Interventions to Improve HIV Care and Treatment Outcomes Among People with HIV Who Have Substance Use Disorder or At-Risk Substance Use: A Narrative Review

Abstract

Substance use adversely affects engagement in HIV care, adherence to medication, and HIV viral suppression. This review assessed the scope of US interventions designed to promote positive outcomes along the HIV care continuum for people with HIV who have substance use disorder (SUD) or at-risk substance use. A literature search identified 27 interventions published in peer-reviewed articles found on PubMed and PsycINFO databases between January 1, 2019, and December 31, 2023. Common strategies to improve HIV care continuum outcomes included support for HIV medication adherence, motivational interviewing, medications to treat SUD, contingency management, cognitive-behavioral skills building, patient navigation, mindfulness practice, and low-barrier entry to care. Contingency management (offering financial or material incentives for attaining desired outcomes) alone or combined with other strategies was most consistently associated with positive HIV outcomes, but more research is needed to understand how these outcomes can be sustained. Few intervention studies addressed or measured linkage to care (12%) or retention in care (15%), despite a clear need to better engage this population. Further innovation is needed to improve HIV engagement and retention among people with SUD or at-risk substance use.

Keywords

substance misuse drug use alcohol use stimulant use opioid use

Introduction

Engagement of people with HIV along the HIV care continuum, including linkage to HIV care, adherence to antiretroviral therapy (ART), retention in care, and viral suppression, is essential for reducing morbidity and mortality, improving quality of life, and minimizing HIV transmission.¹ Among all people with an HIV diagnosis in the United States, however, only 76% received some HIV care, 54% were retained in care, and 65% achieved viral suppression on their most recent viral load test.² Evidence points to substance use disorder (SUD) and at-risk substance use as a major impediment to reaching and sustaining HIV viral suppression among people with HIV.³ The substances with the strongest evidence of adversely impacting HIV health outcomes are methamphetamine, opioids, and at-risk levels of alcohol.^3–6 SUDs are highly prevalent among people with HIV³—an estimated 48% of people with HIV in the United States have an SUD, compared with 17% in the general population.⁷

Substance use can adversely affect the health of people with HIV through both behavioral and biological mechanisms.^6,8 Importantly, drug and alcohol use can greatly diminish adherence to ART while also decreasing the efficacy and increasing the toxicity of ART.⁹ Frequent heavy substance use can also suppress immune function.^6,10 In addition, the stigma associated with SUD and HIV can deter people from seeking SUD treatment, taking ART, or engaging in HIV care.^11,12 People with HIV and SUD also have an increased risk of mental health disorders, incarceration, homelessness, and poverty, all of which can interfere with adherence and engagement in care.^13–15 Successful treatment of SUD, however, is associated with increased engagement in HIV care and treatment among people with HIV.^16,17

Substance use not only impacts the health outcomes of people with HIV but also increases the risk of HIV transmission.^18,19 Notably, substance use can increase risk-taking sexual behaviors, such as condomless sexual activity, which can lead to HIV transmission if the infected partner has unsuppressed HIV RNA. HIV can also be transmitted through the sharing of injection drug equipment.²⁰ For these reasons, interventions tailored for people with HIV and SUD, or who are at risk for developing an SUD, are critical for ending the HIV epidemic in the United States.²¹ In this review, we sought to assess the scope of US interventions designed to promote positive health outcomes along the HIV care continuum for people with HIV and SUD or who use substances at levels that put them at risk for an SUD.

Methods

We searched PubMed and PsycINFO databases for peer-reviewed articles using combinations of the following search terms in the title and abstract fields: HIV, alcohol, opioid, opiate, methamphetamine, cocaine, stimulant, addiction, substance abuse, drug use, substance use, intervention, trial, and evaluation. We limited the search to articles published between January 1, 2019, and December 31, 2023, to highlight more recent innovations and advances. Intervention inclusion criteria were as follows: (1) the sample consisted entirely of people with HIV who have a diagnosis of an SUD (excluding tobacco use disorder), report criteria consistent with an SUD diagnosis, report recent use of an illicit drug, or report alcohol use at levels deemed by the intervention study authors as “unhealthy,” “risky,” “at-risk,” “problem-related/problematic,” “hazardous,” or “harmful” (summarized for the present publication as “at-risk”); (2) the study quantitatively measured at least one of the following outcomes: linkage to HIV care (also referred to as receipt of care or engagement in care), retention in HIV care, adherence to ART, viral load, or viral suppression; and (3) the intervention was conducted in the United States.

Results

We identified 27 interventions that met our inclusion criteria. Table 1 describes the interventions, including their key strategies, population characteristics, and settings. Table 2 provides frequencies of intervention population characteristics, substances of focus, and settings.

Table 1.

Summary of Interventions Designed for People with HIV Who Have Substance Use Disorder and At-Risk Substance Use, 2019 to 2023

