Substance use disparities by age,race,sex,and sexual orientation among persons living with HIV in the Southern U.S.

Abstract

Background

Alcohol and drug use is overrepresented among individuals living with Human Immunodeficiency Virus (HIV) and is associated with poor health outcomes. Determining the extent to which substance use differs between demographic profiles of people living with HIV (PLWH) would determine at-risk groups that would benefit from intervention.

Methods

Cross-sectional screening data (N = 1307, M_age = 42.7 years, 66% male, 86% African American, 39% sexual minority) was examined from an HIV clinic in the southern U.S. largely treating underserved and low-income patients. Age, gender, race/ethnicity, sexual orientation, and their interactions were entered as predictors of substance use and related impairment in a series of zero-inflated negative binomial regressions.

Results

African Americans reported more drug use (p = 0.004) and drug-related negative consequences (p = 0.003). Notably, alcohol-related negative consequences of African American heterosexuals were much higher at younger ages, compared to sexual minorities (regardless of race) and White heterosexuals of all age groups (p = 0.04).

Conclusions

Among PLWH in the U.S. South, African Americans may be uniquely at-risk with for problems related to drug-related functional impairment. Specifically, young heterosexual African Americans are at high risk for alcohol-related impairment. Implications are discussed.

Keywords

Human immunodeficiency virus viral disease high-risk behaviour other epidemiology heterosexual homosexual

Introduction

The Southern United States (U.S.) is a region of the U.S., generally considered a collection of around 7–11 states, that share geographic proximity and a distinct history and culture influenced by the institution of slave labor from the 17th through 19th centuries. Today, the Southern U.S. carries a disproportionate burden of HIV incidence compared to other U.S. regions.^1,2 Specifically, young African Americans in the South have the highest number of HIV diagnoses compared to racial/ethnic groups in other regions.³ The burden of HIV in the South is explained, in part, by poverty, insurance, HIV-related stigma, rurality, and a lack of public sexual health programs.⁴ Therefore, it is crucial to examine factors that can affect quality of life and HIV disease progression among People Living with HIV (PLWH) in southern states, especially for African Americans.

Relatedly, Substance Use Disorders (SUDs) are overrepresented among PLWH. In one large-scale study, nearly 50% of PLWH had a co-occurring SUD, compared to around 15% in the general population.^5,6 Substance Use Disorders can significantly compromise health outcomes in PLWH, as SUDs are associated with poorer adherence to antiretroviral therapy,^7,8 higher rates of hepatitis C virus co-infection (up to 30%),⁹ worse prognoses in diseases like cirrhosis¹⁰ and cardiovascular disease,¹¹ and poorer health-related quality of life.¹² Therefore, it is vital to identify PLWH who are either at risk or have SUDs to provide interventions tailored to their needs.

Race can be an important correlate to examine risk of substance use and/or SUDs among PLWH. While young African American males display a disproportionate burden of HIV incidence,³ rates of SUDs tend to be highest for young adult White males.¹³ However, while younger White men (as a group) generally have higher SUD risk, this is not be necessarily true for PLWH. Skeer and colleagues¹⁴ found that, among a large cohort of men who have sex with men (MSM) in the Northeastern U.S., substance use and SUD symptoms differed depending on race. They found that African American men living with HIV reported more excessive alcohol use (i.e., 5+ drinks in one sitting) compared to White MSM. In contrast, a recent U.S. representative survey of MSM documented, among those with HIV, African Americans reported less substance use (marijuana, methamphetamines, and or other drugs) than White MSM.¹⁵ Null findings have also been reported: among MSM from the Midwest and Southeastern U.S., Brown and colleagues¹⁶ found no meaningful differences in substance use when comparing White and African American individuals. The conflicting findings of these studies mean that racial differences in substance use among PLWH warrant further investigation.

