and 33% had detectable HIV viral load at the first study visit. In unadjusted analyses, PWH with any past-year cannabis use had 21% higher odds of a detectable viral load than those with no past-year use (OR = 1.21; 95% CI, 1.07-1.37). However, there was no significant association between cannabis use and viral load after adjustment. Conclusions: Among PWH engaged in care and receiving ART, cannabis use is associated with decreased adherence in unadjusted analyses but does not appear to directly impact viral control. Future studies are needed to understand other potential risks and benefits of cannabis use among PWH.

HIV infection is linked with reduced error-related default mode network suppression and poorer medication management abilities

OBJECTIVE

Brain activity linked with error processing has rarely been examined among persons living with HIV (PLWH) despite importance for monitoring and modifying behaviors that could lead to adverse health outcomes (e.g., medication non-adherence, drug use, risky sexual practices). Given that cannabis (CB) use is prevalent among PLWH and impacts error processing, we assessed the influence of HIV serostatus and chronic CB use on error-related brain activity while also considering associated implications for everyday functioning and clinically-relevant disease management behaviors.

METHODS

A sample of 109 participants, stratified into four groups by HIV and CB (HIV+/CB+, n = 32; HIV+/CB-, n = 27; HIV-/CB+, n = 28; HIV-/CB-, n = 22), underwent fMRI scanning while completing a modified Go/NoGo paradigm called the Error Awareness Task (EAT). Participants also completed a battery of well-validated instruments including a subjective report of everyday cognitive failures and an objective measure of medication management abilities.

RESULTS

Across all participants, we observed expected error-related anterior insula (aI) activation which correlated with better task performance (i.e., less errors) and, among HIV- participants, fewer self-reported cognitive failures. Regarding awareness, greater insula activation as well as greater posterior cingulate cortex (PCC) deactivation were notably linked with aware (vs. unaware) errors. Regarding group effects, unlike HIV- participants, PLWH displayed a lack of error-related deactivation in two default mode network (DMN) regions (i.e., PCC, medial prefrontal cortex [mPFC]). No CB main or interaction effects were detected. Across all participants, reduced error-related PCC deactivation correlated with reduced medication management abilities and PCC deactivation mediated the effect of HIV on such abilities. More lifetime CB use was linked with reduced error-related mPFC deactivation among HIV- participants and poorer medication management across CB users.

CONCLUSIONS

These results demonstrate that insufficient error-related DMN suppression linked with HIV infection, as well as chronic CB use among HIV- participants, has real-world consequences for medication management behaviors. We speculate that insufficient DMN suppression may reflect an inability to disengage task irrelevant mental operations, ultimately hindering error monitoring and behavior modification.

Substance Use Predicts Sustained Viral Suppression in a Community Cohort of Sexual and Gender Minority Youth Living with HIV

Retention in care and sustained viral suppression are integral outcomes in the care continuum for people living with HIV (PLWH) and HIV prevention; however, less is known about how substance use predicts sustained viral suppression over time. This study seeks to examine the predictive effects of substance use on sustained viral suppression in a sample of cisgender sexual minority men and gender minority PLWH (n = 163) drawn from a longitudinal sample in the Chicago area collected 2015-2019. Using data from 3 visits separated by 6 months, participants were coded persistently detectable, inconsistently virally suppressed, and consistently virally suppressed (< 40 copies/mL at all visits). Multinomial logistic regressions were utilized. About 40% of participants had sustained viral suppression. In multinomial logistic regressions, CUDIT-R predicted persistent detectable status and stimulant use was associated with inconsistent viral suppression. Substance use may create challenges in achieving sustained viral suppression, which has important implications for care and prevention.

Daily and near-daily cannabis use is associated with HIV viral load suppression in people living with HIV who use cocaine

Disparities remain in HIV viral load (VL) suppression between people living with HIV (PLWH) who use cocaine and those who do not. It is not known how cannabis use affects VL suppression in PLWH who use cocaine. We evaluated the relationship between cannabis use and VL suppression among PLWH who use cocaine. We conducted a secondary data analysis of 119 baseline interviews from a randomized controlled trial in the Bronx, NY (6/2012 to 1/2017). Participants were adult PLWH prescribed antiretrovirals for ≥16 weeks, who endorsed imperfect antiretroviral adherence and used cocaine in the past 30-days. In bivariate and multivariable regression analyses, we examined how cannabis use, is associated with VL suppression among PLWH who use cocaine. Participants were a mean age of 50 years; most were male (64%) and non-Hispanic black (55%). Participants with VL suppression used cocaine less frequently than those with no VL suppression (p < 0.01); cannabis use was not significantly different. In regression analysis, compared with no use, daily/near-daily cannabis use was associated with VL suppression (aOR = 4.2, 95% CI: 1.1-16.6, p < 0.05). Less-frequent cannabis use was not associated with VL suppression. Further investigation is needed to understand how cannabis use impacts HIV outcomes among PLWH who use cocaine.

General risks of harm with cannabinoids, cannabis, and cannabis-based medicine possibly relevant to patients receiving these for pain management: an overview of systematic reviews

ABSTRACT

The growing demand for improved pain treatments together with expanding legalization of, and access to, cannabinoids, cannabis, and cannabis-based medicines has intensified the focus on risk-benefit considerations in pain management. Given limited harms data from analgesic clinical trials, we conducted an overview of systematic reviews focused on all harms possibly relevant to patients receiving cannabinoids for pain management. This PROSPERO-registered, PRISMA-compliant systematic overview identified 79 reviews, encompassing over 2200 individual reports about psychiatric and psychosocial harms, cognitive/behavioral effects, motor vehicle accidents, cardiovascular, respiratory, cancer-related, maternal/fetal, and general harms. Reviews, and their included studies, were of variable quality. Available evidence suggests variable associations between cannabis exposure (ranging from monthly to daily use based largely on self-report) and psychosis, motor vehicle accidents, respiratory problems, and other harms. Most evidence comes from settings other than that of pain management (eg, nonmedicinal and experimental) but does signal a need for caution and more robust harms evaluation in future studies. Given partial overlap between patients receiving cannabinoids for pain management and individuals using cannabinoids for other reasons, lessons from the crisis of oversupply and overuse of opioids in some parts of the world emphasize the need to broadly consider harms evidence from real-world settings. The advancement of research on cannabinoid harms will serve to guide optimal approaches to the use of cannabinoids for pain management. In the meantime, this evidence should be carefully examined when making risk-benefit considerations about the use of cannabinoids, cannabis, and cannabis-based medicine for chronic pain.