First author, year	Intervention name (in bold) and description	Key strategies	Demographic group	Setting types
Attonito J, 2020²²	Holistic Health Recovery Program—Adapted (HHRP-A). Eight weekly, manualized, 2-h group sessions, facilitated by two paraprofessionals using cognitive remediation strategies; sessions focused on decision-making, problem-solving, goal setting, adherence, stress management, coping, and health care participation	• ART adherence support • Mindfulness	People with at-risk alcohol use or AUD and who have an ART prescription	Research setting; recruited from community-based organizations
Carrico AW, 2019²³	Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS). Five manualized positive affect and mindfulness sessions, delivered by a licensed counselor, during enrollment in a 3-month contingency management program of escalating cash incentives for stimulant-free urine samples	• Contingency management • Cognitive-behavioral skills building • Mindfulness	Gay, bisexual, and other men who have sex with men who use methamphetamine	Community-based organization and research setting; recruited from community
Cook RL, 2019²⁴	Will Having Alcohol Treatment Improve My Functioning? (WHAT-IF?). 50 mg of oral naltrexone for 4 months, with regular naltrexone adherence encouragement; delivered by research staff	• Medication	Women with at-risk alcohol use or AUD	Research setting; recruited from clinical and community-based organizations
Cunningham CO, 2020²⁵	16-week contingency management program consisting of escalating vouchers in exchange for urine samples free from opiates, oxycodone, and cocaine	• Contingency management	People with cocaine or OUD and a detectable viral load	Research setting and drug treatment centers; recruited from community
Defulio A, 2021²⁶	SteadyRx. Phone app with medication reminder texts, information on HIV and community resources, and contingency management: participants receive rewards for submitting a video of taking ART within dosing window	• ART adherence support • Contingency management	People with SUD who are engaged in HIV care and take ART	In community/at home via phone app; delivered by research staff
Edelman EJ, 2019²⁷	Project DAWN. Monthly extended-release naltrexone injection over 24 weeks, plus biweekly then monthly counseling on medication management and ART adherence; delivered by study nurses and physicians; referral to Alcoholics Anonymous	• Medication • ART adherence support	People with at-risk alcohol use or AUD who have less than optimal ART adherence	Four HIV care clinics
Edelman EJ, 2019²⁸	Starting Treatment for Ethanol in Primary Care (STEP): Alcohol Use Disorder (AUD) trial. Step 1: Eight sessions over 24 weeks of medication management to treat AUD, delivered by addiction psychiatrist; Step 2: those who continue heavy drinking at week four receive psychologist-delivered Motivational Enhancement Therapy; Step 3: those who continue heavy drinking at week 12 are referred to specialty services	• Medication • Motivational interviewing	Veterans with AUD	Five HIV clinics within the Veterans Health Administration
Edelman EJ, 2019²⁹	STEP: Moderate Alcohol Use with Liver Disease (MALD) Trial. Step 1: Brief Negotiated Interview (based on motivational interviewing) and one phone booster, delivered by a social worker; Step 2: those reporting any alcohol use at week four receive psychologist-delivered Motivational Enhancement Therapy; Step 3: those reporting any alcohol use at week 12 receive AUD medication management	• Motivational interviewing • Medication	Veterans with liver disease and at-risk alcohol use	Five HIV clinics within the Veterans Health Administration
Edelman EJ, 2020³⁰	STEP: At-Risk Alcohol Use Trial. Integrated stepped alcohol treatment of increasing intensity, if needed: Step 1: Brief Negotiated Interview and phone booster, delivered by a social worker; Step 2: those reporting any alcohol use at week four receive psychologist-delivered Motivational Enhancement Therapy; Step 3: those who exceed at-risk thresholds for alcohol use at week 12 receive AUD medication management	• Motivational interviewing • Medication	Veterans with at-risk alcohol use or AUD	Five HIV clinics within the Veterans Health Administration
Flentje A, 2022^31,32	Nine weekly individual manualized sessions, delivered by a clinical psychologist, using cognitive-behavioral techniques, psychoeducation, and coping strategies to manage stigma-related stress	• Cognitive-behavioral skills building • Mindfulness	Gay, bisexual, and other men who have sex with men who report any illicit drug use, at-risk alcohol use, or AUD	Mental health clinic, delivered by research staff; recruited from community and clinics
Garner BR, 2020³³	Substance Abuse Treatment to HIV Care (SAT2HIV). Brief motivational interviewing intervention to address at-risk substance use as an adjunct to usual care; organizational-level implementation and sustainment facilitation as an adjunct to standard staff training alone	• Motivational interviewing	People with at-risk substance use or SUD	39 HIV service organizations
Glasner S, 2022³⁴	TXT-CBT. One in-person ART adherence session, informed by cognitive-behavioral therapy delivered by a master’s-level clinician (Life-Steps); followed by 12 weeks of text messages (medication reminders and cognitive-behavioral skills-building messages on substance relapse prevention, risk reduction, and ART adherence)	• ART adherence support • Cognitive-behavioral skills building	People with opioid or stimulant use disorder and not optimally adherent to ART	Research setting and in community/at home via text; recruited from community
Hickey MD, 2022³⁵	Positive-Health Onsite Program for Unstably Housed Populations (POP-UP). Drop-in primary care and integrated case management; incentives for attending visits and reaching viral suppression; peer navigation; harm reduction supplies; and medications for OUD	• Contingency management • Low-barrier care • Patient navigation • Medication	People experiencing unstable housing and homelessness who have an SUD, are not engaged in HIV care, and have a detectable viral load	HIV clinic
Hoff E, 2023³⁶	Community Health Worker Plus Re-Entry Organization Intervention (CHW+). Six months of peer (formerly incarcerated people) navigation for health care and SUD treatment; access to a re-entry organization to help with employment, housing, and recidivism	• Patient navigation	People who use opioids, stimulants, or have at-risk alcohol use, and were released from incarceration in the past 60 days; have detectable viral load, not adherent to ART, and/or not engaged in HIV care	Research setting; recruited from county jail
Horvath KJ, 2019³⁷	APP+. Novel mobile phone app, used over 4 months, consisting of daily content on HIV and adherence; choose your own adventure stories with tips on adherence in realistic situations; daily adherence reminders; adherence self-monitoring tool	• ART adherence support	Gay, bisexual, and other men who have sex with men who use stimulants and have an ART prescription	In community/at home via phone app; recruited online
Jemison D, 2019³⁸	Four expressive writing sessions while enrolled in a 3-month contingency management program of escalating cash incentives for cocaine-free urine samples and refilling ART prescriptions	• Contingency management • Expressive writing	Women who use cocaine, struggle with ART adherence or care engagement, and have a history of psychological trauma	Research setting; recruited from HIV clinic and community
Korthuis PT, 2022³⁹	Comparing Treatments for HIV‐Infected Opioid Users in an Integrated Care Effectiveness Study (CHOICES). Six monthly injections of extended-release naltrexone (XR‐NTX)	• Medication	People with untreated OUD who have not yet started HIV treatment	Six HIV clinics
Magidson JF, 2022⁴⁰	Act Healthy. Eight behavioral activation sessions, delivered by a therapist, during 4 weeks of residential SUD treatment; one session of manualized ART adherence intervention (Life-Steps); eight outpatient sessions after discharge	• ART adherence support • Cognitive-behavioral skills building	Black/African American people entering residential SUD treatment	Residential SUD treatment center
McCaul ME, 2021⁴¹	Two brief sessions delivered by a 3-D avatar on a touch screen tablet, using motivational interviewing strategies to provide information and strategies on reducing alcohol use	• Motivational interviewing	People with at-risk alcohol use or AUD who are engaged in HIV care	Two HIV clinics
Naar S, 2020⁴²	Healthy Choices. Four brief (30-min) motivational interviewing sessions, delivered by a community health worker over 10 weeks, to improve ART adherence and drinking behavior	• Motivational interviewing • ART adherence support	Youth (16–24 years) with at-risk alcohol use and detectable viral load	Five adolescent HIV clinics; in community/at home
Pollock S, 2020⁴³	Financial incentives provided in exchange for obtaining an ART prescription, lowering HIV viral load, and reaching viral suppression	• Contingency management	People who use cocaine or opioids and are not engaged in care or have a detectable viral load	Research setting; recruited from community
Rowell-Cunsolo TL, 2020⁴⁴	Project ADHerence Education and Risk Evaluation (ADHERE). Three 2-h group sessions on ART adherence and sexual and drug use risk reduction	• ART adherence support	People who use cocaine or heroin and were incarcerated within the past 5 years	Community setting
Satre DD, 2019⁴⁵	Health and Motivation. Screening, brief intervention, and referral to treatment plus either (1) three sessions of motivational interviewing, delivered by a behavioral health counselor or (2) emailed feedback from physician regarding alcohol risks	• Motivational interviewing • Physician feedback	People with at-risk alcohol use or AUD	HIV clinic; in community/at home via email
Starks TJ, 2022⁴⁶	Positive Living through Understanding and Support (Project PLUS). Six manualized sessions over 3 months, delivered by practicing HIV clinicians, grounded in motivational interviewing and cognitive-behavioral skills building to reduce at-risk substance use and improve ART adherence	• ART adherence support • Motivational interviewing • Cognitive-behavioral skills building	People with at-risk substance use or SUD who have an ART prescription and a detectable viral load	Four HIV clinics
Tookes HE, 2021⁴⁷	Low-barrier, on-demand telehealth access to HIV care team for people accessing syringe service sites; community engagement team with peer navigators who use motivational interviewing; medications for OUD; overdose prevention supplies; medication storage and delivery	• ART adherence support • Low-barrier care • Medication • Motivational interviewing • Patient navigation	People who inject drugs and visit a participating syringe service site	Three fixed and five mobile syringe service sites; HIV clinic via telehealth
Traynor SM, 2021⁴⁸	Hospital Visit as Opportunity for Prevention and Engagement (Project HOPE). Over 6 months, up to 11 patient navigation sessions for care coordination, addressing barriers, and psychosocial support; financial incentives for attending sessions, HIV and SUD treatment visits, nonreactive specimens, blood draws, and ART prescriptions	• Contingency management • Patient navigation	People who report substance use (at-risk alcohol use, opioids, or stimulants), are leaving hospitalization, and have a detectable viral load	In the community with research staff; recruited from 11 hospitals
Wimberly AS, 2020⁴⁹	12 weekly 90-min hatha yoga classes by a trained yoga teacher	• Mindfulness	People with an SUD who were incarcerated within the past year	HIV service organization

ART, antiretroviral treatment; AUD, alcohol use disorder; Medication, medications for substance use disorder; Mindfulness, mindfulness practice and stress management; OUD, opioid use disorder; SUD, substance use disorder.