Beyond race, expanding research to examine other demographic correlates of substance use among PLWH would assist in identifying subgroups of individuals who may benefit from a health-related intervention. For example, most existing research exclusively examines MSM; however, 22% of recent U.S. HIV diagnoses were acquired through heterosexual contact,¹⁷ suggesting heterosexual PLWH are an important group to include within such research. Sex is another variable important to consider. In contrast to race, in which findings are more mixed, studies examining sex as a demographic correlate of substance use among PLWH more clearly document that men use alcohol and other drugs at higher levels compared to women.^18,19 However, women tend to experience more functional impairment due to substance use,²⁰ indicating gender disparity in substance use consequences. Age has been identified as correlate of substance use in PLWH as well: younger (e.g., aged 18–34) PLHW reported more excessive alcohol use, tobacco, cannabis, and other substance use compared to those aged 55 and older.^21,22 But, like women, older PLWH tend to experience more substance use-related functional impairment.²³ Taken together, these findings suggest that, in tandem with race, other demographic influences such as age, sex, and sexual orientation are important to consider because they are associated with unique effects on substance use and/or SUD symptomology among PLWH.

When considering these influences, it is critical to understand the interactions among race/ethnicity, age, sex, and sexual orientation variables, rather than examining these as identities as independent of one another. Intersectionality theory suggests that individuals’ multiple identities can interact within societal systems (i.e., structural racism, sexism, ageism, heterosexism) to influence health inequalities like SUD.²⁴ Through this lens, the disparities in substance use and related functional impairment among PLWH would be influenced by such demographic intersections as well. This remains untested, since most research has examined these identities independently of one another, with none to our knowledge examining interactions among race, age, sex, and sexual orientation simultaneously.

The current study examines the interactions between these variables and their associations with alcohol use, other drug use, and related functional impairment. Based on extant research,^25,26 we hypothesized that younger White males who identified as sexual minorities would display the highest levels of substance use, while older women who identified as both racial and sexual minorities would display higher levels of SUD-related functional impairment.

Method

Data collection was implemented in a large urban HIV clinic operated by the Division of Infectious Diseases at an academic medical center in the U.S. Deep South. Data we were collected between February, 2018 and March, 2020 on 2205 patients from a self-administered computerized tablet version of Screening Brief Intervention and Referral to Treatment (SBIRT; https://www.samhsa.gov/sbirt). Information was gathered on demographics, alcohol use, and drug use, and HIV viral load. Patients who reported any drug use or who exceeded the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA) guidelines for alcohol use (>14 drinks per week or 5+ drinks in a single day for males, >7 drinks in a week or 4+ drinks in a single day for females) were administered the Drug Abuse Screening Test (DAST)²⁷ and/or Alcohol Use Disorders Identification Test (AUDIT).²⁸ Patients identified as “High Risk” or “Dependent” on the AUDIT or DAST were offered a brief intervention by a trained healthcare provider.

Measures

Age

“What is your age?” Patients self-reported their answer.

Gender

“What is your gender?” Patients selected between Female, Male, Transgender- Female-to-Male, and Transgender- Male-to-Female selections.

Race/Ethnicity

“What is your race?” Patients selected between African American, American Indian/Alaska Native, Asian, Caucasian, MS Band Choctaw Indian, Multiracial, or Other choices.

Sexual orientation

If the patient was a referral to the HIV clinic, their sexual orientation was included within their chart by the previous provider. If it was a first-time patient, sexual orientation information was gathered at the time of first contact. Patients chose options between Heterosexual, Men who have Sex with Men, Women who have Sex with Women, Bisexual, or Other sexual orientations.

Weekly alcohol use

“In the past year, how many days per week do you typically drink alcohol?” Patients who endorsed at least 1 day were then asked, “In the past year, on a typical day when you drink, how many drinks do you tend to have?” Results were multiplied to obtain average drinks consumed per week.

