Human Immunodeficiency Virus Infection in Young Adults: Treatment of Substance Use Disorders as a Priority Component of HIV Prevention, Care and Treatment in Low and Middle Income Countries

Keywords

Young adults; Drug Use; Substance Use Disorder Treatment; HIV Infection; Alcohol Use.

Introduction to Substance Abuse and HIV Infection Among Young Adults

The time span determining young adulthood is imprecise and is a function of psychosocial development and physical development which varies region to region and culture to culture. Studies have identified the age range to be between 16-40 years of age for young adulthood [1-3]. For the purpose of addressing substance use and substance use disorders in the context of Human Immunodeficiency Virus (HIV) infection during young adulthood, the age range of 16-30 years has been selected to reflect a time when life goals are formulated, along with meeting the challenges of independently facing a diverse, global and rapidly changing environment. This time frame, based on social norms, is the period of sexual debut (average age of first sex in 44 countries is 18.4 years) [4] and the consequences of first exposure to legal drugs, such as alcohol [5]. Globally, the median age for the initiation of alcohol use has been reported at 16-19 years of age, with nearly half of those initiating between the ages of 14-21[5]. Exposure to alcohol in childhood or early adolescence and binge drinking in late adolescence confer an increased venerability to alcohol dependence as young adults [6, 7]. National surveys, globally, show that approximately 70% of young adults consume alcohol and research studies show that young adults drink the most in their late teens to mid-twenties [8-11]. These data also show a gender component with more men being consumers of alcohol compared to women. Global burden of disease studies have shown that alcohol use disorders have been reported as the highest risk factor for disability adjusted life-years for young adults 20-24 years of age [12].

With regard to illicit drug use and young adults, prescription drug abuse is reported high in national surveys of developed countries with approximately 6% of young adults reporting non-medical use of prescription drugs in the last month [13]. One in six urban young adults attending partying venues has been reported to combine illicit drug use with prescription drug abuse [14]. Of those abusing prescription drugs, 66% used the prescription drug with at least one illicit drug in common combination with marijuana, cocaine, ecstasy and psychotropic drugs. The misuse of over-the counter medications can also result in serious adverse medical events particularly when mixed with alcohol and other drugs [15]. Globally, young adults who misuse over-the-counter medications report a higher prevalence of hazardous alcohol use and illicit drug use [15-17]. Female sex workers and male clients in resource limited settings, who report over-the-counter or prescription drug abuse, are at higher risk for HIV infection through unsafe sex practices [18, 19]. Illicit drugs most identified with an elevated risk of HIV transmission, either through injection drug practices or high-risk sexual behavior, are opioids, amphetamines and cocaine [20]. Globally, it has been reported that the median age of cocaine use is 21-24 years of age with nearly half initiating cocaine use between 19-28 years of age [5]. An estimate of global use of these illicit drugs can be found in the World Drug Report where it is reported that between 3.5 and 7.0% of the global population (ages 15-64) has used an illicit drug in the previous year [21]. It is also estimated that 10% of these individuals exhibit symptoms of a substance use disorder, indicating an uncontrolled use and abuse of the illicit drug. These latter individuals are at highest risk for either injection or sexual behaviors that place the illicit drug user at elevated risk for HIV transmission. Thus for young adults, data from global studies and national surveys show a convergence of the consequences of the initiation of drug and alcohol use along with a time of sexual debut, linking the young adult period with an elevated risk of HIV infection.

