Substance Abuse, HIV, and Mental Health Issues: Prevention and Treatment Challenges

  • Dionne J. Jones
  • George W. Roberts


Two decades of research has established a link between substance abuse and HIV/AIDS, often referred to as the twin epidemics.1,2 Additionally, substance abuse and mental disorders are often co-occurring conditions;3 persons with substance use disorders are at elevated risk for mental health disorders and vice versa. People infected with HIV/AIDS and having co-occurring mental health and substance abuse disorders face enormous difficulty in accessing treatment and they often fail to receive adequate treatment for one or more of their illnesses.4 People with triple diagnoses (substance abuse, mental health disorders, and HIV) represent a growing challenge to health care service providers. This is even more tenuous for racial/ethnic minorities who are disproportionately represented and impacted by these diseases.

This chapter presents data on the prevalence of drug use, mental illness, and HIV/AIDS among racial/ethnic minorities; addresses the link between substance abuse and HIV/AIDS; the link between mental disorder and HIV; and examines the effectiveness of HIV risk reduction strategies for drug-using populations. Further, the chapter discusses mental health issues and the needs of HIV-positive substance abusers and sets forth optimal management strategies for engaging the dually and triply diagnosed in treatment. Focus will be placed on racial/ethnic minorities, particularly African Americans, where appropriate.


Mental Illness Severe Mental Illness Mental Health Issue Dual Diagnosis Substance Abuse Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Marcus MT, Walker T, Swint JM, Smith BP, Brown C, Busen N, Edwards T, Liehr P, Taylor WC, Williams D, von Sternberg K. Community-based participatory research to prevent substance abuse and HIV/AIDS in African-American adolescents. J Interprof Care. 2004; 18(4): 347–359PubMedCrossRefGoogle Scholar
  2. 2.
    Gabel LL, Pearsol JA. The twin epidemics of substance use and HIV: a state-level response using a train-the-trainer model. Fam Pract. 1993;10(4): 400–405PubMedCrossRefGoogle Scholar
  3. 3.
    National Institute on Drug Abuse (NIDA). Drugs, Brains, and Behavior: The Science of Addiction. Atlanta, GA: US Department of Health and Human Services, National Institutes of Health, February 2007 .Google Scholar
  4. 4.
    Caslyn RJ, Klinkenbert WD, Morse GA, Miller J, Cruthis R. Recruitment, engagement, and retention of people living with HIV and co-occurring mental health and substance use disorders. AIDS Care. 2004; 16(Suppl. 1): S56–S70Google Scholar
  5. 5.
    National Institute on Drug Abuse (NIDA). Drug Use Among Racial/Ethnic Minorities. Revised Ed. Atlanta, GA: US Department of Health and Human Services, National Institutes of Health, 2003 .Google Scholar
  6. 6.
    Centers for Disease Control and Prevention. HIV/AIDS Fact Sheet, HIV/AIDS Among African Americans, 2006. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008 .Google Scholar
  7. 7.
    Blankenship KM, Smoyer AB, Bray SJ, Mattocks K. Black–White disparities in HIV/AIDS: the role of drug policy and the corrections system. J Health Care Poor Underserved. 2005; 16(4 Suppl. B): 140–156PubMedCentralPubMedGoogle Scholar
  8. 8.
    Centers for Disease Control and Prevention. Drug-Associated HIV Transmission Continues in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, May 2002 .Google Scholar
  9. 9.
    Centers for Disease Control and Prevention. Trends in HIV/AIDS diagnoses ‐ 33 States, 2001–2004. MMWR Morb Mort Wkly Rep. 2005; 54(45): 1149–1153 .Google Scholar
  10. 10.
    Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 2006, Vol. 18. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008 .Google Scholar
  11. 11.
    Pendergast ML, Urada D, Podus DJ. Meta-analysis of HIV risk-reduction interventions within drug abuse treatment programs. J Consult Clin Psychol. 2001; 69: 389–405CrossRefGoogle Scholar
  12. 12.
    Angelino AF, Treisman GJ. Management of psychiatric disorders in patients infected with human immunodeficiency virus. Clin Infect Dis. 2001; 33: 847–856PubMedCrossRefGoogle Scholar
  13. 13.
    Soto TA, Bell J, Pillen MB. Literature on integrated HIV care: a review. AIDS Care. 2004; 16(Suppl. 1): S43–S55PubMedCrossRefGoogle Scholar
  14. 14.
    Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA. 2001; 286(22): 2857–2864PubMedCrossRefGoogle Scholar
  15. 15.
    Walkup J, Blank MB, Gonzalez JS, Safren S, Schwartz R, Brown L, Wilson I, Knowlton A, Lombard F, Grossman C, et al. The impact of mental health and substance abuse factors on HIV prevention and treatment. J Acquir Immune Defic Syndr. 2008; 47(Suppl. 1): S15–S19PubMedCrossRefGoogle Scholar
  16. 16.
    Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London AS, Turner BJ, Eggan F, Beckman R, Vitiello B, Morton SC, Orlando M, Bozzette SA, Ortiz-Barron L, Shapiro M. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001; 58: 721–728PubMedCrossRefGoogle Scholar
  17. 17.
    Tegger MK, Crane HM, Tapia KA, Uldall KK, Holte SE, Kitahata MM. The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals. AIDS Patient Care STDS. 2008; 22(3): 233–243PubMedCrossRefGoogle Scholar
  18. 18.
    Whetten K, Reif S, Ostermann J, Pence BW, Swartz M, Whetten R, Conover C, Bouis S, Thielman N, Eron J. Improving health outcomes among individuals with HIV, mental illness, and substance use disorders in the Southeast. AIDS Care. 2006; 18(Suppl. 1): S18–S26PubMedCrossRefGoogle Scholar
  19. 19.
    Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6): 593–602PubMedCrossRefGoogle Scholar
  20. 20.
    Asch SM, Kilbourne AM, Gifford AL, Burnam MA, Turner B, Shapiro MF, Bozzette SA. Underdiagnosis of depression in HIV: who are we missing? J Gen Intern Med. 2003; 18(6): 450–460PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Klinkenberg WD, Sacks S. HIV/AIDS Treatment Adherence, Heath Outcomes and Cost Study Group. Mental disorders and drug abuse in persons living with HIV/AIDS. AIDS Care. 2004; 16(Suppl. 1): S22–S42PubMedCrossRefGoogle Scholar
  22. 22.
    Brief DJ, Bollinger AR, Vielhauer MJ, Berger-Greenstein JA, Morgan EE, Brady SM, Buondonno LM, Keane TM. Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes. AIDS Care. 2004; 16(Suppl. 1): S97–S120PubMedCrossRefGoogle Scholar
  23. 23.
    Kalichman SC, Benotsch EG, Rompa D, Gore-Felton C, Austin J, Juke W, DiFonzo K, Buckles J, Kyomugisha F, Simpson D. Unwanted sexual experiences ad sexual risks in gay and bisexual men: associations among revictimization, substance use, and psychiatric symptoms. J Sex Res. 2001; 38(1): 1–9CrossRefGoogle Scholar
  24. 24.
    Atkinson JH, Grant I. Natural history of neuropsychiatric manifestations of HIV disease. Psychiatr Clin North Am. 1994; 17(1): 17–33PubMedGoogle Scholar
  25. 25.
    Cook JA, Grey D, Burke J, Cohen MH, Gurtman AC, Richardson JL, Wilson TE, Young MA, Hessol NA. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health. 2004; 94(7): 1133–1140PubMedCrossRefGoogle Scholar
  26. 26.
    Perdue T, Hagan H, Thiede H, Valleroy L. Depression and HIV risk behavior among Seattle-area injection drug users and young men who have sex with men. AIDS Educ Prev. 2003; 15(1): 81–92PubMedCrossRefGoogle Scholar
  27. 27.
    Hardman JG, Limbird LE, Gilman AG. Goodman and Gilman's The Pharmacological Basis of Therapeutics, 100 edition. 2001, p. 624 .Google Scholar
  28. 28.
    Volkow ND, Fowler JS, Wang GJ. The addicted human brain viewed in the light of imaging studies: brain circuits and treatment strategies. Neuropharmacology. 2004; 47(Suppl. 1): 3–13PubMedCrossRefGoogle Scholar
  29. 29.
    Hendershot CS, Stoner SA, George WH, Norris J. Alcohol use, expectancies, and sexual sensation seeking as correlates of HIV risk behavior in heterosexual young adults. Psychol Addict Behav. 2007; 21(3): 365–372PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    National Institute on Drug Abuse (NIDA). Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders. Second Ed. Atlanta, GA: US Department of Health and Human Services, National Institutes of Health, 2003 .Google Scholar
  31. 31.