Past-year drug use

“Please indicate which, if any, of the following drugs or medications (used more than prescribed or use of someone else’s medication) you used in the past year”. Patients selected from Cocaine (powder, crack), Methamphetamines (speed, crystal, meth), Cannabis (marijuana, pot), Hallucinogens (acid, LSD, mushrooms), Inhalants (paint thinner, aerosol, glue), Opioids (heroin, oxycodone, hydrocodone, fentanyl, methadone), or Other (bath salts, salvia, formaldehyde, ecstasy/x, MDMA, spice).

Alcohol-related problems

Patients who indicated alcohol consumption were administered the Alcohol Use Disorders Identification Test. The AUDIT is a ten-item screening questionnaire developed by the World Health Organization to identify persons whose alcohol consumption has become hazardous for their health.

Drug-related problems

Patients who indicated any illicit drug use were administered the Drug Abuse Screening Test. The DAST is a ten-item screening questionnaire developed to identify those at risk for drug-related problems, as it yields a quantitative index of the degree of negative consequences.

Data analytic approach

Gender was dummy coded to identify male and transgender persons. Females served as the reference group. Race/ethnicity was dummy coded to identify African American and Other (i.e., Native American, Hispanic/Latino, Asian, Multiracial, or Other) groups. Whites served as the reference group. Sexual orientation was dummy coded to identify sexual minorities, with heterosexuals serving as the reference group. Age was retained as a continuous variable.

Past-year marijuana, cocaine, methamphetamines, opioids, hallucinogens, inhalants, or other drugs were combined to create a continuous variable representing the frequency of past-year drug use. Weekly alcohol use, AUDIT scores, and DAST scores were retained as continuous variables.

All analyses were conducted in SAS version 9.4.²⁹ Distribution plots determined that both the drug use variable and drinks per week variable demonstrated positive skew and zero-inflation. Zero-inflated negative binomial models were compared to negative binomial hurdle models to determine the best fit. The negative binomial hurdle models evinced lower AIC and BIC estimates. Further, given the structural nature of the zeroes (i.e., individuals with no AUDIT or DAST symptoms were not necessarily abstainers), the negative binomial hurdle model was determined to be most appropriate.

Due to variable distribution for interactions (e.g., only one participant identified as transgender and non-White) and model convergence for models containing gender, fit of models with and without transgender and “Other” race/ethnicity (i.e., non-White, non-African American) interactions were compared. Negative binomial hurdle models without transgender and “Other race” interactions evinced lower AIC and BIC estimates and more stable convergence. Thus, those models are presented in the results.

Results

Patients who were missing measures of their relevant demographics were removed from the dataset, leaving a sample size of 1,307. Patients’ mean age was 42.7 years (SD = 12.0) and they ranged in age from 17–73 years. Patients were mostly male (66.0%), followed by female (32.0%) and transgender (2.0%) persons. Patients were mostly African American (86.2%), followed by White (12.6%) and other racial/ethnic groups (i.e., Native American, Hispanic/Latino, Asian, Multiracial, or Other groups; 1.2%). Most patients identified as heterosexual (60.7%), while 39.3% identified as a sexual minority (i.e., gay, MSM, bisexual, or lesbian. Mean drinks per week was 7.28 (SD = 12.4; range = 1–70). 49.8% of patients reported cannabis use, 12.9% reported cocaine use, 5.7% reported methamphetamine use, 3.2% reported opioid use, 0.7% reported hallucinogen use, 0.5% reported inhalant use, and 2.5% endorsed other drug use.

Table 1 presents the means, standard deviations, skewness, and kurtosis among study variables. Age (r = −0.17, p < 0.01), male gender (r = 0.09, p < 0.01), and sexual minority status (r = 0.11, p < 0.01) were correlated with past-year drug use. Identifying as a sexual minority was weakly correlated with decreased drinks per week (r = −0.08, p < 0.05). African American race/ethnicity (r = −0.15, = p < 0.01) was correlated with lower DAST severity. Drinks per week, past-year drug use, AUDIT scores, and DAST scores were all significantly correlated at p < 0.01 with correlations r’s ranging from 0.15 (drinks per week and past-year drug use) to 0.63 (drinks per week and AUDIT scores).