Confound, Cause, or Cure: The Effect of Cannabinoids on HIV-Associated Neurological Sequelae

The persistence of human immunodeficiency virus-1 (HIV)-associated neurocognitive disorders (HAND) in the era of effective antiretroviral therapy suggests that modern HIV neuropathogenesis is driven, at least in part, by mechanisms distinct from the viral life cycle. Identifying more subtle mechanisms is complicated by frequent comorbidities in HIV⁺ populations. One of the common confounds is substance abuse, with cannabis being the most frequently used psychoactive substance among people living with HIV. The psychoactive effects of cannabis use can themselves mimic, and perhaps magnify, the cognitive deficits observed in HAND; however, the neuromodulatory and anti-inflammatory properties of cannabinoids may counter HIV-induced excitotoxicity and neuroinflammation. Here, we review our understanding of the cross talk between HIV and cannabinoids in the central nervous system by exploring both clinical observations and evidence from preclinical in vivo and in vitro models. Additionally, we comment on recent advances in human, multi-cell in vitro systems that allow for more translatable, mechanistic studies of the relationship between cannabinoid pharmacology and this uniquely human virus.

The Link between Cannabis Use, Immune System, and Viral Infections

Cannabis continues to be the most used drug in the world today. Research shows that cannabis use is associated with a wide range of adverse health consequences that may involve almost every physiological and biochemical system including respiratory/pulmonary complications such as chronic cough and emphysema, impairment of immune function, and increased risk of acquiring or transmitting viral infections such as HIV, HCV, and others. The review of published research shows that cannabis use may impair immune function in many instances and thereby exerts an impact on viral infections including human immune deficiency virus (HIV), hepatitis C infection (HCV), and human T-cell lymphotropic type I and II virus (HTLV-I/II). The need for more research is also highlighted in the areas of long-term effects of cannabis use on pulmonary/respiratory diseases, immune dysfunction and the risk of infection transmission, and the molecular/genetic basis of immune dysfunction in chronic cannabis users.

Cannabis and the Gut-Brain Axis Communication in HIV Infection

People living with HIV infection (PWH) disclose that cannabis is an effective strategy for alleviating symptoms associated with HIV disease. However, some medical providers feel ill-informed to engage in evidence-based conversations. HIV leads to alterations in the gut microbiome, gut-brain axis signaling, and chronic inflammation. The endocannabinoid system regulates homeostasis of multiple organ systems. When deficient, dysregulation of the gut-brain axis can result in chronic inflammation and neuroinflammation. Cannabis along with the naturally occurring endocannabinoids has antioxidant and anti-inflammatory properties that can support healing and restoration as an adjunctive therapy. The purpose of this literature review is to report the physiologic mechanisms that occur in the pathology of HIV and discuss potential benefits of cannabinoids in supporting health and reducing the negative effects of comorbidities in PWH.

Understanding disparities in viral suppression among Black MSM living with HIV in Atlanta Georgia

INTRODUCTION

Due to factors associated with structural racism, Black men who have sex with men (MSM) living with HIV are less likely to be virally suppressed compared to white MSM. Most of these data come from clinical cohorts and modifiable reasons for these racial disparities need to be defined in order to intervene on these inequities. Therefore, we examined factors associated with racial disparities in baseline viral suppression in a community-based cohort of Black and white MSM living with HIV in Atlanta, GA.

METHODS

We conducted an observational cohort of Black and white MSM living with HIV infection in Atlanta. Enrolment occurred from June 2016 to June 2017 and men were followed for 24 months; laboratory and behavioural survey data were collected at 12 and 24 months after enrolment. Explanatory factors for racial disparities in viral suppression included sociodemographics and psychosocial variables. Poisson regression models with robust error variance were used to estimate prevalence ratios (PR) for Black/white differences in viral suppression. Factors that diminished the PR for race by ≥5% were considered to meaningfully attenuate the racial disparity and were included in a multivariable model.

RESULTS

Overall, 26% (104/398) of participants were not virally suppressed at baseline. Lack of viral suppression was significantly more prevalent among Black MSM (33%; 69/206) than white MSM (19%; 36/192) (crude Prevalence Ratio (PR) = 1.6; 95% CI: 1.1 to 2.5). The age-adjusted Black/white PR was diminished by controlling for: ART coverage (12% decrease), housing stability (7%), higher income (6%) and marijuana use (6%). In a multivariable model, these factors cumulatively mitigated the PR for race by 21% (adjusted PR = 1.1 [95% CI: 0.8 to 1.6]).

CONCLUSIONS

Relative to white MSM, Black MSM living with HIV in Atlanta were less likely to be virally suppressed. This disparity was explained by several factors, many of which should be targeted for structural, policy and individual-level interventions to reduce racial disparities.

