“Nobody’s Going to Say No to a Dollar”: Framing HIV Medication Diversion Through the Lens of Economies of Diversion

Abstract

People living with HIV (PLWH) experiencing chronic poverty may divert their antiretroviral therapy (ART) as an economic survival strategy, yet their lived experiences remain under examined. We conducted a phenomenological analysis of in-depth interviews with Black and Latino (N = 38) PLWH from two trials using the Intervention Innovations Team’s Integrated Conceptual Model (IIT-ICM), which centers systemic and socioeconomic inequities in HIV care. Participants (74% cisgender men; 84% Black, mean age 48 years) reported high rates of food insecurity (85%), unemployment (90%), and unstable housing (52%), moderate-to-high-risk substance use (57% alcohol, 52% cannabis, 48% cocaine), and 76% reported past substance use treatment. Through inductive analysis of participant interviews, we identified three interrelated diversion processes: (1) Commodification, the transformation of prescribed medication into a material resource within informal or underground markets; (2) Navigation, the strategic management of care and survival within and against institutional systems; and (3) Reorientation, shifts in how individuals relate to treatment and its value over time, shaped by changing material, health, and emotional conditions. We characterize these processes as the “Economies of Diversion” model. By framing ART diversion as a structurally driven adaptive strategy, this work reveals how socioeconomically marginalized Black and Latino PLWH reconcile ART adherence guidelines with urgent material demands. Findings highlight the need to integrate economic supports, expand pharmacy-based financial incentives as harm-reduction alternatives, adopt autonomy-affirming clinical approaches, invest in upstream social protections, and pair long-acting injectable rollouts with economic benefits. Importantly, the Economies of Diversion model may also apply to other forms of medication diversion.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10461-025-04924-3.

Introduction

The present study is a qualitative exploration of an under-studied phenomenon: HIV antiretroviral therapy (ART) diversion within pharmaceutical and community settings. Diversion of prescription medications is a known pathway through which structural vulnerabilities translate into health inequities [1]. Although diversion of opioids, benzodiazepines and insulin has received growing attention [2–4], diversion of antiretroviral therapy (ART) remains understudied.

In this qualitative study, we explore ART diversion in these settings to elucidate how redistribution practices may reflect and reinforce social and economic marginalization [5]. We also situate this inquiry in relation to systemic racism, health inequities, and punitive health care systems, drawing on structural competency scholarship [6], alongside an intersectional framework [7–9]. Together, these perspectives provide a lens for understanding how race, class, gender, and structural inequities interlock to shape health outcomes [10], positioning ART diversion not as an isolated behavior but as one emerging from compounded systems of marginalization.

Grounded in a phenomenological approach, this study centers the perspectives of Black and Latino people living with HIV (PLWH) who experience persistent low rates of engagement along the HIV care continuum and navigate HIV management in the context of chronic poverty [11]. Despite HIV medications being widely available in the United States (US), Black and Latino PLWH evidence the lowest prevalence of sustained viral suppression [12]. Barriers to viral suppression shaped by structural exclusion and social marginalization, processes that intersectionality scholarship has shown to be interlocking rather than additive [13], not only impede adherence but may also drive ART diversion, contributing to care disengagement and HIV viral rebound [11, 14].

ART diversion involves the unlawful redistribution of filled, partially used, or unfilled ART prescriptions into secondary unregulated markets. These transactions constitute a felony under US law which prohibits the unauthorized sale or distribution of prescription drugs [15, 16]. In this study, we advance the literature by centering the perspectives of Black and Latino PLWH living within chronic poverty, who have engaged in illicit sale of HIV medications, illuminating how diversion practices reflect broader tensions between survival, stigma, and structural exclusion.

ART diversion is often initiated by pharmacists, pharmacy technicians and physicians, who offer to pay PLWH to fill prescriptions, engaging even those not seeking it. Such providers have been implicated in schemes that issue unnecessary prescriptions, redirect diverted stock and sometimes reintroduce compromised medication into the legitimate supply chain [17, 18]. Additionally, community-based “pill brokers”, play a central role in ART diversion. While some pill brokers operate as intermediaries who target economically vulnerable PLWH, others are PLWH themselves who engage in brokering as a means of survival [16]. Pill brokers offer PLWH compensation in exchange for ART medications or prescriptions, which are then resold to other individuals, brokers, or pharmacies operating within fraudulent networks [15]. These networks appear to capitalize on structural exclusion by targeting buyers who may be uninsured, undocumented, or otherwise unable to access ART through formal channels, while others, such as complicit pharmacists, profit by diluting or splitting medication supplies (“cutting”), repackaging, reselling, or submitting fraudulent reimbursement claims [5, 15].

Although limited knowledge of ART diversion persists, it has been documented in at least seven states, with high rates reported in New York City, Atlanta, and South Florida [5]. In a 2013 South Florida study, 27% of the PLWH in their sample reported having sold or traded their ART medications [16], and in a 2015 multi-site survey of over 2,800 PLWH, 9% reported ever engaging in diversion and 7% reported diversion in the past year [14]. Federal investigations in 2012 uncovered diversion operations involving dozens of co-conspirators (e.g., pharmacists, medical providers and brokers) who collectively defrauded public insurance programs and undermined medication safety [18]. More recently, a Florida-based pill broker pled guilty to operating a multi-state scheme that trafficked over $16.7 million in misbranded and adulterated HIV medications, including Truvada and Biktarvy, which were diluted or tampered with before reintroduction into pharmacy supply chains and dispensing to unsuspecting patients [19]. These findings underscore that ART diversion can be widespread, organized and recurring, and linked to cycles of economic precarity and instability.