Table 1.

Variable pearson correlations, means, standard deviations, skewness, and kurtosis.

	1	2	3	4	5	6	7	8	9	10
1. Age	–
2. Male	−0.07	–
3. Transgender	−0.06	−0.21	–
4. African American	−0.02	−0.02	0.01	–
5. Other race	−0.02	0.00	0.03	−0.28	–
6. Sexual orientation	−0.36	0.46	0.16	−0.05	0.02	–
7. Drinks per week	0.05	0.02	0.03	0.00	0.03	−0.08	–
8. Drug use	−0.17	0.09	−0.02	−0.04	−0.02	0.11	0.15	–
9. AUDIT	0.04	0.02	0.07	0.03	0.01	−0.05	0.63	0.27	–
10. DAST	0.04	−0.06	−0.02	−0.15	−0.03	0.01	0.30	0.55	0.45	–
Mean							7.28	0.75	5.90	2.05
Standard deviation							12.43	0.86	6.12	2.03
Skewness							3.30	1.34	2.19	1.88
Kurtosis							12.15	2.26	5.85	3.34

Notes. Bold indicates significance at p < 0.05. Male coded as female = 0, male = 1; Transgender coded as female = 0, transgender = 1; African American coded as White = 0, African American = 1; Other Race coded as White = 0, non-White or non-African American = 1; Sexual Orientation coded as heterosexual = 0, sexual minority = one.

Table 2 presents the results of tests for main effects for the negative binomial hurdle models. Sexual minority status was significantly associated with higher levels of alcoholic drinks per week (b = 0.47, p = <0.001) compared to heterosexuals. African Americans endorsed more past-year drug use (b = 0.52, p < 0.01) and DAST scores (b = 0.25, p = 0.003) compared to White persons. Transgender individuals had significantly lower AUDIT scores compared to females (b = −0.78, p = 0.02). Identifying as a sexual minority was associated with significantly higher AUDIT scores compared to those identifying as heterosexual (b = 0.27, p = 0.02). Age and race were unrelated to AUDIT scores. Gender, age, and sexual orientation were unrelated to DAST scores.

Table 2.

Main effects for zero-inflated hurdle models of substance use on demographic indicators.

Indicator	Drinks per week			Drug use			AUDIT-C score			DAST score
Indicator	b	S.E.	p	b	S.E.	p	b	S.E.	p	b	S.E.	p
Age	0.002	0.001	0.65	−0.01	0.01	0.09	0.00	0.00	0.62	0.15	0.22	0.47
Male	−0.18	0.14	0.21	0.01	0.19	0.98	−0.18	0.11	0.09	0.40	0.21	0.06
Transgender	−0.66	0.38	0.08	0.27	0.59	0.65	−0.78	0.32	0.02	0.77	0.63	0.22
African American	0.26	0.18	0.14	0.52	0.18	0.004	−0.15	0.13	0.25	0.70	0.23	0.003
Other race	−0.14	0.53	0.79	1.62	1.05	0.12	−0.15	0.37	0.69	0.96	0.84	0.26
Sexual orientation	0.47	0.14	<0.001	−0.09	0.18	0.62	0.27	0.11	0.02	−0.30	0.20	0.13

Table 3 examines two-way and three-way interactions among our demographic variables. There was a significant two-way interaction for race and sexual orientation, such that sexual minorities endorsed higher AUDIT scores and this effect was especially pronounced for African Americans (b = 2.38, p = 0.02; see Table 3). However, we suggest this finding should be taken in context of a larger three-way interaction. The three-way interaction between age, race, and sexual orientation demonstrated that at older ages, African American, White, and sexual minorities endorsed low-level, relatively similar AUDIT scores; in contrast, African American heterosexuals demonstrate drastically higher-level AUDIT scores at younger ages, much more so than young White or young sexual minority persons (b = −0.05, p = 0.04; see Table 3 and Figure 1).