Self-Reported Cannabis Use and Markers of Inflammation in Men Who Have Sex With Men With and Without HIV

Background: Chronic inflammation contributes to aging and organ dysfunction in the general population, and is a particularly important determinant of morbidity and mortality among people with HIV (PWH). The effect of cannabis use on chronic inflammation is not well understood among PWH, who use cannabis more frequently than the general population. Materials and Methods: We evaluated participants in the Multicenter AIDS Cohort Study (MACS) beginning in 2004 with available data on cannabis use and inflammatory biomarkers. Associations of current cannabis use with plasma concentrations of inflammatory markers were adjusted for hepatitis C, tobacco smoking, and comorbidities. Markers were analyzed individually and in exploratory factor analysis (EFA). Results: We included 1352 men within the MACS. Twenty-seven percent of HIV-negative men, 41% of HIV viremic men, and 35% of virologically suppressed men reported cannabis use at baseline. Among cannabis users, 20-25% in all groups defined by HIV serostatus were daily users, and the same proportion reported weekly use. The remaining ∼50% of users in all groups reported monthly or less frequent use. Four biomarker groupings were identified by EFA: Factor 1: immune activation markers; Factor 2: proinflammatory cytokines; Factor 3: Th1- and Th2-promoting cytokines; and Factor 4: inflammatory chemokines. In EFA, daily users had 30% higher levels of Factor 2 biomarkers than nonusers (p=0.03); this was the only statistically significant difference by cannabis use status. Among individual markers, concentrations of IL-1β, IL-2, IL-6, and IL-8 (Factor 2); IL-10 (Factor 3); and BAFF (Factor 1) were higher (p<0.05) among daily cannabis users than among nonusers, after adjusting for HIV serostatus and other covariates. Discussion: Associations between daily cannabis use and proinflammatory biomarker levels did not differ by HIV serostatus. Further prospective studies with measured cannabis components are needed to clarify the impact of these compounds on inflammation. Our findings can facilitate for hypothesis generation and selection of biomarkers to include in such studies.

Trajectories of Viral Suppression in People Living With HIV Receiving Coordinated Care: Differences by Comorbidities

BACKGROUND

In March of 2013, the Los Angeles County (LAC) Division of HIV and STD Programs implemented a clinic-based Medical Care Coordination (MCC) Program to increase viral suppression (VS) (<200 c/mL) among people living with HIV (PLWH) at high risk for poor health outcomes.

OBJECTIVE

This study aimed to estimate trajectories of VS and to assess whether these trajectories differed by stimulant use, housing instability, and depressive symptom severity as reported by PLWH participating in MCC.

METHODS

Data represent 6408 PLWH in LAC receiving services from the MCC Program and were obtained from LAC HIV surveillance data matched to behavioral assessments obtained across 35 Ryan White Program clinics participating in MCC. Piecewise mixed-effects logistic regression with a random intercept estimated probabilities of VS from 12 months before MCC enrollment through 36 months after enrollment, accounting for time by covariate interactions for 3 comorbid conditions: housing instability, stimulant use, and depressive symptoms.

RESULTS

The overall probability of VS increased from 0.35 to 0.77 within the first 6 months in the MCC Program, and this probability was maintained up to 36 months after enrollment. Those who reported housing instability, stimulant use, or multiple comorbid conditions did not achieve the same probability of VS by 36 months as those with none of those comorbidities.

CONCLUSIONS

Findings suggest that MCC improved the probability of VS for all patient groups regardless of the presence of comorbidities. However, those with comorbid conditions will still require increased support from patient-centered programs to address disparities in VS.

Mini-review: The therapeutic role of cannabinoids in neuroHIV

In the era of combined antiretroviral therapy (cART), human immunodeficiency virus type 1 (HIV-1) is considered a chronic disease with an inflammatory component that specifically targets the brain and causes a high prevalence of HIV-1-associated neurocognitive disorders (HAND). The endocannabinoid (eCB) system has attracted interest as a target for treatment of neurodegenerative disorders, due to the potential anti-inflammatory and neuroprotective properties of cannabinoids, including its potential therapeutic use in HIV-1 neuropathogenesis. In this review, we summarize what is currently known about the structural and functional changes of the eCB system under conditions of HAND. This will be followed by summarizing the current clinical and preclinical findings on the effects of cannabis use and cannabinoids in the context of HIV-1 infection, with specifically focusing on viral load, cognition, inflammation, and neuroprotection. Lastly, we present some potential future directions to better understand the involvement of the eCB system and the role that cannabis use and cannabinoids play in neuroHIV.

Medical Marijuana and Opioids (MEMO) Study: protocol of a longitudinal cohort study to examine if medical cannabis reduces opioid use among adults with chronic pain

INTRODUCTION

In the USA, opioid analgesic use and overdoses have increased dramatically. One rapidly expanding strategy to manage chronic pain in the context of this epidemic is medical cannabis. Cannabis has analgesic effects, but it also has potential adverse effects. Further, its impact on opioid analgesic use is not well studied. Managing pain in people living with HIV is particularly challenging, given the high prevalence of opioid analgesic and cannabis use. This study's overarching goal is to understand how medical cannabis use affects opioid analgesic use, with attention to Δ9-tetrahydrocannabinol and cannabidiol content, HIV outcomes and adverse events.

METHODS AND ANALYSES

We are conducting a cohort study of 250 adults with and without HIV infection with (a) severe or chronic pain, (b) current opioid use and (c) who are newly certified for medical cannabis in New York. Over 18 months, we collect data via in-person visits every 3 months and web-based questionnaires every 2 weeks. Data sources include: questionnaires; medical, pharmacy and Prescription Monitoring Program records; urine and blood samples; and physical function tests. Using marginal structural models and comparisons within participants' 2-week time periods (unit of analysis), we will examine how medical cannabis use (primary exposure) affects (1) opioid analgesic use (primary outcome), (2) HIV outcomes (HIV viral load, CD4 count, antiretroviral adherence, HIV risk behaviours) and (3) adverse events (cannabis use disorder, illicit drug use, diversion, overdose/deaths, accidents/injuries, acute care utilisation).

ETHICS AND DISSEMINATION

This study is approved by the Montefiore Medical Center/Albert Einstein College of Medicine institutional review board. Findings will be disseminated through conferences, peer-reviewed publications and meetings with medical cannabis stakeholders.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03268551); Pre-results.