While ART diversion has been framed as a form of nonadherence or misuse, it may also reflect broader structural gaps in access to HIV treatment. Emerging evidence suggests that diverted ART is sometimes purchased by individuals in the U.S. who are uninsured, undocumented, or otherwise experience barriers to consistent medical care, as well as by buyers in countries with limited access to antiretroviral therapy [15, 20]. These dynamics indicate an informal redistribution system that emerges in response to inequities within and beyond formal healthcare systems, involving both the survival strategies of economically marginalized PLWH and the profit motives of intermediaries who may seek to exploit gaps in healthcare access. This underscores the importance of understanding diversion not only as an individual act, but as part of a larger survival economy shaped by structural barriers [2].

Scant literature links diversion with chronic poverty, housing instability, untreated substance use, depression, anxiety, and food insecurity [21, 22]. Yet, these intersecting conditions have the potential to drive decisions to sell or trade ART to meet immediate needs or maintain a sense of stability and dignity, even as such choices may undermine HIV treatment goals [15, 16, 23]. In our prior work with Black and Latino PLWH, participants spontaneously described engaging in ART diversion for a variety of reasons, including to pay for rent, food, substances, or to achieve a relative quality of life [24–26]. However, little is known about how ART diversion unfolds and shapes HIV treatment trajectories.

These broader systems of harm and survival suggest that ART diversion is not simply a straightforward or individual-level decision. At the same time, the consequences of ART diversion may reinforce health inequities, particularly along the HIV care continuum. Black and Latino PLWH who divert their ART may experience disruptions in adherence, leading to HIV viral rebound, loss of immune system protection, and the development of drug-resistant HIV [16, 27]. Buyers of diverted ART face risks of improper dosing, lack of clinical oversight, and exposure to degraded or tampered medications. These dynamics undermine public health goals such as treatment-as-prevention and universal viral suppression, particularly in underserved communities [21, 28]. At the system level, ART diversion compromises supply chain integrity and imposes financial costs through insurance fraud and Medicaid billing schemes. Taken together, these patterns raise questions about how Black and Latino PLWH experience the intersecting consequences of diversion and the systemic conditions that shape its occurrence [18].

Despite growing evidence of scope and harm, very few studies have explored the motivations, decision-making processes, and survival strategies underlying ART diversion directly from the perspective of PLWH themselves [2, 5, 15]. To our knowledge, limited research has considered these dynamics through an intersectional lens that attends to race/ethnicity, poverty, housing instability, and substance use as interlocking systems of oppression. In doing so, we build on intersectionality’s foundational insights that systems of race, class, gender, and sexuality are mutually constitutive rather than independent [29]. This framework suggests that ART diversion may be better understood not only as an individual choice or behavioral outcome but also in relation to structural arrangements that stratify vulnerability. To address this gap, we draw on in-depth qualitative interviews with Black and Latino PLWH who are long-time HIV survivors who have engaged in ART diversion. By centering their voices, we aim to shed light on the operational and emotional realities of diversion, the structural conditions that shape it and explore possibilities for compassionate and equity-focused interventions [30, 31]. Rather than pathologizing the behavior, this inquiry approaches ART diversion as a social and structural phenomenon, one that reflects the challenges of surviving and managing HIV in the face of chronic material deprivation and systemic exclusion.

This study is grounded in the Intervention Innovations Team integrated conceptual model (IIT-ICM), developed by our team to examine how structural, social and individual factors shape health outcomes among populations most affected by HIV [25]. The model integrates critical race theory, harm reduction and self-determination theory [32–34] and emphasizes “centering the margins”, recognizing any positive change and supporting autonomy in health-related decision-making [25, 26]. Building on this lens, we explore ART diversion from the perspectives of Black and Latino PLWH to understand how ART diversion affects well-being and HIV management, and explore the strategies participants employ to navigate, resist, or adapt to the systemic conditions that give rise to diversion [24].

Methods

Overview

The present study seeks to address the ART diversion knowledge gap by drawing on qualitative data with (N = 38) Black and Latino PLWH, collected during two larger parent studies conducted by our team. These studies, described in detail below, shared comparable eligibility criteria and methods, and both focused on Black and Latino PLWH who face barriers to engagement along the HIV care continuum. Although ART diversion was not a primary focus of either study, it was identified as an unexpected yet salient phenomenon across interviews. The depth and complexity of participants’ narratives around ART diversion warranted a focused analysis given its potential implications for HIV care and public health. Given the methodological and demographic similarities between the two studies, we elected to combine the relevant data to develop as comprehensive an account as possible of this underground phenomenon.

Parent Studies

Both studies enrolled Black and Latino PLWH who did not evidence HIV viral load suppression. Each was an intervention optimization randomized controlled trial (ORCT) guided by the multiphase optimization strategy (MOST) framework [35], with HIV viral suppression as the primary outcome. Both were conducted in New York City, but the studies differed in size, duration, and candidate behavioral intervention components. Study 1 (Heart to Heart 2; HTH2) was conducted from July 2016 to March 2022; Study 2 (Silver Community Action Project 2; SCAP2) from September 2020 to January 2022. HTH2 tested five candidate intervention components in a factorial experiment. From a larger sample of 512 individuals, participants were randomly selected across 16 experimental conditions to complete semi-structured, in-depth interviews at two time points (N = 46). SCAP2 also used a factorial design. From a sample of 87 individuals, participants were purposively sampled for qualitative interviews at two follow-up points, with attention to diversity in years since diagnosis, sex assigned at birth, and viral suppression at follow-up (N = 41). Full descriptions of both studies are available elsewhere [36–38]. From these 87 participants engaged in qualitative interviews across the two larger studies, a total of 38 referenced ART diversion, and they are the focus of the present study (approximately 44% of the full qualitative sample reported experiences with diverting their ART).

Study Procedures

Sampling and Data Collection Procedures

Interviews were conducted by study team members trained in anthropology and public health. Each interview lasted 60–90 min each, and some were conducted over the phone due to COVID-19 restrictions. The interviewers used a semi-structured interview guide. Participants received $30 as compensation for their participation. Additionally, both studies used quantitative data gathered during baseline assessments to describe the sample’s sociodemographic and background characteristics. Detailed descriptions of these structured measures are provided elsewhere [37, 38]. Qualitative interview data from both studies were audio-recorded, transcribed, coded separately, and then combined to identify themes.