Table 3.

Two- and three-way interactions for zero-inflated hurdle models of substance use on demographic indicators.

Indicator	Drinks per week			Drug use			AUDIT-C score			DAST score
Indicator	B	S.E.	p	b	S.E.	p	b	S.E.	p	b	S.E.	p
Age	0.00	0.01	0.90	0.00	0.01	0.76	0.00	0.01	0.72	0.00	0.01	0.79
Male	2.97	1.92	0.12	1.29	3.22	0.69	1.26	2.33	0.59	5.94	4.88	0.22
Transgender	0.79	1.14	0.49	0.72	1.67	0.67	−0.22	2.01	0.91	2.08	2.58	0.42
African American	−0.87	0.89	0.33	1.31	1.08	0.22	−1.18	0.67	0.08	−1.41	1.86	0.45
Other race	−0.12	0.55	0.83	1.77	1.05	0.09	−0.05	0.37	0.89	1.09	0.86	0.20
Sexual orientation	0.19	0.60	0.75	0.54	0.67	0.42	−0.21	0.46	0.65	0.68	0.83	0.41
Age * male	−0.01	0.04	0.26	−0.02	0.07	0.70	−0.03	0.03	0.35	−0.14	0.10	0.18
Age * African American	0.02	0.02	0.24	−0.02	0.03	0.30	0.02	0.02	0.21	0.04	0.04	0.33
Age * sexual orientation	0.01	0.01	0.67	−0.01	0.02	0.27	0.01	0.01	0.34	−0.02	0.02	0.22
Male * sexual orientation	−2.94	2.09	0.16	−2.40	3.36	0.47	−1.65	2.41	0.50	−7.15	5.02	0.15
African American * sexual orientation	1.98	1.28	0.12	−0.38	1.46	0.74	2.38	0.98	0.02	2.86	2.30	0.21
Age * male * sexual orientation	0.04	0.04	0.34	0.05	0.07	0.47	0.03	0.03	0.30	0.18	0.11	0.10
Age * African American * sexual orientation	−0.04	0.03	0.14	0.03	0.03	0.45	−0.05	0.02	0.04	−0.05	0.05	0.31

Figure 1.

Three-way interaction between age, race, and sexual orientation with AUDIT scores.

Discussion

Our study examined race, sex, sexual orientation, age, and their interactions as correlates of clinically relevant substance use and related negative consequences among a sample of PLWH in the U.S. Deep South. Our findings suggest that sexual minority status conferred nearly a half drink increase (b = 0.47) in standard drinks per week in PLWH. Transgender individuals reported less AUDIT symptoms, but sexual minorities status reported more AUDIT symptoms. African Americans endorsed more drug use and increased DAST symptoms compared to White individuals. When examining the interactions between identities, we found that younger, heterosexual African American males endorsed very high levels of AUDIT symptoms, contrary to our expectations. Interestingly, this effect dissipated drastically as age increased: AUDIT symptoms were much more low-level and similar across groups in older persons in our sample.

Contrary to prior work, we did not demonstrate a main effect of age on alcohol and other drug use. Prior studies have found that younger adults with HIV consume more alcohol specifically compared to older adults,^30,31 but these studies measured binge alcohol use specifically or treated age as a categorical predictor (i.e., <35 years or >35 years). Also, our finding main effect findings that African Americans reported both more instances of past-year drug use and more negative drug-related consequences is unique within the wider HIV literature: it contrasts earlier null findings of race,¹⁶ as well as findings reporting African American PLWH have less drug use.¹⁵ The samples from these studies were exclusively MSM, however, highlighting the importance of including heterosexual PLWH as a contrast group within substance use research.