Trauma exposure, PTSD, and suboptimal HIV medication adherence among marginalized individuals connected to public HIV care in Miami

Individuals living with HIV report disproportionately high levels of trauma exposure and PTSD symptoms, both which have been associated with suboptimal ART adherence. Often conflated, the question arises as to which construct is driving subsequent HIV self-care behavior. Given the HIV disparities among Black and Hispanic/Latinx individuals, and that Miami is a geographic region with a high racial/ethnic minority make up and a unique socioeconomic environment, it is important to explore factors related to HIV outcomes in Miami to mitigate its uncontrolled epidemic. This study aimed to examine the association of trauma exposure, PTSD symptoms, and relevant additional key factors with adherence to ART among a sample of majority Black and Hispanic/Latinx individuals who are economically marginalized receiving public HIV care in Miami, FL (N = 1237) via a cross-sectional survey. Sequential linear regression was used to examine the study aim in four blocks: (1) trauma, (2) PTSD symptoms, and key covariates of ART adherence including (3) depression and substance use (potential psychological covariates), and (4) indicators of socioeconomic status (potential structural covariates). In the first block, trauma exposure was associated with worse adherence. However, in the second block, the association with trauma dropped and PTSD was significantly associated with worse adherence. Of note, for those experiencing high levels of trauma exposure, adherence was negatively impacted regardless of PTSD. When other key factors associated with adherence were entered in the third and fourth blocks, neither trauma exposure nor PTSD were uniquely significant. In this final model, depression, substance use, and unstable housing were uniquely associated with worse adherence. Trauma-informed models of HIV care that holistically address co-occurring factors are warranted to cater to communities with HIV health disparities and keep them from falling off the HIV care continuum.

Clinical Data for the Use of Cannabis-Based Treatments: A Comprehensive Review of the Literature

Objective:

To compile and synthesize the available literature describing medical cannabis use across various disease states.

Data Sources:

PubMed, EBSCO, and Google Scholar searches were conducted using MeSH and/or keywords.

Study Selection and Data Extraction:

Studies were included if they described the use of cannabis-based products and medications in the treatment of a predefined list of disease states in humans and were published in English. The extraction period had no historical limit and spanned through April 2019.

Data Synthesis:

Evidence was compiled and summarized for the following medical conditions: Alzheimer disease, amyotrophic lateral sclerosis, autism, cancer and cancer-associated adverse effects, seizure disorders, human immunodeficiency virus, inflammatory bowel disease, multiple sclerosis (MS), nausea, pain, posttraumatic stress disorder, and hospice care.

Relevance to Patient Care and Clinical Practice:

Based on identified data, the most robust evidence suggests that medical cannabis may be effective in the treatment of chemotherapy-induced nausea and vomiting, seizure disorders, MS-related spasticity, and pain (excluding diabetic neuropathy). Overall, the evidence is inconsistent and generally limited by poor quality. The large variation in cannabis-based products evaluated in studies limits the ability to make direct comparisons. Regardless of the product, a gradual dose titration was utilized in most studies. Cannabis-based therapies were typically well tolerated, with the most common adverse effects being dizziness, somnolence, dry mouth, nausea, and euphoria.

Conclusions:

As more states authorize medical cannabis use, there is an increasing need for high-quality clinical evidence describing its efficacy and safety. This review is intended to serve as a reference for clinicians, so that the risks and realistic benefits of medical cannabis are better understood.

HIV Stigma, Depressive Symptoms, and Substance Use

Substance use problems undermine HIV treatment and secondary prevention efforts. Research is needed to better understand predictors of substance use among people living with HIV (PLWH). We examined whether internalized stigma and enacted HIV stigma are associated with three indicators of substance use among PLWH, including numbers of (1) substances used, (2) substances used at moderate to high risk, and (3) times substances were used before sex, through the mediator of depressive symptoms. Participants included 358 PLWH aged 18-35 years from Georgia, United States. At baseline, participants completed measures of internalized and enacted stigma, depressive symptoms, and substance use severity. Substance use was additionally tested with urinalysis. Following baseline, participants reported their use of substances before sex for 28 days through daily text messaging. Data were analyzed using path analysis in R. On average, participants tested positive for 1.24 (range: 0-6) substances used, reported moderate to high risk on 2.01 (range: 0-8) substances, and reported using substances 1.57 (range: 0-20) times before sex over 28 days. Internalized stigma and enacted stigma were associated with greater depressive symptoms, and depressive symptoms were associated with all three indicators of substance use. Moreover, the indirect effects between internalized and enacted stigma with indicators of substance use were significant, suggesting that depressive symptoms partially mediated associations between stigma and substance use. Interventions may be needed to address both stigma and depressive symptoms among PLWH to reduce substance use and support HIV treatment and prevention efforts.

Self-reported Cannabis Use and Changes in Body Mass Index, CD4 T-Cell Counts, and HIV-1 RNA Suppression in Treated Persons with HIV

Cannabis use is prevalent among HIV-positive persons, but evidence regarding the impact of cannabis in HIV-positive persons is limited. We conducted a retrospective cohort study of HIV-positive adults initiating their first antiretroviral therapy (ART) regimen. A dedicated intake form assessed self-reported cannabis use in the preceding 7 days at each visit. The relationships between time-varying cannabis use and body mass index (BMI), CD4+ T-cell count, and HIV-1 RNA levels were assessed using random effects models adjusted for age, sex, race, and other reported substance use. 4290 patient-visits from 2008 to 2011 were available from 1010 patients. Overall, there were no statistically significant differences in CD4+ T-cell count and BMI across multiple adjusted models using different measures of cannabis use (ever use during the study period, any use, and number of times used in the preceding 7 days). Cannabis use by all three measures was associated with greater odds of having a detectable viral load at a given visit than no reported use (OR 2.02, 1.72, and 1.08, respectively; all adjusted p < 0.05). Self-reported cannabis use was not associated with changes in BMI or CD4+ T-cell count in ART-naïve HIV-positive persons starting treatment. However, reported cannabis use by multiple categories was associated with having a detectable HIV-1 RNA during the study period. Associations between cannabis use, adherence, and HIV-related outcomes merit further study.