The qualitative guides for both studies were similar, with two main parts. The research team developed the guides, which included experts on the HIV care continuum, poverty, sexual/gender minority status, and Black and Latino PLWH, and reflected the IIT-ICM, as described above. The first part elicited experiences with the respective ORCT and the acceptability and effects of specific intervention components. The second part focused on experiences with HIV management. Questions from both parts frequently yielded data on ART diversion and thus were used in the analysis. Examples of questions in the first part of the template included: (“What do you think about [intervention component]?”, “How could it be improved?”). Examples of questions in the second part included: (“In the past, do you think there is anything that has made it difficult for you to take HIV medications? Or that has made you not want to take them”) and (“Have you taken HIV medications since you joined [ORCT]? it’s OK if you haven’t, we just want to understand what’s going on with you now”). Probes about possible barriers included quality of housing, types of social support, financial resources, substance use, need to “hustle” to survive, and mental health. As noted above, selling ART arose in the parent study interviews when participants were asked about barriers to ART persistence, and as such, questions regarding experiences with selling ART were added to the interview guide for study 2 (SCAP2). The qualitative guides are included as supplemental materials. For parsimony, we provide the SCAP2 guide. The guide for study 1 (HTH2), which is similar, is available upon request.

Quantitative Measures

The present study also draws on quantitative data collected at the baseline assessment for each parent study to describe the sociodemographic and background characteristics of the sample (e.g., indicators of poverty, HIV related health factors, substance use treatment). We describe those measures in detail elsewhere [37, 38].

Data Analyses

Quantitative Data Analyses

Descriptive statistics, including frequencies and means, were calculated using R to summarize the socio-demographic and background characteristics of the sample [39].

Qualitative Data Analyses

Coding and analyses were led by an experienced team that included a medical anthropologist, a cultural anthropologist, and a social worker, all with extensive qualitative research expertise. The coding and analysis were supported by an interpretive community (comprised of research team members, not study participants) within the larger project. The interpretive team included individuals with HIV experience, from diverse racial/ethnic groups such as those from white, Black, mixed race, Asian, and Latino backgrounds; individuals across various gender identities including cisgender men and women, transgender and non-binary persons, as well as those representing heterosexual, gay, lesbian, bisexual, and queer sexual orientations [40].

The qualitative data analysis took place in the Dedoose platform [41]. The analysis approach was iterative, and the study team used a phenomenological analytic approach [42].The initial qualitative analysis for both parent studies are described elsewhere, where the initial list of “start codes” and their operational definitions are provided [37, 38]. These start codes reflected the parent study aims and were used as an initial organizational framework rather than as theory-driven constructs. The primary analysts re-analyzed the qualitative interview transcripts for the present study, focusing on descriptions of past or current ART diversion. The ART selling code was applied to the coding structure and grouped into broader themes and sub-themes through an iterative process. For the present analysis, coding was inductive: the ART selling code was newly applied and additional codes, sub-codes, and themes were developed iteratively from the data.

To establish rigor, the coding team engaged in iterative cycles of independent coding followed by consensus discussions, meeting weekly during the coding period to review code applications and refine analytic categories. The team further attended to the study’s trustworthiness by maintaining an audit trail comprising process and analytic memos and holding monthly debriefing sessions with the interpretive community which functioned as a mechanism for analytic triangulation and reflexive discussion [42, 43]. The team also attended to the potential effects of their positionality throughout the data analysis process through training and reflections on how their varying positionalities might affect the data analytic process [44].

Results

Sample

Participant sociodemographic and background characteristics are summarized in Table 1, representing data from two parent studies: HTH2 (58%, n = 22) and SCAP2 (42%, n = 16), with a total sample size of N = 38. The average age of participants was 48 years. The majority identified as male (74%), Black (non-Latino) (84%), and heterosexual (66%). Participants had been living with HIV for an average of 19 years (SD = 8.0), and nearly all had previously taken HIV medication (95%). Indications of poverty were notable, over half of participants (52%) were not living in their own home or apartment, indicating homelessness or housing instability. Most reported food insecurity (84%) and half reported running out of funds for basic necessities at least monthly in the past year (52%). Employment levels were low, with only 10% currently employed full- or part-time. Furthermore, approximately half reported moderate-to-high risk use of alcohol (57%), cannabis (52%), and cocaine (47%), and a substantial majority (76%) previously participated in substance use treatment. These findings underscore the complex socioeconomic and health-related challenges faced by this population.

Table 1.

Sociodemographic and background characteristics (N = 38) for black and Latino PLWH who did not evidence viral suppression at study enrollment confirmed via laboratory report

	Mean (SD) or %	N
Heart to Heart 2 (HTH2)	57.8	22/38
Silver Community Action Project 2 (SCAP2)	42.1	16/38
Age, in years	48.7 (9.01)
Median, [minimum, maximum], in years	48.0 [31.0, 60.0]	38/38
Race/ethnicity
Black (non-Latino)	84.2	32/38
Latino	15.8	6/38
Gender identity
Male, cisgender	73.7	28/38
Female, cisgender	13.1	5/38
Transgender, nonbinary, gender fluid	13.1	5/38
Sexual orientation
Heterosexual	65.8	25/38
Lesbian, gay, bisexual, queer	34.2	13/38
HIV-related Factors
Years since HIV Diagnosis	18.7 (8.0)	-
Median, [minimum, maximum], in years	18.5 [1.0, 37.0]	-
Has taken ART in the past	94.7	36/38
Mentioned experience with selling ART	100	38/38
Current housing circumstances
Not in own home or apartment (e.g., living in congregate facility housing/SRO, shelter, or other unstable housing)	52.6	20/38
Indications of poverty
At least one indication of food insecurity	84.2	32/38
Currently employed full- or part-time	10.5	4/38
Ran out of funds for basic necessities monthly or more in past year	52.6	20/38
Substance use
Alcohol Use at a Moderate-to-High Risk Level	57.9	22/38
Cannabis Use at a Moderate-to-High Risk Level	52.6	20/38
Cocaine Use at a Moderate-to-High Risk Level	47.4	18/38
Participated in substance use treatment in the past	76.3	29/38