Etiology of HIV Prevalence and Substance Abuse Prior to Young Adulthood

While young adulthood is a time of high-risk for the transmission of HIV due to drug and alcohol use in the context of sexual activity, the prevalence of HIV infection in young adults comprises both infection prior to and during young adulthood. Prior to young adulthood, HIV infection can result from mother to child transmission (MTCT) or infection during adolescents due to high-risk activities. For MTCT, numerous studies [22-25] have documented that maternal use of cocaine and other illicit drugs results in a greater than three-fold higher risk for vertical transmission of HIV. This increased risk of transmission is evident for drug-using pregnant women who do not receive antiretroviral therapy during pregnancy to reduce the risk of perinatal vertical transmission [26]. Infants born with HIV infection have an excellent survival rate when provided anti-retroviral treatment under WHO treatment guidelines [27]. However, infants born with HIV infection have more factors associated with failure to thrive, and as they progress through childhood, adolescence and young adulthood experience poorer health and lower quality of life [28, 29]. These individuals, living with HIV, as they progress to young adulthood, have a higher risk of prescription drug abuse, as well as, illicit drug and alcohol use due to both increase chronic health issues, as well as, the stigma and discrimination of growing up with HIV infection [30]. In addition, research has shown a genetic component to addiction where allelic phenotypes of genes related to both the brain and nervous system contribute to the onset of problematic drug and alcohol use, particularly in young adulthood [31]. Thus, the perfect storm forms for those acquiring HIV perinatally, comprising neonatal exposure to drugs and alcohol combined with genetic risk, chronic health conditions early in life, and poor quality of life into young adulthood, a time of onset for abuse of drugs and alcohol.

Another important risk factor for illicit drug and alcohol use, for individuals living with HIV as well as those without HIV, is growing up in a drug-using household [32]. Household and family substance use coupled with the stigma and discrimination of HIV infection provides a high-risk environment for the early initiation of illicit drug and alcohol use, along with sexual debut in adolescence or young adulthood. Growing up without the knowledge of HIV infection is also an issue. Young adults with perinatal HIV infection, who receive a late diagnosis of HIV infection in their teens or early twenties, face a life changing event during a time of developmental and emotional immaturity. Without significant support, these individuals are at-high risk for not only illicit drug and alcohol abuse and addiction, but also suicide and mental health disorders, such as major depression. Unfortunately, it is not uncommon in both resource rich and resource limited countries for young adults with perinatal HIV infection, and who receive limited health care services early in life, to be diagnosed with HIV infection in late adolescence or early young adulthood [33].

The early initiation of drug and/or alcohol use during adolescence, the developmental stage prior to young adulthood, is a high-risk behavior for the acquisition of HIV infection. The early initiation of drug and/or alcohol use in adolescence results in increased sexual risk-taking with the potential exposure to HIV infection [34]. So, what influences the early initiation of drug and/or alcohol use? Positive protective factors include a good adolescent-school relationship, as well as, good family- adolescent relationship which includes: positive parenting, parental involvement, family cohesion, family communication, parental monitoring of peers, and parent-adolescent communication [35]. Promotional factors for drug and alcohol use include those that foster the social acceptance of drug and alcohol use, such as household drug and/ or alcohol use, peer use of drugs and alcohol, the easy availability of alcohol and drugs, adolescent disengagement from school, poor family relationship(s) and poverty [5].

With regard to household drug/alcohol use, adolescents perinatally exposed to illicit drug use have a two fold increased risk in the use of drugs or alcohol by age 15, as well as, an increased risk of early sexual debut [36, 37]. In a low income setting, minority adolescents who were early initiators of sexual activity also reported substance use and illicit drug selling [38]. In this setting, youth who reported continuous involvement in drug use also reported intense sexual involvement, as compared to sexual experimentation. A highestrisk group for substance use and HIV transmission are homeless street youth. In both high income settings and low-income settings, street youth report daily use of alcohol and illicit drugs, as well as, high-risk sexual activities, including survival sex, that is, the engagement in sex work because of extreme need [39, 40]. The circumstance of social estrangement is a key factor in the lack of access and receipt of health services for substance use disorders and HIV infection [41]. Socially estranged adolescents are frequently involved with the criminal justice system and are a population that has been shown to have repeated sexually transmitted diseases [42]. Behaviors that place these youth at high-risk for HIV infection include binge-drinking, risky sexual encounters while intoxicated, intravenous drug use, and frequent incarceration [43-46]. A history of arrest and detention has been shown to be a marker for both adolescent HIV infection risk and substance abuse [47].

Since illegal behaviors have been shown to be a marker for substance abuse and HIV infection risk, behavior screening of adolescents and young adults is an important tool for health care providers. Adolescents and young adults, who are key at risk populations (people who inject drugs, men who have sex with men, sex workers and transgendered individuals), are confronted with laws and community practices that frequently criminalize their behaviors. This criminalization places them at high risk for HIV infection, sustained violence and discrimination for their behaviors, plus impeded access to drug and HIV-related prevention, care and treatment [48]. These individuals, along with homeless young adults, experience more unprotected sex, sexually transmitted infections, HIV infection, unintended pregnancies, violence, mental health disorders and substance use disorders than young adults in the general population [49]. The result is a marginalized population of young adults with the triple diagnosis of HIV infection, substance use disorder and mental health disorders who are estranged from needed medical care and treatment.