    El-Bassel N, Gilbert L, Wu E, Chang M, Gomes C, Vinocur D, Spevack T. Intimate partner violence prevalence and HIV risks among women receiving care in emergency departments: implications for IPV and HIV screening. Emerg Med J. 2007; 24(4): 255–259PubMedCrossRefGoogle Scholar
  32. 32.
    Freisthler B, Gruenewald PJ, Johnson FW, Treno AJ, Lascala EA. An exploratory study examining the spatial dynamics of illicit drug availability and rates of drug use. J Drug Educ. 2005;35(1): 15–27PubMedCrossRefGoogle Scholar
  33. 33.
    Meade CS, Kershaw TS, Hansen NB, Sikkema KJ. Long-term correlates of childhood abuse among adults with severe mental illness: adult victimization, substance abuse, and HIV sexual risk behavior. AIDS Behav. 2007; (e-pub ahead of print), DOI 10.1007/s10461–007–9326–4 .Google Scholar
  34. 34.
    Singer MC, Erickson PI, Badiane L, Diaz R, Ortiz D, Abraham T, Nicolaysen AM. Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context. Soc Sci Med. 2006; 63(8): 2010–2021PubMedCrossRefGoogle Scholar
  35. 35.
    Chander G, Himelhoch S, Moore RD. Substance abuse and psychiatric disorders in HIV-positive patients. Drugs. 2006; 66(6): 769–789PubMedCrossRefGoogle Scholar
  36. 36.
    Repetto MJ, Petitto JM. Psychopharmacology in HIV-infected patients. Psychosom Med. 2008; 70(5): 585–592PubMedCrossRefGoogle Scholar
  37. 37.
    Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, Constantine NT, Wolford GL, Salyers MP. Prevalence of HIV, Hepatitis B, and Hepatitis C in people with severe mental illness. Am J Public Health. 2001; 91: 31–37PubMedCrossRefGoogle Scholar
  38. 38.
    Whetten K, Reif S, Whetten R, Murphy-McMillan LK. Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care. Psychosom Med. 2008; 70(5): 531–538PubMedCrossRefGoogle Scholar
  39. 39.
    Stoff DM, Mitnick L, Kalichman S. Research issues in the multiple diagnoses of HIV/AIDS, mental illness and substance abuse. AIDS Care.2004; 16(Suppl. 1): S1–S5PubMedGoogle Scholar
  40. 40.
    Coyle SL, Needle RH, Normand J. Outreach-based HIV prevention for injecting drug users: a review of published outcome data. Public Health Rep. 1998; 113(Suppl. 1): 19–30PubMedCentralPubMedGoogle Scholar
  41. 41.
    Sterk CE, Theall KP, Elifson KW. Effectiveness of a risk reduction intervention among African American Women who use Crack Cocaine. AIDS Educ Prev. 2003; 15(1): 15–32PubMedCrossRefGoogle Scholar
  42. 42.
    Wechsberg WM, Lam WK, Zule W, Hall G, Middlesteadt R, Edwards J. Violence, homelessness, and HIV risk among crack-using African-American women. Subst Use Misuse. 2003; 38(3–6): 669–700PubMedCrossRefGoogle Scholar
  43. 43.
    Wingood GM, DiClemente RJ. Enhancing adoption of evidence-based HIV interventions: promotion of a suite of HIV prevention interventions for African American women. AIDS Educ Prev. 2006; 18(4 Suppl. A): 161–170PubMedCrossRefGoogle Scholar
  44. 44.
    Wechsberg WM, Zule WA, Riehman KS, Luseno WK, Lam WK. African American crack abusers and drug treatment initiation: barriers and effects of a pretreatment intervention. Subst Abuse Treat Prev Policy. 2007; 2: 10PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Carey MP, Carey KB, Maisto SA, Gordon CM, Schroder KEE, Vanable PA. Reducing HIV-risk behavior among adults receiving outpatient psychiatric treatment: results from a randomized controlled trial. J Consult Clin Psychol. 2004; 72(2): 252–268PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Metzger DS, Navaline H, Woody GE. Drug abuse treatment as AIDS prevention. Public Health Rep. 1998; 113(Suppl. 1): 97–106PubMedCentralPubMedGoogle Scholar
  47. 47.
    Brooner R, Kidorf M, King V, Beilenson P, Svikis D, Vlahov D. Drug abuse treatment success among needle exchange participants. Public Health Rep. 1998; 113(Suppl. 1): 129–139PubMedCentralPubMedGoogle Scholar
  48. 48.