Participants are from one of two parent studies, HTH2 which was conducted between 7/2016-3/2022 and SCAP2 which was conducted between 9/2020-1/2022 in new York City

Qualitative Results

Overall, participants framed ART diversion as a necessary, though often emotionally fraught, response to the structural constraints of chronic poverty, emphasizing survival amid intersecting pressures including systemic racism, housing instability, food insecurity, limited income, and punitive healthcare systems. Selling ART was not viewed as disengagement from care, but as a strategy to preserve overall well-being and meet basic needs. While some participants sold ART to support substance use, others diverted ART in the absence of substance use or continued selling their ART after reducing or eliminating substance use, underscoring its role as a survival strategy. Participants described feeling caught in a double bind: taking HIV medication as prescribed could protect their health but might leave them without the means to survive or to feel human in the present moment; while selling it allowed them to meet their needs, albeit at the cost of their health. Importantly, they described using this income not only to procure substances or essentials such as food and rent, but also to access moments of dignity, pleasure, and normalcy, which, amid chronic economic deprivation and racialized marginalization, felt vital to sustaining a sense of self. These decisions reflected a painful trade‐off shaped by structural forces that constrained participants’ autonomy. Even within these constraints, many employed creative strategies to manage competing demands.

Through inductive, phenomenological analysis of participant interviews, we identified three core, interrelated processes: (1) Commodification, the transformation of prescribed medication into a material resource within informal or underground markets; (2) Navigation, the strategic management of care and survival within and against institutional systems; and (3) Reorientation, shifts in how individuals relate to treatment and its value over time, shaped by changing material, health, and emotional conditions. We characterize these processes as the “Economies of Diversion” model (see Fig. 1 below). We use the term Economies of Diversion not as an economic model of rational resource allocation, but as an interpretive framework grounded in participants’ accounts that situates ART diversion within survival-based systems shaped by structural inequities. Each process encompasses multiple themes that reflect participants lived experiences and strategies related to ART diversion.

Fig. 1.

Economies of Diversion: a participant-informed conceptual model for understanding the interrelated processes of ART diversion within the broader context of chronic poverty. Double-headed arrows indicate that commodification, navigation, and reorientation are interrelated processes, with movement possible in either direction

The following sections present these eight interconnected themes aligned with the Economies of Diversion model’s three core processes: commodification, navigation, and reorientation. Themes illustrate how Black and Latino PLWH managed ART diversion in relation to structural conditions, offering insights into health engagement, economic survival, and personal agency. The first process, commodification, includes three themes that illuminate the survival-based, systemic, and often exploitative conditions shaping participants’ decisions to sell ART. We use the term commodification not in a strict economic sense, but as an interpretive frame to capture how participants themselves described ART as both a treatment and material resource embedded within survival economies. This process includes: (1) Material survival strategies, where ART functioned as a form of currency amid pressing financial needs and participants weighed adherence against the financial relief selling provided; (2) Substance use and economic survival, where diversion was used to sustain substance use and, for some, remained an income stream even after substance use had ceased or shifted; and (3) Exploitation, which reflects participants’ experiences navigating relationships with pharmacies and pill brokers, often receiving inadequate compensation for high-value medications, underscoring broader devaluation and limited agency. The second process, navigation, captures participants’ use of 4) stretching ART (e.g., stretching medication to remain undetectable while creating surplus to sell); 5) provider scrutiny, reflecting experiences of institutional surveillance and coercion (e.g., directly observed therapy); and 6) perceptions of long-acting injectables (LAI), a formulation of ART administered by injection every 1–2 months in place of the daily pill, which some viewed as more convenient and others as a threat to economic survival. The third process, reorientation, describes conditions in which participants were less inclined to sell, including 7) perceived economic stability (e.g., gaining stable housing, income, or support) and 8) aging and HIV survivorship, which led some participants, as they aged, to view their health through a different lens. Together, these themes illustrate participant-driven definitions of care engagement, showing that ART diversion was, for many, a response to poverty, survival needs, and the desire to exercise autonomy over their health, economic security, and overall well-being. We characterize these processes and their interrelated themes as the “Economies of Diversion” model (see Fig. 1). Importantly, while developed in the context of ART diversion, this model offers a conceptual framework that may be applied to other forms of medication diversion (e.g., opioid, insulin) which may likewise be shaped by structural exclusion.

Commodification

Material Survival Strategies

Participants pointed to a number of contextual factors that made HIV management more difficult, including structural challenges such as frequent and often unpredictable food and housing insecurity. Participants also reported experiencing a conflict between meeting basic needs such as food, toiletries, transportation, and clothing, on one hand, and taking ART and maintaining one’s health, on the other. Therefore, complete ART adherence and viral suppression were seen as part of a larger balancing act which often resulted in outcomes that aligned with either only one or neither of these goals being met. Participants described a double bind wherein selling their ART addressed their material needs but compromised their health.

It’s not really a second income, but it’s definitely a booster. I’m not saying that selling your pills is what you should do. That’s like a horrible thing to do because you need it for yourself, but if you’re in a bind….

Despite the belief that selling ART was in principle “a horrible thing to do,” many participants emphasized that during times of financial hardship, options were nonetheless considerably limited, often resulting in decision-making processes that caused anxiety, guilt, and frustration. For some, having cash in-hand from diverting their ART was necessary to meeting their immediate financial concerns.