Table 2.

Frequencies of Demographic Groups, Substances of Focus, and Settings Among Interventions Designed for People with HIV Who Have Substance Use Disorder and At-Risk Substance Use, 2019–2023 (N = 27)

Demographic group	N	%
No population characteristics specified^{22,25–27,33,34,39,41,43–47}	13	48
Gay, bisexual, and other men who have sex with men^23,31,37	3	11
Military veterans^28–30	3	11
People with incarceration experience^36,44,49	3	11
Women^24,38	2	7
Black/African American people⁴⁰	1	4
People experiencing homelessness or insecure housing³⁵	1	4
Youth (16–24 years)⁴²	1	4
Substances of focus	N	%
Alcohol^{22,24,27–30,41,42,45}	9	33
Any substance^{26,31,33,35,36,40,46,49}	8	30
Stimulants and/or opioids^{25,34,43,44,47}	5	19
Stimulants^23,37,38	3	11
Opioids³⁹	1	4
Alcohol, stimulants, and/or opioids⁴⁸	1	4
Intervention settings	N	%
HIV clinic(s)^{27–30,35,39,41,42,45–47}	11	41
Academic research setting(s)^{22,24,25,34,36,38,43}	7	26
In the community/at home^{26,34,37,42,44,45,48}	7	26
HIV service organization(s)/Community-based organization(s)^23,33,49	3	11
Residential substance use disorder treatment center(s)^25,40	2	7
Mental health clinic(s)³¹	1	4
Syringe service program(s)⁴⁷	1	4

The total number of intervention settings is greater than 27 because some interventions were implemented in more than one setting.

Demographic group characteristics

Fourteen (52%) of the interventions were designed for specific demographic groups that are disproportionately impacted by HIV. Groups sampled included gay, bisexual, and other men who have sex with men,^23,31,37 women,^24,38 Black/African American people,⁴⁰ youth,⁴² people with incarceration experience,^36,44,49 military veterans,^28–30 and people experiencing unstable housing and homelessness.³⁵

Substances of focus

Nearly a third (30%) of the interventions did not focus on a specific substance type but instead recruited participants with any SUD and/or at-risk substance use.^{26,31,33,35,36,40,46,49} The remaining interventions focused either exclusively on alcohol,^{22,24,27–30,41,42,45} stimulants,^23,37,38 opioids,³⁹ or a combination of these substances.^{25,34,43,44,47,48}

Intervention settings

Interventions took place in a broad range of settings, with the largest percentage being based at HIV clinics (42%),^{27–30,35,39,41,42,45–47} followed by academic research settings (26%)^{22,24,25,34,36,38,43} and community or home settings (26%).^{26,34,37,42,44,45,48} The remaining interventions were implemented in HIV service organizations,^23,33,49 residential SUD treatment centers,^25,40 or a mental health clinic,³¹ and at fixed or mobile syringe service programs.⁴⁷ Five interventions also incorporated an electronic delivery method, including text messages,³⁴ email,⁴⁵ telehealth,⁴⁷ and mobile phone applications.^26,37

Key intervention strategies

Each of the 27 interventions used one or more key strategies to achieve the aims of improving HIV care and treatment outcomes among people with HIV. Below is a summary of key strategies among the interventions. Table 3 provides frequencies of the strategies.

Table 3.

Frequencies of Key Strategies Among Interventions Designed for People with HIV Who Have Substance Use Disorder and At-Risk Substance Use, 2019–2023 (N = 27)

Key intervention strategies	N	%
ART adherence support^{22,26,27,34,37,40,42,44,46,47}	10	37
Motivational interviewing^{28–30,33,41,42,45–47}	9	33
Medication for substance use disorder^{24,27–30,35,39,47}	8	30
Contingency management^{23,25,26,35,38,43,48}	7	26
Cognitive-behavioral skills building^{23,31,34,40,46}	5	19
Patient navigation^35,36,47,48	4	15
Mindfulness practice/stress management^22,23,31,49	4	15
Low-barrier entry to care^35,47	2	7
Other intervention strategies (emailed physician feedback, expressive writing)^38,45	2	7

The total number of intervention strategies is greater than 27 because some interventions had more than one strategy.

ART adherence support

ART adherence support refers to the provision of information, education, counseling, skills building, and/or medication reminders focused on enhancing a person’s capacity to take their medication as prescribed. Ten interventions (37%) included the strategy of ART adherence support.^{22,26,27,34,37,40,42,44,46,47} Among these interventions, ART information and adherence skills-building occurred during group sessions,^22,44 as part of peer mentor support,⁴⁷ during sessions with a clinician or facilitator,^27,42,46 or by receiving medication reminders and medication-related information on mobile phones.^26,34,37 Two interventions incorporated Life-Steps,⁵⁰ which is an evidence-based, single-session cognitive-behavioral ART adherence counseling intervention.^34,40

Motivational interviewing

Motivational interviewing is a communication style for guiding people towards making positive behavioral changes based on their own personal reasons and goals.⁵¹ Nine interventions (33%) incorporated motivational interviewing methods to help participants explore ambivalence regarding their substance use, build coping skills, decrease substance use, and/or increase HIV medication adherence behaviors.^{28–30,33,41,42,45–47} Among interventions, the length and duration of motivational interviewing sessions varied widely, ranging from one brief session²⁹ to multiple lengthier sessions delivered over several weeks.^42,46 Sessions were delivered by trained behavioral health clinicians, peers, or medical providers.

Medications for alcohol and opioid use disorders

There are several medications approved by the US Food and Drug Administration for treating opioid and alcohol use disorders.^52,53 Our review found eight (30%) interventions that included the prescription of medications to help treat alcohol and/or opioid use disorders.^{24,27–30,35,39,47} Three interventions looked specifically at the effects of naltrexone, an opioid antagonist that reduces cravings and blocks the euphoric effects of alcohol and opioids. The interventions studied either daily oral naltrexone²⁴ or monthly injections of extended-release naltrexone.^27,39 The other interventions that included medications for alcohol or opioid use disorder were multi-component and not focused on a specific treatment type. For these interventions, clinicians and patients collaborated on choosing medications.^{28–30,35,47}

Contingency management

Contingency management involves providing small financial incentives or rewards (e.g., cash, vouchers, gift cards, public transportation passes) to positively reinforce health-promoting behaviors.^54,55 In the context of substance use, incentives are typically provided in exchange for abstinence from one or more substances (verified through nonreactive urine toxicology tests) or for entering SUD treatment. In the context of HIV care, incentives may be provided for filling ART prescriptions, taking ART medication as prescribed, receiving blood draws, attending medical care visits, or reaching viral suppression. Contingency management programs may also escalate the value of an incentive over time, or whenever a client consistently follows through with a behavior (e.g., an extra $20 gift card after attending three consecutive appointments).