    Kidorf M, Disney E, King V, Kolodner K, Beilenson P, Brooner RK. Challenges in motivating treatment enrollment in community syringe exchange participants. J Urban Health. 2005; 82(3): 456–467PubMedCrossRefGoogle Scholar
  49. 49.
    Copenhaver MM, Lee IC. Optimizing a community-friendly HIV risk reduction intervention for injection drug users in treatment: a structural equation modeling approach. J Urban Health. 2006; 83(6): 1132–1142PubMedCrossRefGoogle Scholar
  50. 50.
    El-Bassel N, Gilbert L, Wu E. A social network profile and HIV risk among men on methadone: do social networks matter? J Urban Health. 2006; 83(4): 602–613PubMedCrossRefGoogle Scholar
  51. 51.
    Neaigus A. The network approach and interventions to prevent HIV among injection drug users. Public Health Rep. 1998; 113(Suppl. 1): 140–150PubMedCentralPubMedGoogle Scholar
  52. 52.
    Latkin CA. Outreach in natural settings: the use of peer leaders for HIV prevention among injecting drug users' networks. Public Health Rep. 1998; 113(Suppl. 1): 151–159PubMedCentralPubMedGoogle Scholar
  53. 53.
    Cottler LB, Compton WM, Abdallah AB, Cunningham-Williams R, Abram F, Fichtenbaum C, Dotson W. Peer-delivered interventions reduce HIV risk behaviors among out-of-treatment drub abusers. Public Health Rep. 1998; 113(Suppl. 1): 31–41PubMedCentralPubMedGoogle Scholar
  54. 54.
    Parry CD, Blank MB, Pithey AL. Responding to the threat of HIV among persons with mental illness and substance abuse. Curr Opin Psychiatry. 2007; 20(3): 235–241PubMedGoogle Scholar
  55. 55.
    Dausey DJ, Desai RA. Psychiatric comorbidity and the prevalence of HIV infection in a sample of patients in treatment for substance abuse. J Nerv Ment Dis. 2003; 191(1): 10–17PubMedCrossRefGoogle Scholar
  56. 56.
    Burnam MA, Bing EG, Morton SC, Sherbourne C, Fleishman JA, London AS, Vitiello B, Stein M, Bozzette SA, Shapiro MF. Use of mental health and substance abuse treatment services among adults with HIV in the United States. Arch Gen Psychiatry. 2001; 58: 729–736PubMedCrossRefGoogle Scholar
  57. 57.
    McCabe MP, Leas L. A qualitative study of primary health care access, barriers and satisfaction among people with mental illness. Psychol Health Med. 2008; 13(3): 303–312PubMedCrossRefGoogle Scholar
  58. 58.
    Bender DS, Skodol AE, Dyck JR, Markowitz JC, Shea MT, Yen S, Sanislow CA, Pinto A, Zanarini MC, McGlashan TH, Gunderson JG, Daversa MT, Grilo CM. Ethnicity and mental health treatment utilization by patients with personality disorders. J Consult Psychol. 2007; 75(6): 992–999CrossRefGoogle Scholar
  59. 59.
    Weissman G, Melchior L, Huba G, Smereck G, Needle R, McCarthy S, Jones A, Genser S, Cottler L, Booth R, et al. Women living with drug abuse and HIV disease: drug abuse treatment access and secondary prevention issues. J Psychoactive Drugs. 1995; 27(4): 401–411PubMedCrossRefGoogle Scholar
  60. 60.
    Smith R, Rossetto K, Peterson BL. A meta-analysis of disclosure of one's HIV-positive status, stigma and social support. AIDS Care. 2008; 20(10): 1266–1275 (e-pub. June 27, 2008)PubMedCrossRefGoogle Scholar
  61. 61.
    Kidorf M, King VL, Neufeld K, Stoller KB, Peirce J, Brooner RK. Involving significant others in the care of opioid-dependent patients receiving methadone. J Subst Abuse Treat. 2005; 29(1): 19–27PubMedCrossRefGoogle Scholar
  62. 62.
    Perdue B, Johnson D, Singley D, Jackson C. Assessing spirituality in mentally ill African Americans. ABNF J. 2006 Spring; 17(2): 78–81PubMedGoogle Scholar
  63. 63.
