recent immigrants, and people who are homeless (Hsu, 2001). Low-income women of color face multiple barriers in that they, too, are more likely to lack health insurance coverage and have dependent children. It is estimated that nearly two-thirds of women of color with HIV infection have at least one child under the age of 20, adding further complexity to their lives and their care (Hsu, 2001; HRSA, 1999).

Once in care, HIV-infected substance abusers face obstacles to staying in care and receiving quality care. Studies have shown that substance abusers are more likely to receive sporadic care in emergency departments. Chronic drug users are less likely to have a regular source of health care and are more likely than nondrug users to utilize emergency room and inpatient care (Markson et al., 1998; Laine et al., 2001; Welch and Morse, 2001). Other studies have shown that substance abusers are less likely to receive HAART than nonusers (Soloman et al., 1998; Celentano et al., 2001; Metsch et al., 2001; Turner et al., 2001). This is partly because of provider beliefs that substance abusers are less likely to adhere to treatment regimens and because of concerns surrounding interactions between HAART drugs and illicit drugs, psychotropic medications, and methadone.

Though active substance abuse is considered a predictor of poor adherence, the evidence indicates that the link is not always clear. Some studies have 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). Substance abuse, however, 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.

PLWH/A with co-morbid substance abuse and/or mental illness encounter many obstacles to accessing treatment, remaining in care, and adhering to treatment regimens. However, there are interventions that can improve utilization, retention, and adherence rates for these populations. Substance abuse and mental illness often co-occur with one another as well as HIV, and can be the underlying cause of other conditions that complicate HIV care, such as homelessness. Effective management of the HIV epidemic requires that the issues of substance abuse and mental illness be confronted by providing appropriate treatment to those who need it in care settings that are also equipped to provide HIV care.

Co-Morbid Infections

The most common medical co-morbidities associated with HIV are sexually transmitted diseases (STDs), hepatitis C virus (HCV) infection,



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