“Nobody’s Going to Say No to a Dollar”: Framing HIV Medication Diversion Through the Lens of Economies of Diversion

People living with HIV (PLWH) experiencing chronic poverty may divert their antiretroviral therapy (ART) as an economic survival strategy, yet their lived experiences remain under examined. We conducted a phenomenological analysis of in-depth interviews with Black and Latino (N = 38) PLWH from two trials using the Intervention Innovations Team's Integrated Conceptual Model (IIT-ICM), which centers systemic and socioeconomic inequities in HIV care. Participants (74% cisgender men; 84% Black, mean age 48 years) reported high rates of food insecurity (85%), unemployment (90%), and unstable housing (52%), moderate-to-high-risk substance use (57% alcohol, 52% cannabis, 48% cocaine), and 76% reported past substance use treatment. Through inductive analysis of participant interviews, we identified three interrelated diversion processes: (1) Commodification, the transformation of prescribed medication into a material resource within informal or underground markets; (2) Navigation, the strategic management of care and survival within and against institutional systems; and (3) Reorientation, shifts in how individuals relate to treatment and its value over time, shaped by changing material, health, and emotional conditions. We characterize these processes as the "Economies of Diversion" model. By framing ART diversion as a structurally driven adaptive strategy, this work reveals how socioeconomically marginalized Black and Latino PLWH reconcile ART adherence guidelines with urgent material demands. Findings highlight the need to integrate economic supports, expand pharmacy-based financial incentives as harm-reduction alternatives, adopt autonomy-affirming clinical approaches, invest in upstream social protections, and pair long-acting injectable rollouts with economic benefits. Importantly, the Economies of Diversion model may also apply to other forms of medication diversion.