It is tough, you know, when you’re getting all that money. You know, you’ve got it in your hand, you’re like, hey, that’s four or five hundred dollars right now I could get. You know? That would get me out of this jam easily, get me straight.

For such participants, the conflict between being healthy by adhering to ART and affording basic life necessities such as home maintenance is clear. For others, this conflict eventually became less of an issue, as they began to “give up” on adhering to ART altogether.

Well, I just gave up [on taking my medications]. And money was hard, people pay for meds, and I needed money. Sometimes I needed the money not so much for recreational use, for drugs or nothing, sometimes I just needed money for food. Or some things I needed in the house, toiletries. So, I just said, hey, [I miss a month], I just sell a bottle.

Participants also described how the financial incentives offered by local pharmacies and others often seemed more pragmatic than ART adherence.

The pharmacy – I don’t know. It’s not only the buyback, but I get a hundred [dollars] just for filling it. And then I’ll sell them for 200 [dollars] on the street. So, I mean, you can have all the best-made plans in the world, but the second money hits you – your – hits your pocket, those plans become complicated.

Many noted the relative ubiquity of pharmacies that offered incentives to customers who filled their ART prescriptions there. These incentives often took the form of informal “buyback” offers, where participants were given additional money, often between one and five hundred dollars, if they were willing to part with their monthly medication. For these participants, the availability of much-needed funds often played a significant role in their decision-making related to ART diversion and adherence.

What’s going on is that everyone wants to buy your pills, and then to me I’m like that’s – if I need some money I’m not going to lie I’ll go sell a bottle here or there…I have a house to maintain.

Against this backdrop of competing needs, struggling to make ends meet and to maintain an acceptable lifestyle frequently presented itself as requiring a complex, dynamic, and individual calculus within which ART adherence often became exceedingly difficult.

Substance Use & Economic Survival

Substance use was common in the lives of many participants, including periods of heavy use. For these participants, the ability to understand and navigate the phenomenon of ART diversion in a large metropolitan area meant relatively easy money. Despite the stated overall goal of being healthy and sustaining undetectable HIV viral load, some participants described times during which selling ART to support substance use became almost second nature, particularly during periods of heavy and/or chaotic substance use.

So, within the eight months what was happening was, alright so every month I would get the prescriptions, and I’d sell my medicine and I would [laughter] I feel so bad. I would run down the street, and I’d buy a whole bunch of drugs and I’d go to the park, and I’d just literally just get high until I couldn’t function. Like literally I’d be stuck, and that’s what I was doing, you know, for them eight months.

For some participants, the very idea that motivation to sell HIV medications for anything other than for substance use seemed highly unlikely, highlighting the degree to which ART diversion and substance use were connected in many participants’ minds. As was the case with the need to make ends meet financially, the need to procure substances frequently found itself at odds with the desire to take ART with high levels of adherence and achieving suppressed HIV viral load, leaving many participants in an exceedingly difficult position.

But make no mistakes about it, the temptation [to divert ART] is fucking great. And I’m only dealing with less than a week doing the right thing. I’m not getting high, I’m taking meds and everything, just living normal, normal-ish. This is the first time I’ve gone this long, ever. I mean, there’s moments in a day where I feel awesome. But there’s moments in a day where I ask myself why the fuck I’m kidding myself. So, the devil and the angel are definitely hard at work on my shoulder.

However, even after participants reduced substance use to non-hazardous levels or stopped using substances, ART remained a critical income source. Participants describe that it was hard to give up the extra source of income once they knew it was available to them, particularly in the context of pressing financial needs. Indeed, funds from ART diversion were often described as essential to meeting daily needs, despite participants wanting to maintain optimal health by adhering to ART.

It’s either choosing to take the meds and stay financially twisted, because that $350 is my biggest check in the month from the medicine I sell. And I need the money. And I’m no longer using hardcore drugs… though when I was using hardcore drugs, I was selling it and spending it all. Now I need my money so I can just eat and do my regular household stuff like my laundry and go to restaurants that I eat at… You know? $350 makes a big difference.

Exploitation

Nonetheless, even receiving a few hundred dollars for their HIV medications left some participants feeling exploited at the intersection of poverty and racism. Participants expressed frustration that they were offered less than $300 for their monthly ART, despite knowing that these medications can retail for over $4,000 per month in the US. This stark discrepancy contributed to a sense of being undervalued within both the healthcare system and the informal economies surrounding ART diversion, systems that often left participants feeling surveilled, constrained, or economically taken advantage of.

Oh, please, what they’re actually getting for this medication is a fucking rip-off. Yeah, my shit actually costs $3300 or so, yet I can only make 10% of that.

While some participants acknowledged that the health risks of ART non-adherence outweighed the financial gain of selling their own medication, they still described acting as brokers for others. Even in the context of acting as a broker, participants acknowledged that the amount of money they could make facilitating selling ART was significantly less than the actual cost of the medication.

I think the cheapest bottle is two thousand dollars, you know?

However, serving as a pill broker allowed them to maintain some economic stability without compromising their own health, but also reflected the difficult moral calculus participants navigated within a system shaped by structural racism and economic scarcity, where limited options forced them to choose between supporting their well-being and facilitating pill brokering practices that could jeopardize others.

I’m not going to lie, I’ve got dumb asses that will be like yo, call your friend for me…and then give me their medication for $100- $160 and I will [sell it] and walk away with $20-$60. They call because they are so thirsty to get money for drugs… you know what I’m saying? I got a family, and I got to eat too. So, if I can make money off of you, I’m not going to say no. Nobody’s going to say no to a dollar…So a hustle is a hustle. I’m fucking sorry but hey, this is how it goes. You want to be stupid enough to sell your shit? All right, come on.