Seven interventions (26%) in this review included the strategy of contingency management. Two of these interventions provided incentives for abstinence from stimulants or opioids,^23,25 three for HIV-related health behaviors (e.g., obtaining an ART prescription, demonstrating ART adherence, reaching viral suppression),^26,35,43 and two for both types of behaviors.^38,48 Interventions either focused on contingency management alone^25,43 or on contingency management in combination with one or more additional strategies (i.e., ART adherence support, positive affect regulation therapy, mindfulness, expressive writing, patient navigation, and low-barrier care).^{23,26,35,38,48}

Cognitive-behavioral skills building

Cognitive-behavioral skills building aims to instill new thinking and behavioral patterns with the goal of improving one’s capacity to manage life challenges. Five interventions (19%) involved cognitive-behavioral skills building.^{23,31,34,40,46} While these cognitive-behavioral skills-building interventions had characteristics in common, each also incorporated unique approaches. For example, one intervention provided clients with behavioral activation treatment, a method that helps clients choose to use substance-free, mood-boosting activities based on personal core values.⁴⁰ Another intervention taught skills to cultivate positive affect and mindfulness in response to stressors that trigger stimulant use.²³ One intervention incorporated psycho-education to manage experiences of discrimination and stigma-related stress³¹; one added motivational interviewing to self-manage substance use and ART adherence⁴⁶; and one combined an adherence counseling session with text messages to prevent SUD relapse and risk-taking behaviors.³⁴ Both the behavioral activation⁴⁰ and positive affect interventions²³ were designed to enhance the effectiveness of a simultaneous SUD intervention (i.e., residential treatment and contingency management, respectively).

Patient navigation

Patient navigation involves having a trained staff person (often a peer with lived experience similar to the client, such as HIV, SUD, or incarceration, who has overcome individual-level barriers) help clients with accessing, attending, and processing health care and social service appointments, including SUD treatment as appropriate. Navigators may also provide social support and adherence counseling and education.⁵⁶ Four interventions (15%) in this review included patient navigation,^35,36,47,48 with three of these employing peers.^35,36,47 All four interventions combined patient navigation with at least one additional strategy, specifically: re-entry social services for people recently released from incarceration,³⁶ low-barrier access to HIV care,^35,47 and contingency management.⁴⁸

Mindfulness practice/stress management

Mindfulness practice entails nonjudgmental awareness of one’s mind, body, and surroundings in the present moment. Activities that increase mindfulness and teach skills to manage stress have been shown to increase a person’s capacity to reduce substance use.⁵⁷ In this review, four interventions (15%) included a focus on mindfulness practice and stress management. Two were manualized interventions that incorporated mindfulness, stigma coping, and/or stress management techniques.^22,31 One intervention held yoga classes for recently incarcerated people with HIV and SUD.⁴⁹ In addition, the positive affect/contingency management intervention (described above) integrated mindfulness techniques and exercises.²³

Low-barrier entry to care

Low-barrier entry to HIV care aims to engage people who are out of care by offering drop-in, on-demand access to highly supportive and comprehensive HIV care and services. Two interventions (7%) in this review offered low-barrier care.^35,47 One intervention reduced barriers by being situated within syringe service programs and offering on-demand telehealth care to an HIV care team located offsite. This intervention also provided a community engagement team with peer navigation, medication storage, medication for opioid use disorder, and ART adherence support.⁴⁷ The other low-barrier intervention was a drop-in HIV primary care clinic that provided integrated case management, peer navigators, and contingency management for attending visits and attaining viral suppression.³⁵

Intervention study designs and outcomes

Study design quality was overall high among the 27 interventions reviewed. See Table 4. Among the studies, 24 (89%) had a comparison group, including 13 (48%) randomized controlled trials (RCTs),^{22–25,27–30,40,43,45,48,49} 2 (7%) randomized comparative effectiveness trials,^39,42 7 (30%) pilot RCTs,^{26,31,34,36–38,44} 1 (4%) cluster-randomized type 2 hybrid trial,³³ and 1 (4%) quasi-experimental study.⁴⁶ The other studies included one (4%) pre–post implementation study⁴¹ and two (7%) postimplementation evaluations.^35,47 Among the pilot RCTs, none were powered to detect statistical significance, and all reported moderate-to-high feasibility and acceptability.^{26,31,34,36–38,44}

Table 4.

Study Designs and HIV Care Continuum Outcomes of Interventions for People with HIV and Substance Use Disorder, 2019–2023