HIV infection is an epidemic among adolescent girls and young women in many parts of the world [50]. In Eastern and Southern Africa, young girls account for 80% of all new HIV infections and HIV/AIDS is the leading cause of death for girls aged 15-19. The vulnerability to HIV results from gender inequality, lack of economic opportunity, intergenerational and transactional sex, stigma and discrimination due to sexual violence, forced marriage, trafficking and sex work. In Southwest Asia, roughly one-in-three trafficked women were determined to be living with HIV when provided health services [51]. Those trafficked into sex work have also been shown to be high consumers of drugs and alcohol [52]. Thus, for young women, the convergence of young age, sexual activity and drug or alcohol use presents a high-risk for HIVinfection and other social consequences [53].

Prevalence of Substance Use/Substance Use Disorders and HIV Infection in Young Adults

Currently, there are roughly 1.6 billion young people 12-24 years of age and, thus, young adults represent roughly one-quarter of the global population [54, 55]. With regard to HIV infection, young people aged 15-24 account for 42% of new HIV infections and roughly 4 million of these young adults living with HIV live in sub-Saharan Africa [54]. AIDS is the number one cause of death for young adults in Africa. Young women in sub-Saharan Africa account for 58% of the young adults living with HIV [55]. Africa has one of the highest alcohol per capita consumption levels in young adults at 19.5 liters per person per year, as well as emerging regional drug abuse epidemics with heroin abuse along the coast in Eastern Africa, stimulant use in Southern and Western Africa [56, 57]. Local situations vary with a high variability of multiples substances including local brews and spirts “gongo”, as well as, cannabis “bhang” or other locally grown plants. Youths start using substances between the ages of 10 and 15 years and graduate to more potent substances as young adults [58].

In Central Asia and Eastern Europe, the HIV epidemic is driven by injection drug use and focused in key populations [59]. Recent studies have shown that young adults who were homeless were most likely to be living with HIV and injecting illicit drugs [60, 61]. Studies have shown that key populations who initiate drug use as young adults may have a 20-fold risk for HIV infection and are less likely to seek HIV services [62]. In Central Asia and Eastern Europe, there are an estimated 3.7 million people who inject drugs, nearly one-quarters of the global total [63].

In the United States, young adults are the only age group to experience a rise in new HIV infection with nearly 40% of new infections occurring between the ages of 13-29 [64]. Men who have sex with men account for 72% of HIV infections in people under the age of 25. Also in the United States, there is a rapid onset of substance use disorders for young adults under the age of 20, with one-in-three young adults reporting lifetime alcohol use and 24% reporting illicit drug use- mostly marijuana or prescription drug abuse [65].

Elsewhere, in Asian countries, numerous studies have shown that for key populations the risk for HIV infection is substantial, but becomes even greater with alcohol or injection drug use [66-69]. In South America, cocaine is the drug of choice. Studies have shown young adult crack cocaine users experience health and economic marginalization, an elevated risk for HIV infection and compromised health along with poor health services utilization [70-72]. In the Dominican Republic, a recent study has addressed alcohol use in young adults in the context of risk for HIV infection [73]. This study notes that 18% of AIDS cases occur in young adults between the ages of 15-24, with 29% of young adults reporting sexual debut before the age of 15. These sexually active young adults are drug and alcohol experienced with one-inthree reporting binge drinking prior to the age of 12. Hazardous chronic alcohol use is common with 25% of girls and 35% of boys reporting heavy episodic drinking.

