time that would be required to address their substance use, mental health, and health care needs (Weiss, Kluger et al., 2000).

Receipt of standard of care

The association of HAART with decreased morbidity and increased survival is clear. However, studies have shown that substance users are less likely to receive HAART than non-users (Solomon et al., 1998; Celentano et al., 2001; Metsch et al., 2001; Turner et al., 2001)—a clear marker that HIV-infected substance users are not getting the same level of care as their non-using counterparts. One such study found that only 34 percent of HIV-positive crack cocaine smokers in care received HAART (Metsch et al., 2001). ALIVE—a longitudinal study of the natural history of HIV infection in Baltimore—found that consistent drug use was associated with a 58 percent decrease in the probability of initiating HAART (Celentano et al., 2001).

One reason fewer substance users receive HAART is that many providers believe that substance users are less likely than non-users to appropriately adhere to medication regimes (Bamberger, Unick et al., 2000; Bogart, Kelly et al., 2000; Bogart, Catz et al., 2001; Ramos and Tiger, 2001). They may also be concerned about the interactions between HIV medication, illicit drugs, methadone, and psychotropic medications. While it is true that some HIV medications can increase the metabolism of methadone, causing opiate withdrawal symptoms (Munsiff, 2002), this issue can be addressed by adjusting dosages. However, medical care providers’ fears about these interactions and uncertainty about how to address them often prevent them from prescribing HIV medication in the first place (Ramos and Tiger, 2001).

Substance use and adherence

Despite providers’ concerns about substance users, the data on substance use and adherence point to a more refined approach than simply refusing HAART to all substance users. Some studies have, indeed, found an association between active substance use (particularly crack cocaine use) or heavy alcohol abuse and lower adherence (Cook et al., 2001; Hinkin et al., 2002; Mannheimer et al., 2002). Of note, however, substance abuse may also be associated with depression or other affective disorders that can affect adherence (Ekstrand et al., 2002; Mannheimer et al., 2002; Perry et al., 2002). This association may in turn further complicate adherence, while substance abuse symptoms may mask symptoms of depression or vice versa.

When discussing adherence, distinguishing between active and former substance use is important. While a few studies have shown a relationship



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