First author, year	Intervention name/acronym (in bold) and brief description	Study design (comparison group)	Sample size	HIV care continuum outcomes
Attonito J, 2020²²	HHRP-A. Eight group sessions with adherence support using cognitive remediation strategies	RCT (8 health education groups)	N = 243	Adherence: No between-group differences at 3 months; intervention group had higher adherence (93%) than control group (80.6%) at 6 months (RR = 1.55; 95% CI: 1.09, 2.18)^a VS: No between-group differences at 3 months; intervention group had higher VS (74.6%) than control group (56.7%) at 6 months (RR = 1.49; 95% CI: 1.05, 2.13)^a
Carrico AW, 2019²³	ARTEMIS. Positive affect counseling and contingency management for stimulant use	RCT (Attention control and contingency management)	N = 110	VL: Intervention group had lower log10 VL over 15 months compared with control group (group-by-time interaction χ²(3) = 7.83, p = 0.049)^a VS: Intervention group had lower risk of one or more unsuppressed VL measurements over 15 months (RR = 0.33; 95% CI: 0.15, 0.69; p < 0.001)^a
Cook RL, 2019²⁴	WHAT-IF? Oral naltrexone for 4 months	RCT (Placebo)	N = 194	Adherence: No between-group differences over time (to 7 months) VS: No between-group differences over time (to 7 months)
Cunningham CO, 2020²⁵	Contingency management for cocaine/opioid use	RCT (Attention control)	N = 73	Adherence: No between-group differences at 16 weeks VL: Intervention group had a greater mean reduction in log10 VL than control group over 16 weeks (−0.16 log10 VL copies/mL per 4-week period; 95% CI: −0.29, −0.03, p < 0.05)^a
Defulio A, 2021²⁶	SteadyRx. Phone app with ART reminder texts, HIV information, and remote contingency management for ART adherence	Pilot RCT (Usual care)	N = 50	Adherence: Intervention group adherence was 16% higher than control group at 6 months. Group × time interaction: F(5, 214) = 3.3, p = 0.007 (covariate excluded model), F(5, 214) = 3.35, p = 0.006 (covariate included model)^a
Edelman EJ, 2019²⁷	Project DAWN. Injectable XR‐NTX plus medication counseling over 24 weeks	RCT (Placebo injection plus medication counseling)	N = 51	Adherence: No between-group differences over time (to 52 weeks) VS: No between-group differences over time (to 52 weeks)
Edelman EJ, 2019²⁸	STEP AUD. (1) Medication for AUD, (2) motivational enhancement therapy, (3) referral to specialty services	RCT (Referral to SUD treatment services)	N = 128	VS: No between-group differences at 24 weeks (primary timepoint); higher proportion of intervention group had VS at 52 weeks
Edelman EJ, 2019²⁹	STEP MALD. (1) Brief sessions, (2) motivational enhancement therapy, (3) medication for AUD	RCT (Health handout plus routine care)	N = 95	VS: No between-group differences at 24 weeks
Edelman EJ, 2020³⁰	STEP At-Risk. (1) Brief sessions, (2) motivational enhancement therapy, (3) medication for AUD	RCT (Health handout plus routine care)	N = 93	VS: No between-group differences at 24 weeks
Flentje A, 2022³¹	Sessions to address stigma-related stress, with cognitive-behavioral skills building and mindfulness	Pilot RCT (Attention control)	N = 41	Adherence: No between-group differences over 4 months VS: No between-group differences over 4 months
Garner BR, 2020³³	SAT2HIV. Brief motivational interviewing sessions plus organizational-level coaching for implementation and sustainment	Cluster-randomized, type II hybrid trial (Usual care)	N = 824	Adherence: No between-group differences at 20 months
Glasner S, 2022³⁴	TXT-CBT. Adherence counseling, tailored CBT reminders and texts	Pilot RCT (Informational pamphlet)	N = 50	Adherence: Intervention group had higher adherence (M = 1.00), relative to control group (M = 0.87) at 12 weeks (t(48) = 2.15, p = 0.02); and increase over time relative to controls (p = 0.02, d = 0.70)^a VL: Intervention group had lower VL (log M = 3.38 copies/mL) than control group (log M = 4.88 copies/mL) at 12 weeks (t(49) = 2.42, p = 0.02, d = 0.68)^a
Hickey MD, 2022³⁵	POP-UP. Drop-in care, contingency management, peer navigation, integrated case management	Pre–post and postevaluation	N = 112	LtC: 61% at 12 months (no baseline measured) RiC: 70% at 12 months (no baseline measured) VS: 44% at 12 months (0% at baseline); cumulative incidence 66% (95% CI: 57%, 74%) over 12 months^a
Hoff E, 2023³⁶	CHW+. Health care navigation by a community health worker plus access to a community re-entry organization	Pilot RCT (List of HIV clinics)	N = 31	RiC: No between-group differences at 6 months Adherence: No between-group differences at 6 months VS: No between-group differences at 6 months
Horvath KJ, 2019³⁷	APP+. Phone app to support adherence	Pilot RCT (No intervention)	N = 90	Adherence: No between-group differences at 2, 4, or 6 months
Jemison D, 2019³⁸	Expressive writing and contingency management for stimulant use and HIV behavior	Pilot RCT (Attention control and contingency management)	N = 16	VL: No between-group differences at 6 months
Korthuis PT, 2022³⁹	CHOICES. Injectable XR‐NTX for OUD	Open‐label, randomized, non‐inferiority comparative effectiveness trial (Offered usual care: buprenorphine or methadone)	N = 114	VS: No between-group differences; both improved from baseline (0%) to 24 weeks: XR-NTX (52.7%) vs. control (49.2%)
Magidson JF, 2022⁴⁰	Act Healthy. Behavioral activation	RCT (Time-matched supportive counseling + Life-Steps)	N = 61	Adherence: No between-group differences at 14 weeks or 12 months
McCaul ME, 2021⁴¹	Two brief interventions on a tablet during clinic; informed by motivational interviewing,	Prospective, pre–post implementation study	N = 226	VS: No change from 4 to 12 months
Naar S, 2020⁴²	Healthy Choices. Four motivational interviewing sessions with a community health worker	Randomized comparative effectiveness trial (Home/community delivery vs. clinic)	N = 183	VS: No between-group differences at 16 weeks; clinic group had higher VS (35%) than home/community group (20%) at 1 year (unstandardized βslope2 = −0.07; 95% CI: −0.14, −0.01; p = 0.02)^a
Pollock S, 2020⁴³	Contingency management for HIV health behaviors and outcomes	RCT, secondary analysis (Usual care)	N = 52	RiC: No between-group differences at 1 year Adherence: No between-group differences at 1 year VS: Intervention group had higher VS (69%) than control group (41%) at 1 year (Odds Ratio: 4.0, 95% CI: 1.6,10.3, p = 0.004)^a
Rowell-Cunsolo TL, 2020⁴⁴	Project ADHERE. Group sessions, adherence and risk reduction support	Pilot RCT (1-h adherence information group)	N = 32	Adherence: Control group had better adherence (43.7%) compared with intervention group (35.7%) at 3 months^a VL: Control group more likely to experience VL reduction (RR: 0.25) at 3 months^a
Satre DD, 2019⁴⁵	Health and Motivation. Screening, brief intervention, and referral to treatment (SBIRT) plus motivational interviewing sessions, or emailed feedback from physician	Three-arm RCT (SBIRT + motivational interviewing vs. SBIRT + Emailed feedback vs. SBIRT)	N = 614	Adherence: No between-group differences at six or 12 months VS: No between-group differences at six or 12 months
Starks TJ, 2022⁴⁶	Project PLUS. Clinician-delivered motivational interviewing and cognitive-behavioral skills-building sessions	Quasi-experimental (Waitlist; no intervention matched controls)	N = 174	Adherence: No between-group differences over 12 months VS: No between-group differences over 12 months
Tookes HE, 2021⁴⁷	Low-barrier telehealth HIV care for people accessing syringe service sites; peer navigation; medication for OUD	Pilot test, retrospective chart review	N = 35	LtC: 100% of enrolled clients completed a visit with HIV provider and case manager (no baseline measure) VS: 78.1% at 6 months (no baseline measure)
Traynor SM, 2021⁴⁸	Project HOPE. Patient navigation with or without contingency management for substance use and HIV behaviors	RCT, secondary analysis (Passive referrals)	N = 801	LtC: Patient navigation group and patient navigation plus contingency management group were more likely to have an HIV care visit by 6 months compared with control group (patient navigation only: β = 0.371, p = 0.004; patient navigation plus contingency management: β = 0.672 p < 0.001)^a RiC: No between-group differences at 12 months VS: No between-group differences at 12 months
Wimberly AS, 2020⁴⁹	Yoga classes	RCT (secondary analysis) (Usual care)	N = 75	Adherence: No between-group differences at 3 months VS: No between-group differences at 3 months

Statistically significant.

LtC, linkage to care; RCT, randomized controlled trial; RiC, retention in care; VL, viral load; VS, viral suppression; XR‐NTX, extended-release naltrexone.

HIV care continuum outcomes

Three intervention studies (11%) measured linkage to care,^35,47,48 4 (15%) measured retention in care,^35,36,43,48 16 (59%) measured ART adherence,^{22,24–27,31,33,34,36,37,40,43–46,49} and 23 (85%) measured viral suppression or reduction in viral load.^{22–25,27–31,34–36,38,39,41–49}

Comparative effectiveness studies

Among the two comparative effectiveness studies, one study found no differences in viral suppression outcomes between oral naltrexone and extended-release naltrexone for people who use opioids.³⁹ The other study found that a motivational interviewing intervention for youth was associated with higher viral suppression when received inside the clinic than when received at home or in the community.⁴²

Studies with statistically significant HIV outcomes

There were 10 intervention studies (37%) that found a positive and statistically significant HIV care continuum outcome at the primary^{23,25,26,34,35,43,48} or secondary timepoint.^22,28 Notably, six of these interventions had a contingency management component.^{23,25,26,35,43,48}

Interventions with a contingency management component

In an RCT by Cunningham et al., participants in the contingency management intervention (incentives for abstinence from cocaine and opioids) had a greater reduction in viral load than the attention control group.²⁵ The RCT by Pollock et al., which offered incentives for positive HIV-related health behaviors among people using cocaine or opioids, found that the intervention was associated with increased odds of reaching viral suppression.⁴³ Of note, neither study found significant between-group differences in ART adherence.^25,43

Studies that found positive outcomes when contingency management was paired with one or more strategies included the RCT by Carrico et al., which compared contingency management alone (incentives in exchange for methamphetamine abstinence) with contingency management plus cognitive-behavioral skills building and mindfulness practice (positive affect regulation treatment). This study, which recruited men who have sex with men and who use methamphetamine, found that the positive affect treatment group had significantly lower log10 HIV viral load over 15 months.²³