    Loue S, Sajotovic M. Spirituality, coping, and HIV risk and prevention in a sample of severely mentally ill Puerto Rican women. J Urban Health. 2006; 83(6): 1168–1182PubMedCrossRefGoogle Scholar
  64. 64.
    Simoni JM, Martone MG, Kerwin JF. Spirituality and psychological adaptation among women with HIV/AIDS: implications for counseling. J Couns Psychol. 2002; 49(2): 139–147CrossRefGoogle Scholar
  65. 65.
    Nelson G, Aubry T, Lafrance A. A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless. Am J Orthopsychiatry. 2007; 77(3): 350–361PubMedCrossRefGoogle Scholar
  66. 66.
    Pressman SD, Cohen S. Does positive affect influence health? Psychol Bull. 2005; 131(6): 925–971PubMedCrossRefGoogle Scholar
  67. 67.
    Moneyham L, Murdaugh C, Phillips K, Jackson K, Tavakoli A, Boyd M, Jackson N, Vyavaharkar M. Patterns of risk of depressive symptoms among HIV-positive women in the southeastern United States. J Assoc Nurses AIDS Care. 2005; 16(4): 25–38PubMedCrossRefGoogle Scholar
  68. 68.
    Weaver KE, Llabre MM, Durán RE, Antoni MH, Ironson G, Penedo FJ, Schneiderman N. A stress and coping model of medication adherence and viral load in HIV-positive men and women on highly active antiretroviral therapy (HAART). Health Psychol. 2005; 24(4): 385–392PubMedCrossRefGoogle Scholar
  69. 69.
    Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K, Kola L, Lynde D, Osher FC, Clark RE, Rickards L. Implementing dual diagnosis services for clients with severe mental illness. Psychiat Serv. 2001; 52(4): 469–476CrossRefGoogle Scholar
  70. 70.
    Treisman G, Angelino A. Interrelation between psychiatric disorder and the prevention and treatment of HIV infection. Clin Infect Dis. 2007; 45: S313–S317PubMedCrossRefGoogle Scholar
  71. 71.
    Douaihy AB, Jou RJ, Gorske T, Salloum IM. Triple diagnosis: dual diagnosis and HIV disease, Part 1. AIDS Read. 2003; 13(7): 331, 332, 339–341Google Scholar
  72. 72.
    Blount A, Schoenbaum M, Kathol R, Rollman BL, Thomas M, O'Donohue W, Peek CJ. The economics of behavioral health services in medical settings: a summary of the evidence. Prof Psychol Res Pr. 2007; 38(3): 290–297CrossRefGoogle Scholar
  73. 73.
    Weaver MR, Conover CJ, Proescholdbell RJ, Arno PS, Ang A, Ettner SL. Utilization of mental health and substance abuse care for people living with HIV/AIDS, chronic mental illness, and substance abuse disorders. J Acquir Immune Defic Syndr. 2008; 47(4): 449–458PubMedCrossRefGoogle Scholar
  74. 74.
    The HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study Group. 2004 The HIV/AIDS treatment adherence, health outcomes and cost study: conceptual foundations and overview. AIDS Care. 16(Suppl. 1): S6–S21 Google Scholar
  75. 75.
    Nebelkopf E, Penagos M. Holistic Native network: integrated HIV/AIDS, substance abuse, and mental health services for Native Americans in San Francisco. J Psychoactive Drugs. 2005; 37(3): 257–264PubMedCrossRefGoogle Scholar
  76. 76.
    Stone VE. Optimizing the care of minority patients with HIV/AIDS. Clin Infect Dis. 2004; 38: 400–404PubMedCrossRefGoogle Scholar
  77. 77.
    Zaller N, Gillani FS, Rich JD. A model of integrated primary care for HIV-positive patients with underlying substance use and mental illness. AIDS Care. 2007; 19(9): 1128–1133PubMedCrossRefGoogle Scholar
  78. 78.
    Bouis S, Reif S, Whetten K, Scovil J, Murray A, Swartz M. An integrated, multidimensional treatment model for individuals living with HIV, mental illness, and substance abuse. Health Soc Work. 2007; 32(4): 268–278PubMedCrossRefGoogle Scholar
  79. 79.
    Goldsmith RJ, Garlapati V. Behavioral interventions for dual-diagnosis patients. Psychiatr Clin North Am. 2004; 27(4): 709–725PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Services Research Branch, Division of Epidemiology, Services & Prevention ResearchNational Institute on Drug AbuseBethesdaU.S.

Personalised recommendations