Identifying as transgender appeared to be a protective factor for alcohol-related negative consequences. Some studies have reported similar protective effects for non-binary gender identities,³² while others have reported more alcohol use/negative consequences³³ or mixed findings.³⁴ Future research should consider larger samples of transgender and non-binary PLWH to determine whether our finding replicates or is specific to our sample.

Sexual minorities reported worse functional impairment related to their alcohol use, in line with prior research.³⁵ This could be related to minority stress, a theory which postulates that sexual minorities may experience higher rates of substance use than heterosexual individuals due to the unique group stressors they experience (e.g., internalized homophobia, concealment of sexual identity, etc).³⁶ HIV-related internalized stigma could compound this effect: it was associated with more mental health and risky sexual behavior outcomes among MSM in one study.³⁷ To corroborate our findings, future work should examine whether HIV-related stigma is associated with more alcohol use across sexual minorities more broadly, including bisexual and lesbian women.

When examining the interactions between demographics, our hypotheses were not supported. As a group, African Americans endorsed the most drug and drug-related functional impairment, not younger White sexual minorities as we had originally hypothesized. Therefore, African American PLWH, as a group, may benefit from interventions designed to lessen the functional impairment of recreational drug use to mitigate any negative effects of substance use on health-related quality of life. Our second hypothesis, which predicted that older female racial and sexual minorities would endorse the most SUD-related functional impairment, was also not supported. Interestingly, it was young heterosexual African Americans who endorsed the most functional impairment for alcohol (∼8 AUDIT symptoms), when compared to young heterosexual White, young sexual minority White, and young sexual minority African Americans groups in our sample (∼2–3 AUDIT symptoms each).

Zapolski and colleagues’ review provides sound evidence that African Americans drink less than their White counterparts but experience more negative consequences (i.e., social, and legal consequences, alcohol-related illness and injury, AUD symptoms) for their use. They theorize this may occur, in part, due to social norms, religiosity, and racial socialization that dissuades African American youth from drinking, but provide within-group social disapproval when heavy drinking does occur.³⁸ These norms may not hold true for sexual minority or White youth, who tend to endorse more permissive social norms and perceived positive reinforcement from substance use.^39,40 Thus, our finding that young African American heterosexual PLWH by far endorsed the most alcohol-related functional impairment, despite drinking at comparable levels to White and sexual minority groups, suggests they could be facing more within-group social disapproval for their alcohol use. Future work should examine this relationship longitudinally, keeping in mind our sample was HIV+ (an extremely stigmatized disease), low-income, and from the Deep South, a U.S. region with excessive HIV disease burden.

Limitations and future directions

Our study’s limitations warrant consideration. First, our data was cross-sectional, which precludes any evidence of cause-and-effect relationships. Second, our sample lacked diversity in some regards. Future research should examine patients with Hispanic/Latinx, Asian, Native American, transgender, and gender non-conforming identities. Lastly, most of our sample had low or undetectable HIV RNA viral loads, meaning most individuals’ disease was well-managed, so our conclusions may not extend to patients with greater HIV/AIDS progression.

Conclusion

In conclusion, the results of our study suggest that substance use, and the negative consequences of use, significantly differs among PLWH among different demographic groups. African Americans endorsed more drug use and drug-related consequences compared to Whites; transgender individuals reported less alcohol-related consequences, and sexual minority individuals reported more alcohol-related negative consequences. Most notably, young African American heterosexual PLWH appear to be a group at particular risk for high levels of alcohol-related problems, compared to White, sexual minority, or older PLWH. Alcohol intervention programming should target this group, as they scored significantly higher in risk for AUD-related functional impairment in our sample.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by the Data collection was supported by a grant from the Substance Abuse and Mental Health Services Administration (#1H79TI080682-01) awarded to Deborah Konkle-Parker, FNP, PhD, Professor, Department of Medicine, Division of Infectious Diseases, University of Mississippi Medical Center. Manuscript preparation was supported by the NIDA Epidemiology Training Program (#5T32DA007292-30) awarded to the first author.

ORCID iD

Timothy Regan

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