Hickey et al. included contingency management (incentives for positive HIV-related health behaviors) as part of a larger holistic low-barrier entry to primary care intervention for people with an SUD. The intervention also offered peer navigation, integrated case management, and medication for opioid use disorder. The authors found that 44% of patients reached viral suppression at least once over the 12-month time period, with a cumulative incidence of 66% over 12 months.³⁵ Of note, a similar low-barrier intervention by Tookes et al., which situated care within syringe service programs and did not use contingency management, found that 78% of pilot participants reached viral suppression within 6 months of care initiation (statistical significance not measured). In the pilot RCT by Jemison et al., adding expressive writing sessions to contingency management was not associated with statistically significant improvements in viral load compared with contingency management alone; however, the sample was very small (n = 16).³⁸

A three-arm RCT (Traynor et al.) of an intervention for people with at-risk alcohol, opioid, or stimulant use compared patient navigation alone, patient navigation plus contingency management (rewards for HIV health-related behaviors), and usual care (passive referrals) alone. While participants in both intervention arms were more likely to link to HIV care by 6 months compared with those receiving usual care, the patient navigation plus contingency management arm had a larger effect size.⁴⁸ This RCT, however, did not find statistically significant between-group differences in retention in care or viral suppression.⁴⁸

Finally, the pilot RCT by Defulio et al. looked at the preliminary efficacy of an app that combined contingency management (financial rewards given after participants upload a selfie video of themselves taking ART) with ART adherence support (reminder texts and access to HIV information) for people with an SUD. Adherence was significantly higher in the intervention group compared with the control group (usual care) at 6 months.²⁶

Interventions without a contingency management component

The Glasner et al. pilot RCT tested the preliminary efficacy of a one-to-one adherence support session followed by ART adherence support texts with elements of cognitive-behavioral skills-building for people with opioid or stimulant use disorder.³⁴ Compared with the control group, intervention participants had higher ART adherence and lower viral load at 12-week follow-up. The RCT of a group-based weekly adherence education and stress management intervention by Attonito et al. for people with at-risk alcohol use or alcohol use disorder found that the intervention group had higher ART adherence and viral suppression relative to controls at 6-month follow-up but not at three-month follow-up (the primary timepoint).²² In addition, the Edelman et al. RCT comparing a stepped intervention (medication for alcohol use disorder, followed by motivational interviewing sessions and referral to SUD treatment, if needed) with usual care (referral to SUD treatment) reported higher viral suppression in the intervention group at the secondary timepoint (52 weeks) but not at the primary timepoint (24 weeks).²⁸

Discussion

This review identified 27 US-based HIV care continuum interventions designed for people with HIV who have an SUD or are at risk for an SUD. Despite the large number of intervention studies, few interventions were designed to improve linkage to care or retention in care. A lack of investigation into these areas may be a missed opportunity, given that linkage and retention are necessary precursors to reaching viral suppression and that people with SUD have an increased risk of disengaging from HIV care.⁵⁸ In addition, only about a third of the interventions found any statistically significant HIV care continuum outcomes at the primary or secondary timepoint, suggesting that new and innovative strategies are needed to support the HIV care needs of this population.

Consistent with the broader literature base,^54,55 we found that interventions with a contingency management component^{23,25,26,35,38,43,48} showed the most promise for improving HIV care continuum outcomes. When considering the successful outcomes of the contingency management interventions, however, it is important to acknowledge the high heterogeneity across the interventions and samples with regard to the behaviors that were incentivized (substance abstinence, HIV care engagement, viral suppression, or a combination of behaviors), the substances used by the groups sampled (cocaine, methamphetamine, opiates, or a combination of substances), and the selected group demographics (e.g., women, people experiencing unstable housing and homelessness, or no specific demographic group). This level of heterogeneity may indicate that financial incentive programs are effective in a range of populations and for a variety of behaviors, possibly because small rewards can make a difference for the many people with HIV and SUD who experience food, housing, and transportation insecurity.^59–61 At the same time, different substances can affect HIV care engagement in unique ways,⁶² suggesting that the efficacy of contingency management may also vary by substance.

Previous studies have found that the effect of contingency management tends to diminish or disappear once a client completes participation in the contingency management program.^54,55 To extend and expand the effects of contingency management, interventions that pair contingency management with other strategies may prove more effective over the long term. For example, the Carrico et al. study of contingency management plus cognitive-behavioral skills building and mindfulness practice found that viral suppression was significantly lower in the intervention group at 15 months despite the intervention lasting only 3 months.²³ Other intervention studies that combined contingency management with one or more other components (e.g., low-barrier entry to care, adherence support, medication) showed positive outcomes for adherence²⁶ and viral suppression³⁵ at 6 and 12 months, respectively, but more research is needed to see if the effects are sustained over time.

Notably, all but one³⁵ of the interventions with a contingency management component were conducted in research settings or by study staff members in clinic settings. This finding is important because the efficacy of an intervention in a controlled research study does not always translate to effectiveness in real-world clinical settings.⁶³ The low-barrier-to-entry pilot intervention studies showed promising outcomes^35,47 while being set in real-world contexts, such as syringe service programs that support clients in overcoming complex implementation barriers.⁶⁴ Designing studies using an implementation science approach would allow researchers to assess implementation outcomes, such as the acceptability of the intervention by different local populations, as well as the financial and logistical feasibility of providing frequent drug testing and rewards.⁶⁵

Authors’ Contributions

H.G.: Conceptualization (equal), writing—original draft (lead), and writing—review and editing (equal); M.D.: Conceptualization (equal), writing—review and editing (equal), and methodology (equal); E.J.Y.: Writing—original draft (equal) and writing—review and editing (equal); D.R.A.C.: Methodology (equal) and writing—review and editing (equal); D.P.: Conceptualization (equal) and writing—review and editing (equal); J.S.: Writing—review and editing (equal); C.D.-R.: Writing—review and editing (equal); K.H.M.: Writing—review and editing (equal); A.S.K.: Supervision (lead), conceptualization (equal), and writing—review and editing (equal).

Disclaimer

The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of the US Department of Health and Human Services or the Health Resources and Services Administration nor does mention of the department or agency names imply endorsement by the US Government.

Footnotes

Author Disclosure Statement

A.S.K. declares royalties as editor of a McGraw Hill textbook and an American Psychiatric Association Publishing textbook. The authors have no competing interests.

Funding Information

This work was supported by the US Department of Health and Human Services, Health Resources and Services Administration, grant number U90HA42153.

References

1. Fauci

, Redfield

, Sigounas

, et al. Ending the HIV epidemic: A plan for the United States. JAMA 2019;321(9):844–845; doi: 10.1001/jama.2019.1343

2.Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 territories and freely associated states, 2022. HIV Surveillance Supplemental Report 2024.2024. Available from: https://www.cdc.gov/hivdata/nhss/national-hiv-prevention-and-care-outcomes.html [Last accessed: October 25, 2024].

3. Garner

, Gotham

, Knudsen

, et al. The prevalence and negative impacts of substance use disorders among people with HIV in the United States: A real-time delphi survey of key stakeholders. AIDS Behav 2022;26(4):1183–1196; doi: 10.1007/s10461-021-03473-9

4. Goodman-Meza

, Shoptaw

, Weiss

, et al. Methamphetamine use drives decreases in viral suppression for people living with HIV released from a large municipal jail: Results of the LINK LA clinical trial. Drug Alcohol Depend 2019;202:178–184; doi: 10.1016/j.drugalcdep.2019.05.007

5. Reback

, Runger

, Fletcher

. Drug use is associated with delayed advancement along the HIV care continuum among transgender women of color. AIDS Behav 2021;25(Suppl 1):107–115; doi: 10.1007/s10461-019-02555-z

6. Williams

, Hahn

, Saitz

, et al. Alcohol use and Human Immunodeficiency Virus (HIV) infection: Current knowledge, implications, and future directions. Alcohol Clin Exp Res 2016;40(10):2056–2072; doi: 10.1111/acer.13204

7. Hartzler

, Dombrowski

, Crane

, et al. Prevalence and predictors of substance use disorders among HIV care enrollees in the United States. AIDS Behav 2017;21(4):1138–1148; doi: 10.1007/s10461-016-1584-6

8. Li

, Humes

, Lee

, North American AIDS Cohort Collaboration on Research and Design of the International Epidemiologic Databases to Evaluate AIDS. et al.; Toward ending the HIV epidemic: Temporal trends and disparities in early ART initiation and early viral suppression among people newly entering HIV care in the United States, 2012–2018. Open Forum Infect Dis 2022;9(8):ofac336; doi: 10.1093/ofid/ofac336

9. Desai

, Burns

, Gong

, et al. An update on drug–drug interactions between antiretroviral therapies and drugs of abuse in HIV systems. Expert Opin Drug Metab Toxicol 2020;16(11):1005–1018.