Thus from Europe, Asia, Africa and the Americas-globally-the prevalence of substance use/substance use disorders and HIV infection in young adults is elevated and can be characterized as a heavy health burden. The relationship between substance use disorders and HIV infection is bidirectional and multifaceted with multiple components. The bidirectional nature of the relationship is the sequential exposure to either the HIV virus or illicit drugs or alcohol. The common direction is initial exposure to illicit drugs and alcohol followed by exposure to the HIV virus through high-risk sexual encounters or high-risk injection drug practices. Alternatively, young adults who acquire HIV infection through vertical transmission can initiate illicit drug or alcohol use early in life in adolescence or as young adults. In addition, in a less common scenario, young adults could be exposed to both the HIV virus and illicit drugs or alcohol in utero during pregnancy by women living with HIV who are using/addicted to drugs or alcohol during the pregnancy. The components of the relationship between substance use/substance use disorders and HIV infection in young adults comprise social, economic, familial, educational, legal, and human rights issues. These issues describe the young adult subpopulations (see Table 1) and risk factors as noted above in the etiology of exposure to the HIV virus and illicit drugs and alcohol. Regardless of the timing of the exposure to illicit drugs and alcohol, young adults who have hazardous levels of consumption or who are dependent on illicit drugs or alcohol,need to seek medical care through comprehensive substance abuse treatment programs. The importance and prioritization of seeking and receiving substance use disorder treatment cannot be over stated. Recent studies have shown that people who inject drugs that are in care or treatment are more likely to receive HIV testing and people living with HIV are more likely to have reduced survival due to drug or alcohol use [74, 75].

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Table 1:

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Table 1. Subpopulations of Young Adults and the Etiology of Substance Abuse and HIV Infection.

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Prioritizing Comprehensive Substance Abuse Treatment Programs Targeting Young Adults to Impact Global Health

Young adults should routinely seek medical care from health care providers who are familiar with and have experience in providing primary care to individuals through their developmental stage(s) in life. In seeking care and treatment for substance use/substance use disorders in young adulthood, health care providers who are familiar with the stages of substance use progression and patterns of adolescent drug and alcohol use can provide evidence-based interventions, such as screening and brief interventions, to reduce hazardous levels of consumption [76]. Based on the level of abuse, an individual treatment plan should be developed as part of the assessment and intake process [77]. If the young adult is not ready for treatment, then the healthcare provider, even in a resource limiting setting, can engage the young adult with motivational interviewing techniques with the goal of reducing consumption levels of alcohol and other drugs [78, 79]. For young adults seeking or entering treatment, comprehensive treatment programs that provide services beyond treatment of the substance use disorder are effective evidence-based programs [80-82]. These programs address the health needs of the young adults and through case management and other interventions, as well as addressing family issues and support, educational, legal/ criminal justice and economic issues, including the stigma and discrimination associated with addiction. These programs also provide peer recovery support for the young adults as part of the reintegration effort with social change [83]. For people living with HIV in low and middle income countries, the integration of treatment for substance use disorders with HIV primary care is critical since screening, diagnosis and management of substance use disorders has high impact in achieving good HIV clinical outcomes [84, 85].

The effective treatment for substance use disorders for young adults living with HIV is important since access and adherence to anti-retroviral medication regimens leads to a normal and productive life span, as well as, dramatically decreasing the risk of HIV transmission. Substance use disorders interrupt normal life progression through biological changes in the immune system, increased poor nutrition and health, changes in socio-economic status, increased drug-related mortality, reduced access and uptake of medical care, as well as, poor adherence to medication regimens [86-89]. Treatment of substance use disorders in young adults, in addition to relapse prevention interventions and recovery support services reduces the number of young adults lost to follow-up in HIV care and treatment, as well as, a reduction in HIV transmission [84, 85, 90-92].

The Challenges in Treatment of Substance Use Disorders and HIV Infection in Young Adults

Numerous studies have identified the substantial challenges, particularly in low and middle income countries, in accessing and retaining adults living with HIV in HIV care and treatment [93-95]. These studies have identified patient, clinical and societal challenges that include: remote clinic locations, lack of transportation, fear of disclosing status, stigma, long clinic wait times, clinic staff shortages, fear of drug side effects, need to take time off from work and poverty. These challenges result in a cycling of adults in and out of care, particularly for men and young adults. Interventions to promote retention through the clinical care cascade comprise: 1) health system interventions, such as integration of services; decentralization, task-shifting, use of technology; 2) patient convenience and accessibility, such as point of care services, home based care and treatment, case management, use of first line medications; 3) behavioral interventions and peer support, such as patient referral and education, patient navigators, improved communication; and 4) incentives, such as food support or cash incentives [93, 95].

