Under the Influence: Alcohol, Substance Use and Treatment Adherence in Youth Living with HIV in the Global Adolescent and Young Adult Network of IeDEA (AYANI) Cohort

Alcohol and substance use in youth living with HIV (YLHIV) can influence health and treatment outcomes. We assessed substance use and associations with antiretroviral therapy (ART) adherence among YLHIV. The Adolescent and Young Adult Network of IeDEA enrolled YLHIV (15–24 years old) receiving ART (2021–2024) from 6 global regions. We assessed biopsychosocial experiences with validated tools; adherence with self-reported missed medication doses and unsuppressed viral load (VL > 1,000 copies/ml); and substance use by point-of-care urine tests and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) tool. Among 694 YLHIV, 53% female, median enrolment 20 years old (IQR 18–22), 83% had perinatally-acquired HIV, and 71% received Integrase Inhibitor-based ART. Half (49%) reported missing medication doses and 14% had unsuppressed VL. Any prior alcohol use (47%) was more common than other substances, where cannabis (12%) and sedatives/benzodiazepines (3.9%) contributed. Recent moderate/high-risk alcohol and other substance use were reported by 9.1% of YLHIV. YLHIV with positive urine tests had not reported recent use of alcohol (n = 17/46; 37%), cannabis (n = 12/32; 38%) and benzodiazepines (n = 13/13, 100%). Moderate/high-risk alcohol and other substance use were associated with self-reported adherence difficulties (adjusted odds ratio(aOR) 2.37, 95% CI 1.28–4.38; and aOR 2.13, 95% CI 1.18–3.85) but not unsuppressed VL (aOR 0.80, 95% CI 0.34–1.88; and aOR 1.61, 95% CI 0.79–3.29). Moderate/high-risk alcohol and/or substance use was reported by 15% of YLHIV and was associated with self-reported adherence difficulties. Discrepancies between point-of-care tests and self-reported use suggest alcohol/substance use is underestimated. Enhanced screening and interventions targeting substance use are recommended.