10.

10. Monroe

, Lau

, Mugavero

, et al. Heavy alcohol use is associated with worse retention in HIV care. J Acquir Immune Defic Syndr 2016;73(4):419–425; doi: 10.1097/QAI.0000000000001083

11.

11. Levi-Minzi

, Surratt

. HIV stigma among substance abusing people living with HIV/AIDS: Implications for HIV treatment. AIDS Patient Care STDS 2014;28(8):442–451; doi: 10.1089/apc.2014.0076

12.

12. Biancarelli

, Biello

, Childs

, et al. Strategies used by people who inject drugs to avoid stigma in healthcare settings. Drug Alcohol Depend 2019;198:80–86; doi: 10.1016/j.drugalcdep.2019.01.037

13.

13. Rooks-Peck

, Adegbite

, Wichser

, Prevention Research Synthesis Project. et al.; Mental health and retention in HIV care: A systematic review and meta-analysis. Health Psychol 2018;37(6):574–585; doi: 10.1037/hea0000606

14.

14. Yehia

, Stewart

, Momplaisir

, et al. Barriers and facilitators to patient retention in HIV care. BMC Infect Dis 2015;15:246; doi: 10.1186/s12879-015-0990-0

15.

15. Holtzman

, Shea

, Glanz

, et al. Mapping patient-identified barriers and facilitators to retention in HIV care and antiretroviral therapy adherence to Andersen’s Behavioral Model. AIDS Care 2015;27(7):817–828; doi: 10.1080/09540121.2015.1009362

16.

16. Lambdin

, Kral

, Comfort

, et al. Associations of criminal justice and substance use treatment involvement with HIV/HCV testing and the HIV treatment cascade among people who use drugs in Oakland, California. Addict Sci Clin Pract 2017;12(1):13; doi: 10.1186/s13722-017-0078-9

17.

17. McNamara

, Biondi

, Hernandez-Ramirez

, et al. A systematic review and meta-analysis of studies evaluating the effect of medication treatment for opioid use disorder on infectious disease outcomes. Open Forum Infect Dis 2021;8(8):ofab289; doi: 10.1093/ofid/ofab289

18.

18. Patrick

, O’Malley

, Johnston

, et al. HIV/AIDS risk behaviors and substance use by young adults in the United States. Prev Sci 2012;13(5):532–538; doi: 10.1007/s11121-012-0279-0

19.

19. Compton

, Jones

. Substance use among men who have sex with men. N Engl J Med 2021;385(4):352–356; doi: 10.1056/NEJMra2033007

20.

20. Volkow

, Baler

, Normand

. The unrealized potential of addiction science in curbing the HIV epidemic. Curr HIV Res 2011;9(6):393–395; doi: 10.2174/157016211798038605

21.

21.Centers for Disease Control and Prevention. Ending the HIV Epidemic in the U.S. progress. 2023. Available from: https://www.cdc.gov/ehe/php/about/?CDC_AAref_Val=https://www.cdc.gov/endhiv/ehe-progress/index.html [Last accessed: October 10, 2024].

22.

22. Attonito

, Villalba

, Dévieux

. Effectiveness of an intervention for improving treatment adherence, service utilization and viral load among HIV-positive adult alcohol users. AIDS Behav 2020;24(5):1495–1504; doi: 10.1007/s10461-019-02702-6

23.

23. Carrico

, Neilands

, Dilworth

, et al. Randomized controlled trial of a positive affect intervention to reduce HIV viral load among sexual minority men who use methamphetamine. J Int AIDS Soc 2019;22(12):e25436; doi: 10.1002/jia2.25436

24.

24. Cook

, Zhou

, Miguez

, et al. Reduction in drinking was associated with improved clinical outcomes in women with HIV infection and unhealthy alcohol use: Results from a randomized clinical trial of oral naltrexone versus placebo. Alcohol Clin Exp Res 2019;43(8):1790–1800; doi: 10.1111/acer.14130

25.

25. Cunningham

, Arnsten

, Zhang

, et al. Abstinence-reinforcing contingency management improves HIV viral load suppression among HIV-infected people who use drugs: A randomized controlled trial. Drug Alcohol Depend 2020;216:108230; doi: 10.1016/j.drugalcdep.2020.108230

26.

26. DeFulio

, Devoto

, Traxler

, et al. Smartphone-based incentives for promoting adherence to antiretroviral therapy: A randomized controlled trial. Prev Med Rep 2021;21:101318.

27.

27. Edelman

, Moore

, Holt

, et al. Efficacy of extended-release naltrexone on -related and drinking outcomes among HIV-positive patients: A randomized-controlled trial. AIDS Behav 2019;23(1):211–221; doi: 10.1007/s10461-018-2241-z

28.

28. Edelman

, Maisto

, Hansen

, et al. Integrated stepped alcohol treatment for patients with HIV and alcohol use disorder: A randomised controlled trial. Lancet HIV 2019;6(8):e509–e517; doi: 10.1016/S2352-3018(19)30076-1

29.

29. Edelman

, Maisto

, Hansen

, et al. Integrated stepped alcohol treatment for patients with HIV and liver disease: A randomized trial. J Subst Abuse Treat 2019;106:97–106; doi: 10.1016/j.jsat.2019.08.007

30.

30. Edelman

, Maisto

, Hansen

, et al. Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: A randomized trial. Addict Sci Clin Pract 2020;15(1):28; doi: 10.1186/s13722-020-00200-y

31.

31. Flentje

, Sunder

, Dilley

, et al. AWARENESS: A cognitive behavioral intervention to reduce intersectional minority stress among sexual minority men living with HIV who use substances. Drug Alcohol Depend Rep 2022;3:100059; doi: 10.1016/j.dadr.2022.100059

32.

32. Flentje

. AWARENESS: Development of a cognitive-behavioral intervention to address intersectional minority stress for sexual minority men living with HIV who use substances. Psychotherapy (Chic) 2020;57(1):35–49; doi: 10.1037/pst0000243

33.

33. Garner

, Gotham

, Chaple

, et al. The implementation and sustainment facilitation strategy improved implementation effectiveness and intervention effectiveness: Results from a cluster-randomized, type 2 hybrid trial. Implement Res Pract 2020;1:2633489520948073; doi: 10.1177/2633489520948073

34.

34. Glasner

, Patrick

, Ybarra

, et al. Promising outcomes from a cognitive behavioral therapy text-messaging intervention targeting drug use, antiretroviral therapy adherence, and HIV risk behaviors among adults living with HIV and substance use disorders. Drug Alcohol Depend 2022;231:109229; doi: 10.1016/j.drugalcdep.2021.109229

35.

35. Hickey

, Imbert

, Appa

, et al. HIV treatment outcomes in POP-UP: Drop-in HIV primary care model for people experiencing homelessness. J Infect Dis 2022;226(Suppl 3):S353–S362; doi: 10.1093/infdis/jiac267

36.