Navigation

Stretching ART

Several participants described a strategy to balance financial and medication needs, which involved “stretching a bottle” of ART by skipping some of their daily medication doses, contrary to their prescribed regime. This approach allowed them to prolong the duration of their monthly prescription, maintain HIV viral suppression, and simultaneously generate an opportunity to sell the surplus medication. This strategy was described by participants as a ‘win-win’ scenario, as it allowed them to sustain HIV viral suppression, or, at least, reduce their HIV viral load levels, thus maintaining their health, while also alleviating financial strain.

I’m still doing the same shit with Atripla…how Houdini say…voila! I’ll take one in two days, one in one day, one in three days… And that means when it’s time for my refill, I still got like 14, 15 pills left. And I made $1,000 when I sell that shit. And I can still be undetectable. That’s what I aim for, you feeling me?

Participants recalled the moments they realized they could sell a portion of their medication to pay for bills and other basic necessities yet still maintain an undetectable viral load level.

That’s definitely what opened my eyes as to the fact that I can still maintain undetectable status, like that’s how I realized this, because I was trying to stretch my bottle.

Participants also described stretching their medications as a way of mitigating perceived long-term adverse effects of taking ART, while addressing economic hardships.

Well, you know, when you need money… and once my kidneys failed, I thought it was too much medication, the medication was too hard on me. So, I just chilled out on taking it [ART], because I wanted my kidneys to build themselves back up.

For these and other participants, deciding whether or how to stretch their ART in order to sell the surplus involved a complex decision-making process which involved the contradictory goals of making financial ends meet and maintaining their health as optimally as possible.

Provider Scrutiny

Participants described feeling racially profiled by their providers due to inconsistent ART use, a lack of HIV viral suppression over time, and/or past or current substance use behaviors. Some reported racially biased actions by healthcare providers such as threatening to withhold medication or implementing measures that would make participants’ ability to sell their medication highly improbable. Measures included puncturing seals on medication bottles to render them worthless for diversion, administering ART in blister packs which hold little value on the illicit market, and requiring Directly Observed Therapy (DOT), in which participants are made to take each dose in the presence of a healthcare professional.

[After being threatened with DOT] She put me on a pill incentive which meant I had to come in every day! I said, “Yeah; I’m not taking a bus every day to come in and take a pill. Are you crazy?” I’m saying, “I’ll change hospitals.” I told her, “If you start doing that, I’ll just change hospitals. I’ll go to a whole different hospital.

Many participants reported diverting ART to support past or current substance use patterns. They frequently worried that disclosing either substance use or engagement in ART diversion might jeopardize their relationship with their healthcare provider, especially given experiences of racial bias in clinical settings. They feared this would undermine their autonomy with respect to how, where, and when they are able to procure their medication, regardless of diversion intent. They even hesitated to discuss ART diversion during the qualitative interviews for the present study out of fear of legal repercussions.

I sold it twice. Years ago. Statute of limitations is up. I was having problems. I sold them. I mean, now that’s over, so let’s move on.

For some participants, this meant having their substance use program insist on only sending ART prescriptions to pharmacies that they knew were not in the practice of offering incentives and/or for buying back HIV medications:

My [substance use] program actually did that for my health, you know, they said, “Well you going to that pharmacy, using the pharmacy. Sometimes you sell your medications. So that pharmacy is really no good to you or your health. So, we’re going to help you help yourself by mandating that you use our pharmacy or you can’t come back.

Other participants described how some of their peers had been limited to only being prescribed ART in blister packs, which, as noted above, are far less valuable in illicit markets.

But you know, I know a girl who – they cut off her HIV meds. They wouldn’t give her, her HIV meds, because she had been selling it. Because she kept coming back for more or whatever. I don’t know what the reason was, but they’re doing it, and they cut her off and then they gave it to her in like a bubble pack, which was harder to sell.

And while not every participant experienced these measures as judgmental, racist, or punitive, many expressed deep concerns regarding the limiting of their own agency with respect to HIV and other medical healthcare decisions, which in turn led to interruptions in their ART adherence.

Perceptions of Long-Acting Injectables (LAI)

Participants also shared their thoughts on the potential benefits of long-acting injectable (LAI) HIV medications, particularly the convenience and efficacy associated with less frequent dosing. However, some expressed concerns regarding the financial implications of transitioning from daily oral ART to LAIs. As has been noted, for many participants the ability to divert a portion of their oral medication represented a critical financial resource, helping them to meet economic needs, as well as the ability to experience pleasure and fun in their lives.

No, I wouldn’t [want LAI] because then I couldn’t get my money with the pharmacy; not selling that medicine, the pharmacy. Getting my $100, every month. That’s my party money. Yeah, I don’t want to take injectables. I’m going to get my $100 a month then. I need that.

The shift to LAI, which is administered under medical supervision, does not provide surplus medication and thus an opportunity for diversion and would eliminate this possibility entirely.

I might be willing to do that. I’m not crazy about needles, but…once a month? Yeah, I’d try that. Because it’s not something that you have to worry about every day – getting up and taking the pills, you just take one shot for the month…Yeah, I might do that. I mean, it could work, but …if you get that shot, then you’re not getting the physical pills to exchange for cash. You see what I’m saying? If I take that shot, then that means I don’t get the pills no more and then that means I’m losing my $300 every month.

Considering the potential negative health effects of not taking ART, participants acknowledged that if their health declined significantly and taking LAI became necessary for recovery, they would be willing to take it. While the clinical advantages of LAIs were clear, many remained wary of losing a vital source of financial support, highlighting the complex relationship between health management and economic survival.

Like I said, if it got to the point where it was necessary for me – absolutely necessary [to take LAI] – like say if my viral loads were in the millions and my T-cells were all the way down, and it was like I’ve got to take it to try to get back up, then I would do it. But right now….

However, some participants reported appreciating the health benefits of LAI, such as convenience, reliability, better adherence to ART, and consistent viral suppression, and described a commitment prioritizing their health.

I mean it would definitely show a person if they really were concerned about their health…or they just wanted the pills to sell them because now I like to work for my money, so I’ll take the shot over the pills any day.