Focusing on young adults with substance use disorders, three additional challenges can be identified: (a) transitioning from adolescent care to adult care for those individuals who are living with HIV prior to reaching young adulthood and who were in care, (b) accessing HIV care and treatment from HIV testing with the dual comorbidities of substance use disorder and HIV infection and (c) out-of-care young adults disengaged from medical care. For all of these challenges, providing a young adult friendly venue that integrates comprehensive services for treatment of substance use disorder and HIV care and treatment provides the optimal opportunity for engagement and retention in care with good clinical outcomes [96].

For transitioning youth into adult HIV care, optimal care includes a formal plan for the transition from pediatrics/adolescent/ family care to adult care, as well as, a formal written policy on transfer [97, 98]. The plan should be individualized for each youth based on specific developmental milestones addressing cognitive development, mental health, medication adherence, sexuality, reproductive and gender issues, stigma and discrimination, peer support, socioeconomic status and payment for services. A recent study [99] pilot tested a formal transfer protocol to assist the transition to adult care. Using the “Movin Out” transitioning protocol approximately half the youth were able to transition to adult care. Reasons for not transitioning were relocation, attrition, lost to follow-up and transfer to another service. Interestingly, substance abusing youth were successful in transitioning to adult care using this protocol [99].

For young adults with substance use disorders and diagnosed with HIV infection, accessing HIV care and treatment can be challenging. These individuals can face health system challenges, as well as, social and individual challenges [100,101]. These challenges include stigma, long waits for services, patient provider relationships, system navigation for health services and social services, and lack of family and peer support. Overcoming these barrier to HIV care are critical since patients in HIV treatment that also are retained in care report better treatment outcomes [101]. Interventions that promote linkage to HIV care and treatment include utilizing care coordinators to promote linkage and utilization of care, providing information and education on HIV care, providing motivational counseling, utilizing care navigators, providing coordinated services with good patientprovider communication along with social services [100-102].

For young adults with substance use disorders who are out of care, the priority is to initiate the Test and Treat algorithm [103]. Thus, in outreach efforts to these key populations, testing for HIV infection with concomitant rapid initiation of care and treatment is paramount. Studies have shown community-based HIV testing with facilitated linkage to care and treatment results in improved access to care and initiation of anti-retroviral treatment [104]. Home-based testing, mobile testing and self-testing were found to be accepted and facilitated access to care and entry into treatment for young adults [104, 105]. Subsequent to the initiation of HIV care and treatment, young adults can be further stabilized with entry into comprehensive substance abuse treatment. Thus, interventions have been identified that successfully address the challenges encountered by young adults with substance use disorders in accessing and receiving HIV care and treatment.

Recommendations

Because of the association between substance use disorders and HIV infection, the overarching recommendation is to leverage the large global effort to control the HIV epidemic and further address the growing epidemic of substance use disorders in young adults. While there are substantial efforts in the global programs to address HIV related injection drug use, a greater effort is needed to address the early use of drugs and alcohol in young adults and adolescents. Substance use disorders can be addressed through global, national, regional and local prevention, care and treatment programs. Substance use prevention, care and treatment programs impacting young adults need to be targeted to developmental stages, started at preadolescence, and continued through adolescent stages. Such programs need to reinforce protective factors that promote abstinence for illicit drug and alcohol use, as well as provide resiliency for those young adults exposed and dependent on illicit drugs and alcohol. Effective, evidence-based treatment programs are needed that target the developmental stages of young adults including gender-based, key population focused and trauma-informed care and treatment, as part of the comprehensive package of services [106-108]. Salient specific recommendations are presented in Table 2.

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Table 2. Salient recommendations addressing substance use and substance use disorder treatment in young adults living with HIV.

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Conclusion

The prevalence of substance use and substance use disorders in young adults living with and at high risk for HIV is high with the need to prioritize access to and retention in treatment for substance use disorders as part of HIV prevention, care and treatment in low and middle income countries. Leveraging the global effort to reduce HIV epidemic to provide programming for young adults living with and high risk for HIV and who use and abuse illicit drugs and alcohol will significantly impact the ability to reach the global goal of controlling the HIV epidemic.

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