Cannabinoids and inflammation: implications for people living with HIV

: Thanks to the success of modern antiretroviral therapy (ART), people living with HIV (PLWH) have life expectancies which approach that of persons in the general population. However, despite the ability of ART to suppress viral replication, PLWH have high levels of chronic systemic inflammation which drives the development of comorbidities such as cardiovascular disease, diabetes and non-AIDS associated malignancies. Historically, cannabis has played an important role in alleviating many symptoms experienced by persons with advanced HIV infection in the pre-ART era and continues to be used by many PLWH in the ART era, though for different reasons. Δ-Tetrahydrocannabinol (Δ-THC) and cannabidiol (CBD) are the phytocannabinoids, which have received most attention for their medicinal properties. Due to their ability to suppress lymphocyte proliferation and inflammatory cytokine production, there is interest in examining their therapeutic potential as immunomodulators. CB2 receptor activation has been shown in vitro to reduce CD4 T-cell infection by CXCR4-tropic HIV and to reduce HIV replication. Studies involving SIV-infected macaques have shown that Δ-THC can reduce morbidity and mortality and has favourable effects on gut mucosal immunity. Furthermore, ΔTHC administration was associated with reduced lymph node fibrosis and diminished levels of SIV proviral DNA in spleens of rhesus macaques compared with placebo-treated macaques. In humans, cannabis use does not induce a reduction in peripheral CD4 T-cell count or loss of HIV virological control in cross-sectional studies. Rather, cannabis use in ART-treated PLWH was associated with decreased levels of T-cell activation, inflammatory monocytes and pro-inflammatory cytokine secretion, all of which are related to HIV disease progression and comorbidities. Randomized clinical trials should provide further insights into the ability of cannabis and cannabinoid-based medicines to attenuate HIV-associated inflammation. In turn, these findings may provide a novel means to reduce morbidity and mortality in PLWH as adjunctive agents to ART.

Social and public health implications of the legalisation of recreational cannabis: A literature review

BACKGROUND

After many years of legal struggles for the legalisation of recreational use of cannabis, the Constitutional Court of South Africa ruled in favour of the applicants in September 2018. Although the ruling issued caution regarding the social challenges accompanying this legalisation, it did not address how the country would deal with the societal consequences of this ruling.

AIM

The aim of this article was to discuss the social and public health implications of the legalisation of recreational cannabis on South Africa.

METHODS

Literature review on the social, health and legal impacts of legalisation of cannabis, considering experiences of other countries that have legalised cannabis.

RESULTS

The legalisation brings a range of significant negative consequences, which include an expected increase in the number of users and the subsequent undesirable effects on the physical, mental and social health of communities.

CONCLUSION

In terms of financial, infrastructural and human resources, South Africa cannot afford the consequences of the legalisation of recreational cannabis. Poor communities, children and the youth will carry the brunt of the scourge of cannabis use.

DSM-5 substance use disorder symptom clusters and HIV antiretroviral therapy (ART) adherence

This study examines self-reported 30-day antiretroviral therapy (ART) adherence among 101 people living with HIV and substance use disorders (SUD) in New York City in terms of Diagnostic and Statistical Manual - 5th Edition (DSM-5) SUD symptom clusters: impaired control, social impairment, risky use and pharmacological criteria. Overall, 60.4% met DSM-5 criteria for stimulant, 55.5% for alcohol, 34.7% for cannabis and 25.7% for opioid SUD. Of the 76 participants with a current ART prescription, 75.3% reported at least 90% 30-day adherence. Participants with vs. without alcohol SUD were significantly less likely to report ART adherence (64.3% vs. 88.2%, p = .017). Endorsement of social impairment significantly differed among adherent vs. non-adherent participants with alcohol SUDs (74.1% vs. 100%, p = .038) and with opioid SUDs (94.1% vs. 50.0%, p = .040). Understanding specific SUD symptom clusters may assist providers and patients in developing strategies to improve ART adherence.

Cannabis Consumption in People Living with HIV: Reasons for Use, Secondary Effects, and Opportunities for Health Education

Introduction: Rates of cannabis consumption range from 40% to 74% among people living with HIV (PLWH). Little is known about the reasons for cannabis use, related modes of administration, effectiveness for symptom relief, or undesirable effects in the modern antiretroviral therapy (ART) era. Our aim was to conduct an exploratory study to identify potential areas for further evaluation and intervention. Materials and Methods: From January to June 2018, health care providers at the Chronic Viral Illness Service in Montreal, Canada, asked their patients about cannabis use during routine visits. Patients reporting cannabis use were invited to complete a 20-min coordinator-administered questionnaire. Questions related to patterns of use, modes of administration, reasons for use, secondary effects, and HIV health-related factors (e.g., adherence to ART). Results: One hundred and four PLWH reporting cannabis use participated. Median age was 54 years (interquartile range [IQR] 46-59), 13% were female, and 42% were HIV-Hepatitis C co-infected. Median CD4 count was 590 cells/mm³ (IQR 390-821), 95% of participants were on ART, and 88% had suppressed viral loads. Reported cannabis use was more than once daily (32%); daily (25%); weekly (22%); monthly (17%); and rarely (twice to thrice per year; 6%). The majority of participants (97%) smoked dry plant cannabis. Other modes included vaping (12%), capsules (2%), edibles (21%), and oils (12%). Common reasons for cannabis use were for pleasure (68%) and to reduce anxiety (57%), stress (55%), and pain (57%). Many participants found cannabis "quite effective" or "extremely effective" (45%) for symptom relief. Secondary effects included feeling high (74%), increased cough (45%), paranoia (22%), palpitations (20%), and increased anxiety (21%). Over two-thirds of participants indicated that secondary effects were not bothersome at all. Most participants (68%) rarely missed doses of their ART, while 27% missed occasionally (once to twice per month). The most commonly accessed sources of information about cannabis were friends (77%) and the internet (55%). Conclusion: The most common reasons for cannabis use in our population were for pleasure, followed by reduction of stress/anxiety and symptoms associated with a medical condition. Most smoke cannabis and rate cannabis as quite effective for symptom relief. While many participants experience secondary effects, most are not bothered by these symptoms. Amid widespread changes in the regulatory landscape of recreational cannabis, health care providers should be prepared to answer questions about cannabis.