Some participants were even more positive about their willingness and desire to consider LAI, citing their desire to live a longer and healthier life as the primary driver of this decision.

Oh, I would absolutely take an injectable, in a heartbeat. Yeah, now I really want to live, I don’t want to die.

Overall, participants described ongoing trade-offs between financial necessity and optimal health management. While some remained concerned about losing a crucial financial strategy by transitioning to LAI HIV treatments, others, who described achieving a perceived level of financial stability after previously selling their oral ART, showed a readiness to embrace LAIs. This readiness was largely motivated by the health benefits that consistent medication adherence could offer. The willingness to adopt LAIs among those who described precarious financial stability reflects broader systemic challenges rather than merely personal choices and highlights how chronic poverty can constrain health management options.

Reorientation

Precarious Stability

Participants provided insights into their decisions to either stop or reduce selling their ART. For these participants, achieving a sense of stability in various aspects of their lives, including obtaining supportive, racially inclusive housing outside of the shelter system, part time employment, increased family or social support, and a reduction in material risks were cited as pivotal reasons for this shift in thinking and behavior. Notably, these shifts were often accompanied by a significant reduction in substance use behaviors. Some participants described moving into higher quality and better resourced single residency occupancy (SRO’s) as their achievement of stability, and as the main reason why they were able to reduce their substance use, which in turn reduced their need to sell their ART.

If I were in a typical crack-infested SRO, there’s a possibility my story will be different. There’s a definite possibility, but I’m not gonna take the credit away from myself because if I wanted to get high, I would be high, but I’m sure that probably would have influenced me to some degree, especially if I would have ran into the right male that fits my crackhead persona. I might have made different choices.

Others described how gaining part-time employment helped them pay their bills, which in turn allowed them the freedom to prioritize their health. They credited their employment as key in reducing their substance use and therefore the need to sell their ART.

I can’t imagine how washing cars is going to knock the crap out of me, too, but [laughs] I got to do something. This means a better way of making some money, better than that stupid crap like selling my medication, you know. And among other things, there’s always the drug factor. I get high once in a while, you know and it doesn’t help because that’s a real attraction like, mentally, you know. But that’s got to stop, and it will stop as long as I’m making some other money, you know.

Additionally, some participants described finding local pharmacies who provided financial incentives for simply filling their ART medications, rather than offering to buy the ART from them. These pharmacies were described as those that did not want to buy participants’ ART, but rather that wanted to provide the participant with a financial reward for filling, and hopefully taking their ART. The provision of financial incentives by pharmacies to encourage medication adherence played an important role, offering a direct benefit that met some of participants’ financial needs, thus reducing the need to sell ART.

I was tempted to sell my ART, but I didn’t because my pharmacy already gives me money to keep it. They pay you $100 to take your medicine. So that’s another incentive, I don’t need to sell it, because I have the money. I was selling it because I wanted to use drugs. But now that the pharmacy pays me to fill it, I don’t sell it, so that’s good for me.

Other participants described these pharmacies’ incentives as a legal bonus which has helped them no longer need to sell their ART.

At the same time nowadays, you don’t have to sell your medication. They have pharmacies that will give you incentive. My pharmacy gives you $50 every time I get my refill. I turn my medication in, and I get cash. It’s like a business promotion. Come to my company or my coffee shop and you buy a cup of coffee, you get one free. That’s a legal incentive.

Other participants described reconnecting to supportive family members as a means of achieving emotional stability, which in turn contributed to their desire to improve their physical health. Participants noted that not everyone has the support and love they see as needed in order to want to stay healthy.

And some people are not strong enough to do that, or they don’t love themselves enough to do that. You know, I have support. I have you guys. I have my family, my brothers. Everybody’s telling me they needed me around. And some people don’t have that, you know? Some people just like, I don’t care. I’m going to just go out. Like this. They don’t have that extra love, give them that boost, support.

Overall, participants described achieving stability in housing, financial, or social domains as having a profound influence on their health and HIV care management decisions. Stable, safer public housing options free from racial discrimination, consistent employment, family support, and supportive pharmacy programs were identified as pivotal factors that allowed participants the freedom to prioritize their health. These conditions also helped participants to stop or reduce their substance use, which further contributed to a desire to take their ART consistently. Participants illustrated how an improvement in their financial circumstances led to improved health and reduced the financial need to sell their ART as a coping strategy. Indeed, pharmacy-led economic interventions which support participants in sustaining ART use was described as a pivotal factor. Their narratives reflect the interconnectedness of socioeconomic stability and effective HIV management, highlighting the critical role that supportive environments play in enabling individuals living with HIV to focus on their health and overall wellbeing.

Aging & HIV Survivorship

Lastly, some participants also emphasized looking at their health through a different lens as they aged, noting that the risks associated with selling ART, such as inconsistent dosing and potential and actual health decline, no longer justified financial relief. This change in perspective highlights a critical turning point wherein the overarching health benefits of consistent ART intake have become paramount, particularly within the context of decreased precarity, getting older, stopping or reducing substance use, and experiencing significant health effects. Many participants described a substantial history with selling ART and engaging in substance use as something they no longer wanted to participate in, noting that as they were aging, they were increasingly concerned about their health.

I’ve done it before, but the money don’t outweigh my peace of mind, my health. I’d rather have my health and not be walking around in pain than have the money and spending it on drugs and stuff. That’s not cool no more. I used to do that. I’m getting too old, and now, I’ve got to maintain it because all the money in the world don’t matter if you haven’t got your health.

Other participants cited concerns about declining CD4 counts, which are a key indicator of immune system health in PLWH, as a reason they had decided to stop selling their ART. One participant described a unique visual strategy that encouraged them to take their ART consistently.

That was exactly four months ago. I didn’t sell my meds because now I need to take them. My CD4 count was at 1100, and then it was 600. “Oh, hell no. We’ve got to get it back up.” Now I am undetectable. Because when I realized that my CD4 count was going down? And my viral had shot up so high? I told myself, “I’m not selling my meds.”