36. Hoff

, Hansen

, Pulitzer

, et al. A randomized control trial of a combined community health worker and re-entry intervention for people with HIV recently released from jail who use substances. J Subst Use Addict Treat 2023;152:209118; doi: 10.1016/j.josat.2023.209118

37.

37. Horvath

, Lammert

, MacLehose

, et al. A pilot study of a mobile app to support HIV antiretroviral therapy adherence among men who have sex with men who use stimulants. AIDS Behav 2019;23(11):3184–3198; doi: 10.1007/s10461-019-02597-3

38.

38. Jemison

, Jackson

, Oni

, et al. Pilot randomized controlled trial of a syndemics intervention with HIV-positive, cocaine-using women. AIDS Behav 2019;23(9):2467–2476; doi: 10.1007/s10461-019-02625-2

39.

39. Korthuis

, Cook

, Lum

, et al. HIV clinic-based extended-release naltrexone versus treatment as usual for people with HIV and opioid use disorder: A non-blinded, randomized non-inferiority trial. Addiction 2022;117(7):1961–1971; doi: 10.1111/add.15836

40.

40. Magidson

, Belus

, Seitz-Brown

, et al. Act healthy: A randomized clinical trial evaluating a behavioral activation intervention to address substance use and medication adherence among low-income, Black/African American individuals living with HIV/AIDS. AIDS Behav 2022;26(1):102–115; doi: 10.1007/s10461-021-03354-1

41.

41. McCaul

, Hutton

, Cropsey

, et al. Decreased alcohol consumption in an implementation study of computerized brief intervention among HIV patients in clinical care. AIDS Behav 2021;25(12):4074–4084; doi: 10.1007/s10461-021-03295-9

42.

42. Naar

, Robles

, MacDonell

, et al. Comparative effectiveness of community-based vs clinic-based healthy choices motivational intervention to improve health behaviors among youth living with HIV: A randomized clinical trial. JAMA Netw Open 2020;3(8):e2014650; doi: 10.1001/jamanetworkopen.2020.14650

43.

43. Pollock

, Toegel

, Holtyn

, et al. Effects of incentives on viral suppression in people living with HIV who use cocaine or opiates. Drug Alcohol Depend 2020;212:108000; doi: 10.1016/j.drugalcdep.2020.108000

44.

44. Rowell-Cunsolo

, Hong

, Mkuu

, et al. Improving medication adherence among drug-using HIV-infected formerly incarcerated individuals: A pilot test of two interventions. J Correct Health Care 2020;26(1):42–54; doi: 10.1177/1078345819897634

45.

45. Satre

, Leibowitz

, Leyden

, et al. Interventions to reduce unhealthy alcohol use among primary care patients with HIV: The health and motivation randomized clinical trial. J Gen Intern Med 2019;34(10):2054–2061; doi: 10.1007/s11606-019-05065-9

46.

46. Starks

, Skeen

, Scott Jones

, et al. Effectiveness of a combined motivational interviewing and cognitive behavioral intervention to reduce substance use and improve HIV-related immune functioning. AIDS Behav 2022;26(4):1138–1152; doi: 10.1007/s10461-021-03467-7

47.

47. Tookes

, Bartholomew

, Suarez

, et al. Acceptability, feasibility, and pilot results of the tele-harm reduction intervention for rapid initiation of antiretrovirals among people who inject drugs. Drug Alcohol Depend 2021;229(Pt A):109124; doi: 10.1016/j.drugalcdep.2021.109124

48.

48. Traynor

, Metsch

, Gooden

, et al. Self-efficacy as a mediator of patient navigation interventions to engage persons living with HIV and substance use. Drug Alcohol Depend 2021;221:108567; doi: 10.1016/j.drugalcdep.2021.108567

49.

49. Wimberly

, Gross

, Layde

. Effect of yoga on antiretroviral adherence postincarceration in HIV+ individuals. J Correct Health Care 2020;26(1):83–94; doi: 10.1177/1078345819897924

50.

50. Safren

, Otto

, Worth

, et al. Two strategies to increase adherence to HIV antiretroviral medication: Life-steps and medication monitoring. Behav Res Ther 2001;39(10):1151–1162; doi: 10.1016/s0005-7967(00)00091-7

51.

51. Naar-King

, Outlaw

, Green-Jones

, et al. Motivational interviewing by peer outreach workers: A pilot randomized clinical trial to retain adolescents and young adults in HIV care. AIDS Care 2009;21(7):868–873; doi: 10.1080/09540120802612824

52.

52. Oesterle

, Thusius

, Rummans

, et al. Medication-assisted treatment for opioid-use disorder. Mayo Clin Proc 2019;94(10):2072–2086; doi: 10.1016/j.mayocp.2019.03.029

53.

53. Akbar

, Egli

, Cho

, et al. Medications for alcohol use disorders: An overview. Pharmacol Ther 2018;185:64–85; doi: 10.1016/j.pharmthera.2017.11.007

54.

54. Rash

, Stitzer

, Weinstock

. Contingency management: New directions and remaining challenges for an evidence-based intervention. J Subst Abuse Treat 2017;72:10–18; doi: 10.1016/j.jsat.2016.09.008

55.

55. Ribeiro

, Pinto

DGA

, Trevisol

, et al. Can contingency management solve the problem of adherence to antiretroviral therapy in drug-dependent individuals? Health Educ Behav 2023;50(6):738–747; doi: 10.1177/10901981221148966

56.

56. Kelly

, Doucet

, Luke

. Exploring the roles, functions, and background of patient navigators and case managers: A scoping review. Int J Nurs Stud 2019;98:27–47; doi: 10.1016/j.ijnurstu.2019.05.016

57.

57. Félix-Junior

, Donate

APG

, Noto

, et al. Mindfulness-based interventions in inpatient treatment for substance use disorders: A systematic review. Addict Behav Rep 2022;16:100467.

58.

58. Pitpitan

, Wiginton

, Bejarano-Romero

, et al. Promoting HIV care continuum outcomes among people who use drugs and alcohol: A systematic review of randomized trials evaluating behavioral HIV care interventions published from 2011 to 2023. BMC Public Health 2023;23(1):2182; doi: 10.1186/s12889-023-17113-5

59.

59. Colasanti

, Armstrong

. Challenges of reaching 90–90–90 in the Southern United States. Curr Opin HIV AIDS 2019;14(6):471–480.

60.

60. Raja

, Heeren

, Walley

, et al. Food insecurity and substance use in people with HIV infection and substance use disorder. Subst Abus 2022;43(1):104–112.

61.

61. Whittle

, Sheira

, Frongillo

, et al. Longitudinal associations between food insecurity and substance use in a cohort of women with or at risk for HIV in the United States. Addiction 2019;114(1):127–136.

62.

62. Hai

, Schnall

, Batey

. Differential effects of substance use on HIV care and symptom outcomes: A longitudinal analysis among people with HIV. AIDS Patient Care STDS 2025;39(10):397–404; doi: 10.1177/10872914251364664

63.

63. Thompson

. Replication of randomized, controlled trials using real-world data: What could go wrong?: Elsevier. Value Health 2021;24(1):112–115.

64.

64. Roth

, Forman

, Akiba

, et al. HIV services implementation within US syringe services programs: A qualitative exploration. AIDS Patient Care STDS 2025;39(11):441–449; doi: 10.1177/10872914251376934

65.

65. Lier

, Tarfa

, Shenoi

, et al. HIV and substance use disorders. Infect Dis Clin North Am 2024;38(3):599–611.