Measuring Antiretroviral Adherence Among Young People Living with HIV: Observations from a Real-Time Monitoring Device Versus Self-report

This report compares self-report (SR) antiretroviral (ARV) adherence data to adherence data collected via Wisepill, a real-time electronic monitoring (EM) device, among young people living with HIV (YPLH) in the southern United States. Participants (n = 66; ages 16 to 26) were followed for 14 weeks. Descriptive analyses were used to compare SR to EM data. Correlations and a linear regression were conducted to explore factors possibly associated with SR-EM discrepancies. We also examined associations between various levels of SR and EM adherence and viral suppression/non-suppression at 14 weeks. Rates of SR adherence were maintained between 87% and 92% while rates of EM adherence declined from 64% to 34%. YPLH who were ARV-experienced, had lower treatment motivation, and reported more frequent recent marijuana use, had a greater discrepancy between their SR and EM adherence levels compared to other YPLH. Higher rates of SR and EM adherence were independently associated with a decline in viral load. A sensitivity analysis also revealed that SR adherence was a better predictor of viral non-suppression, whereas EM adherence was a better predictor of viral suppression. These measurement approaches are discussed in the context of providing clinical care to YPLH.

Medical, therapeutic, and recreational use of cannabis among young men who have sex with men living with HIV

Cannabis plays a role in symptoms management in HIV, especially the alleviation of pain and nausea and stimulation of appetite, and prevalence of cannabis use in HIV-positive populations exceeds that of the general U.S. population. Previous research has described an "overlap" between medical and recreational cannabis use among persons living with HIV. To understand better the motives associated cannabis use among young men who have sex with men living with HIV (HIV+ YMSM), we conducted semi-structured interviews with 30 HIV+YMSM in Denver and Chicago. Interviews were audio-recorded, transcribed, and coded by a diverse team of analysts. In addition to findings that mapped onto previously identified medical motives and recreational motives, we identified several themes that straddled medical and recreational use in a domain we describe as therapeutic. Themes identified in this therapeutic domain of cannabis use include (a) enhanced introspection among individuals that promotes psychological adjustment to an HIV diagnosis, improved medical management, and future orientation; (b) reflection processes that mitigate interpersonal conflict and improve interpersonal communication; and (c) a social-therapeutic phenomena of cannabis use among young persons with living HIV that is characterized by both enhanced introspection and improved interpersonal communication. Our findings suggest a spectrum of cannabis use among HIV+ YMSM that may be characterized not only by an overlap between medical and recreational use, but also by a distinct therapeutic domain that incorporates stress alleviation and cognitive expansion processes to improve focus on HIV management and self-care.

Confirmed marijuana use and lymphocyte count in black people living with HIV

BACKGROUND

Marijuana is a commonly used recreational substance with purported analgesic and mood enhancing properties. Many people living with HIV identify marijuana as a palliative substance. However, through its main psychoactive component, tetrahydrocannabinol (THC), is known to influence the immune system. The effects of marijuana use in people with HIV are still controversial, with very scant literature in Black adults.

METHODS

The current study determined the differences in the lymphocyte count, specifically the number cluster differentiation 4 and 8 (CD4+ and CD8+), among patients who urine drug tested negative for THC (n = 70) and those who tested positive for THC (n = 25). The sample included 95 Black people living with HIV, 51% female, with a mean age of 46 ± 11 years. Participants provided a urine sample for substance use testing and a trained researcher extracted clinical data from clinical charts on the day of appointment.

RESULTS

After adjusting for demographic and HIV-related covariates, THC-positive patients had significantly higher CD4+ and CD8+ counts than their THC-negative counterparts.

CONCLUSION

These results extend previous HIV-related immunity findings in an underrepresented group, and suggest that THC use does not reduce immune function as measured by CD count. Further research is warranted on the overall effects of THC on immune function in HIV positive patients.

The prevalence and patterns of substance use by birth cohort among HIV-positive adults in Florida

OBJECTIVES

Antiretroviral therapy is affording longer lifespans for people living with HIV (PLWH), yet factors such as substance use play an increasing role in morbidity and mortality in this population. Though previous studies have examined substance use differences between age cohorts of PLWH, no study has examined the influence of birth cohort on current substance use patterns. Thus, this study investigated the prevalence of past 12-month self-reported substance use between four birth cohorts, <1970 (M age = 54.1), 1970s (M age = 41.5), 1980s (M age = 31.3 years old), and 1990s (M age = 23.2 years old) of PLWH in Florida.

METHODS

PLWH (N = 934) recruited from community health clinics in Florida completed a questionnaire assessing sociodemographics, health status, and substance use. Multivariate logistic regressions utilizing the <1970 cohort as the referent group examined the relationship between birth cohort and substance use.

RESULTS

The 1980s cohort had significantly greater odds of marijuana use compared to the oldest cohort (<1970s), while the three younger cohorts (1970s, 1980s, and 1990s) evidenced a significantly greater odds of ecstasy use compared to the oldest group. Contrastingly, the three younger birth cohorts reported significantly less crack use than the oldest cohort, while the youngest group (1990s) also demonstrated an 80% reduction in injection drug use compared to the oldest group.

CONCLUSION

The older cohort evidenced significantly greater crack and injection drug use, while the younger cohorts evidenced greater marijuana and ecstasy use. Therefore, it is important to develop age-specific substance use interventions among PLWH.

Differential relationships between cannabis consumption and sleep health as a function of HIV status

BACKGROUND

There is evidence that regular cannabis use has negative effects on sleep health. Relative to HIV- populations, HIV + individuals consistently report greater sleep impairments. The number of HIV + individuals reporting frequent cannabis use, often to treat sleep issues, has significantly increased recently. It is unknown, however, if HIV status moderates the association between cannabis use and sleep health. The current study, therefore, examines these associations in a sample of HIV + and HIV- adults.

METHODS

HIV + and HIV- (N = 107) individuals completed one laboratory visit. Participants completed a 30-day drug use history questionnaire quantifying consumption of cannabis, cigarettes, and alcohol, and a sleep health questionnaire. To verify substance use and HIV status, participants completed a urine toxicology screening and serology testing.

RESULTS

HIV + individuals demonstrated lower sleep health than HIV- individuals. Linear regressions indicated that HIV status moderated the association between total 30-day cannabis consumption and sleep health; cannabis consumption was negatively associated with sleep health in HIV-, but not HIV + individuals. This interactive effect was significant after examining cigarette/alcohol use, depression symptoms, and demographic variables as covariates.

CONCLUSIONS

These results corroborate studies demonstrating an inverse relationship between sleep health and cannabis consumption. This study also suggests that factors other than cannabis may be associated with lower sleep health in HIV + individuals. Emerging studies suggest that inflammation may mediate effects of cannabis on HIV infection. Future studies examining this mechanism are warranted to understand cannabis further and sleep in HIV + individuals.

Substance use patterns among women living with HIV compared with the general female population of Canada

BACKGROUND

HIV infection and substance use synergistically impact health outcomes of people with HIV. In this study, we assessed the prevalence of substance use among women living with HIV (WLWH) and compared them with expected values from general data.

METHODS

Cigarette smoking, frequency of alcohol consumption, last-month non-prescribed cannabis use (vs. last-year use), and last 3 months regular (≥once/week) and occasional (<once/week) use of crack/cocaine, speed (amphetamine), and heroin (vs. last-year use) were examined in WLWH from the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS; N = 1422) and compared with general population women from the 2013-2014 Canadian Community Health Survey (CCHS; N = 46,831). Age/ethnoracial-standardized prevalence differences (SPD) and 95% confidence intervals (CI) were reported.

RESULTS

Compared to expected estimates from general population women, a higher proportion of WLWH reported daily cigarette smoking (SPD: 26.8% [95% CI: 23.9, 29.7]), smoking ≥20 cigarettes/day (SPD: 11.6% [9.8, 13.6]), regular non-prescribed cannabis use (SPD: 8.0% [4.1, 8.6]), regular crack/cocaine use (SPD: 16.7% [13.1, 20.9]), regular/occasional speed use (SPD: 2.4% [1.2, 4.7]), and heroin use (SPD: 11.2% [8.3, 15.0]). However, WLWH reported lower frequencies of alcohol consumption and binge drinking than their counterparts in the general population.

CONCLUSIONS

Cigarette smoking and illicit drug use, but not alcohol use or binge drinking, were more prevalent in WLWH than would be expected for Canadian women with a similar age and ethnoracial group profile. These findings may indicate the need for women-centered harm reduction programs to improve health outcomes of WLWH in Canada.

Substance Use and Adherence to Antiretroviral Therapy: What Is Known and What Is Unknown

PURPOSE OF REVIEW

People who use drugs face multiple challenges to achieve optimal HIV treatment outcomes. This review discusses the current knowledge in substance use and antiretroviral therapy adherence, highlighting recent findings and potential interventions.

RECENT FINDINGS

Studies continue to demonstrate the negative impacts of substance use and related disorders on antiretroviral therapy adherence, with the exception of cannabis. Evidence-based addiction treatment, in particular, opioid agonist therapy, appears to improve adherence levels. Most individual-level adherence specific interventions did not provide sustained effects, and no studies evaluating structural-level interventions were found. Findings suggest the urgent need to scale-up opioid agonist therapy, as well as to simultaneously address multiple structural barriers to care to optimize HIV treatment outcomes among people who use drugs.

Regular Marijuana Use is Associated with Poor Viral Suppression in HIV-Infected Adolescents and Young Adults

There is a paucity of data regarding the impact of drug use on HIV suppression and care retention among adolescents and young adults (AYAs). We recruited a clinic-based sample of HIV infected AYAs to assess the prevalence of self-reported drug use. Clinical data, including retention and viral suppression, were abstracted from the electronic medical record. Logistic regression was used to evaluate marijuana and illicit drug use associations and to identify other risk factors. Of 200 participants (mean age 21, 2.4 years, 69% horizontally infected), 46% reported current drug use, with marijuana as the most commonly used drug. Any illicit drug use (aOR 1.99, 95% CI 1.06-3.73, p = 0.032) and lower education (aOR 2.11, 95% CI 1.09-4.08, p = 0.046) were associated with poor viral suppression in multivariable analyses. Considering marijuana use only, an association with poor viral suppression was more pronounced (aOR 2.10, 95% CI 1.12-3.94, p = 0.021). Drug use did not have a significant association with retention in care, but AYAs who were retained in HIV care were less likely to have poorly suppressed HIV (aOR 0.22, 95% CI 0.10-0.49, p < 0.001). High prevalence of marijuana use among HIV infected AYAs, and its association with poorly suppressed HIV, demonstrates the need for intervention strategies to decrease its consumption.

Frequency of Cannabis Use and Medical Cannabis Use Among Persons Living With HIV in the United States: Findings From a Nationally Representative Sample

Little is known about cannabis use frequency, medical cannabis use, or correlates of use among persons living with HIV (PLWH) in United States nationally representative samples. Data came from 626 PLWH from the 2005-2015 National Survey on Drug Use and Health. Logistic regression identified characteristics associated with frequency of cannabis use. Chi-squares identified characteristics associated with medial cannabis use. Non-daily and daily cannabis use was reported by 26.9% and 8.0%. Greater perceived risk of cannabis use was negatively associated with daily and non-daily use. Younger age, substance use, and binge drinking were positively associated with non-daily cannabis use. Smoking and depression were associated with non-daily and daily use. One-quarter reported medical cannabis use. Medical users were more likely to be White, married, and nondrinkers. Cannabis use was common among PLWH. Findings help to differentiate between cannabis users based on frequency of use and medical versus recreational use.

Substance Use, Violence, and Antiretroviral Adherence: A Latent Class Analysis of Women Living with HIV in Canada

We used latent class analysis to identify substance use patterns for 1363 women living with HIV in Canada and assessed associations with socio-economic marginalization, violence, and sub-optimal adherence to combination antiretroviral therapy (cART). A six-class model was identified consisting of: abstainers (26.3%), Tobacco Users (8.81%), Alcohol Users (31.9%), 'Socially Acceptable' Poly-substance Users (13.9%), Illicit Poly-substance Users (9.81%) and Illicit Poly-substance Users of All Types (9.27%). Multinomial logistic regression showed that women experiencing recent violence had significantly higher odds of membership in all substance use latent classes, relative to Abstainers, while those reporting sub-optimal cART adherence had higher odds of being members of the poly-substance use classes only. Factors significantly associated with Illicit Poly-substance Users of All Types were sexual minority status, lower income, and lower resiliency. Findings underline a need for increased social and structural supports for women who use substances to support them in leading safe and healthy lives with HIV.

Influence of Substance Use Disorders on 2-Year HIV Care Retention in the United States

Substance use disorders (SUDs) are thought to predict care discontinuity, though magnitude and substance-specific variance of effects are unclear. This report of analytic work undertaken with a multi-regional American cohort of 9153 care enrollees addresses these gaps. Care retention was computed from 24-month post-linkage clinic visit documentation, with SUD cases identified from patient-report screening instruments. Two generalized estimating equations tested binary and hierarchial SUD predictors of retention, and potential effect modification by patient age-group, sex, and care site. Findings demonstrate: (1) detrimental SUD effect, equivalent to a nine percentage-point decrease in retention, with independent effects of age-group and care site; (2) substance-specific effect of marijuana UD associated with lower retention; and (3) age-modification of each effect on care discontinuity, with SUDs serving as a risk factor among 18-29 year-olds and protective factor among 60+ year-olds. Collective findings document patient attributes as influences that place particular subgroups at-risk to discontinue care.

The Impact of Substance Use on Adherence to Antiretroviral Therapy Among HIV-Infected Women in the United States

Research is scant regarding differential effects of specific types of recreational drugs use on antiretroviral therapy adherence among women, particularly to single-tablet regimens (STR). This is increasingly important in the context of marijuana legalization. We examined the effects of self-reported substance use on suboptimal (<95%) adherence in the Women's Interagency HIV Study, 2003-2014. Among 1799 HIV-infected women, the most prevalent substance used was marijuana. In multivariable Poisson GEE regression, substance use overall was significantly associated with suboptimal adherence (adjusted prevalence ratio, aPR = 1.20, 95% CI 1.10-1.32), adjusting for STR use, socio-demographic, behavioral, and clinical factors. Among STR users, compared to no drug use, substance use overall remained detrimental to ART adherence (aPR = 1.61, 95% CI 1.24-2.09); specifically, both marijuana (aPR = 1.48, 95% CI: 1.11-1.97) and other drug use (aPR = 1.87, 95% CI 1.29-2.70) predicted suboptimal adherence. These findings highlight the need to intervene with drug-using women taking antiretroviral therapy to maintain effective adherence.

The association of therapeutic versus recreational marijuana use and antiretroviral adherence among adults living with HIV in Florida

PURPOSE

Marijuana use is common among people living with HIV (PLWH), but its association with antiretroviral therapy (ART) adherence is unclear. This study examined the association between reason for marijuana use and ART adherence in a sample of adults living with HIV.

PATIENTS AND METHODS

Participants (N=703) recruited from seven community health centers in Florida completed a 45-minute questionnaire assessing demographics, symptoms of anxiety and depression, ART adherence, and substance use, including reasons for marijuana use. ART adherence was defined as the proportion of days in the last 30 days participants did not miss any medication and dichotomized as optimal (≥95%) and suboptimal (<95%). Multivariate logistic regression analysis assessed the association between therapeutic marijuana use to manage HIV symptoms (ie, improve appetite/gain weight, induce sleep, relieve nausea/vomiting, relieve pain, relieve anxiety/depression/stress) versus recreational marijuana use and ART adherence.

RESULTS

Approximately one third (33.2%) of the participants reported using marijuana in the past 3 months. Of marijuana users, 21.8% reported using marijuana only for therapeutic purposes to manage HIV-associated medical symptoms, while 78.2% reported recreational use. After controlling for covariates, therapeutic use of marijuana was not associated with ART adherence (AOR =1.19, 95% CI =0.60-2.38, p=0.602) while recreational marijuana users showed significantly greater odds of suboptimal ART adherence compared to nonusers (AOR =1.80, 95% CI =1.18-2.72, p=0.005).

CONCLUSION

Our results suggest differences in ART adherence between individuals who report recreational versus therapeutic marijuana use. Continued research examining the health implications of marijuana use among adults living with HIV is important as legalization of recreational and medical marijuana proliferates in the United States.