Others described no longer wanting to sell their ART after experiencing health scares in the context of opportunistic infections. This participant described an opportunistic infection which caused visible marks on their face. They describe that their skin is now improving since taking their medication, which instilled in them a desire to take their ART consistently moving forward.

But you’ve got to want to get healthy too, you know? If you can’t take care of yourself… like yeah, it’s a lot of money, but my health is more important, I want to live. I feel better, my skin is better, I’m taking my meds, like, hell yeah. I used to have some spots on my face because like when your T cells are down you can catch anything easily. Your body won’t be able to fight it off, it takes you right out. Finally, I was like, money comes and goes. But my health isn’t always going to be there. So let me get my health right and I can get money later down the line, when I’m well again. That’s my attitude.

Overall, participants described a focus on their health due to the acute awareness of the health consequences associated with irregular ART use, in the context of opportunistic infections for some. Some participants described significant health incidents, including those with visual impacts, as key factors which influenced their desire to develop a consistent ART regime. Furthermore, as participants grow older within the ongoing constraints of chronic poverty, their growing health concerns compel them to reconsider the balance between their economic wellbeing and the imperative of continuous health management.

Discussion

By grounding our intervention and collaborative work with participants in the Intervention Innovations Team Integrated Conceptual Model (IIT-ICM) [25], we established the trust and rapport necessary for candid dialogue about ART diversion. Our findings provoke three critical questions about how structural forces reshape HIV care.

First, when a life-saving medication becomes a form of currency, what does this reveal about the nature of existing clinical and social systems? Participant descriptions of pharmacy “buy-back” schemes and coercive dispensing protocols illustrate how systemic neglect, racialized surveillance, and gaps in social protections co-produce ART diversion as a rational, adaptive strategy, rather than an isolated failure of individual adherence. This reframing compels us to interrogate and redesign anti-racist, equity-driven interventions that dismantle exploitative practices and disrupt the commodification of ART.

Second, how can structural competency be woven into care to move beyond one size fits all adherences models (i.e., “every dose, every day”)? Participant descriptions of stretching a bottle underscore that adherence cannot be separated from material need. Building on the IIT-ICM and structural competency, we must ask what dispensing approaches might support viral suppression without forcing patients into diversion? Care models informed by structural competency might consider incorporating flexible dispensing strategies, such as advance buffer supplies, micro-refills, and integrated financial navigation, to align viral-suppression goals with patients’ economic realities. Equally important is the cultivation of a clinical environment in which ART selling can be discussed without moral judgment. By normalizing conversations about diversion, providers have the opportunity to reduce stigma, encourage disclosure, and offer harm-reduction–informed support. Provider training curricula rooted in IIT-ICM principles should encompass the structural and economic determinants of ART selling and aim to equip clinicians with nonpunitive communication techniques and practical interventions.

Third, what triggers reorientation away from diversion, and how can harm-reduction interventions be optimally designed and timed to catalyze these shifts across diverse settings? Participants reported that stable housing, direct cash stipends, and long-acting injectable formulations often precipitated decisive shifts back to full adherence. These observations suggest that reorientation depends on well-timed, integrated economic and clinical supports that validate autonomy and resilience. Future interventions might consider coordinating services across clinical, community, and policy domains to harness these catalysts and sustain engagement.

Beyond these immediate clinical and material drivers, the economics of ART diversion cannot be fully understood without considering the broader pharmaceutical and insurance structures that shape access to HIV care. High drug pricing and restrictive insurance policies, including formulary limitations, prior authorization requirements, and cost-sharing burdens, create systemic pressures that make ART a valuable commodity within informal economies [45]. For participants navigating chronic poverty, these structural cost barriers amplified the material value of ART and reinforced its circulation as currency [5, 16]. In this sense, diversion emerges not only from local economic survival strategies but also from macro-level health financing systems that determine the affordability and distribution of ART [46, 47]. Interventions that address diversion must therefore be linked with policy reforms around drug pricing and insurance equity to reduce the structural conditions that render ART simultaneously scarce and commodifiable [48, 49].

The existing literature provides partial insights but leaves significant gaps. Prior studies have documented how punitive medication surveillance erodes patient–provider trust [14] and how economic precarity drives ART diversion [20]. We extend this scholarship by demonstrating that surveillance itself catalyzes commodification, that is, participants sell ART not out of defiance but as a rational adaptation to coercive pharmacy practices. Research on chronic illness self-management highlights the importance of patient choice in regimen design [50], yet no investigations to our knowledge have explored how navigation tactics such as dose stretching function as autonomy-affirming strategies. Likewise, harm-reduction programs demonstrate the efficacy of wrap-around supports [51], but their impact on medication diversion remains under-examined. By linking long-acting injectable roll-outs with economic stipends, we identify a novel intervention strategy that warrants empirical evaluation.

Our dual theoretical framing contributes to both adherence research and intervention science. By embedding the IIT-ICM principles within our study design, we created the conditions for participants to disclose ART diversion as resistance rather than failure. Mapping these disclosures onto the Economies of Diversion model yields a comprehensive, multi-level framework in which commodification captures how structural inequities convert ART into currency, navigation reveals autonomy-driven strategies that reconcile clinical goals with material need, and reorientation identifies the supports that enable sustainable re-engagement in care. This integrative lens, offered not as an economic model of rational resource allocation, but as a participant-informed interpretive framework of survival-based systems, moves beyond deficit-based adherence models and offers a transferable framework for other contexts, such as insulin or opioid diversion among marginalized populations [3, 4].

Limitations

The findings from our study should be considered alongside important limitations. First, the analysis was conducted in a single urban context and focused on the experiences of Black and Latino PLWH living within chronic poverty. While this perspective is critical for understanding diversion in structurally marginalized communities, it may not fully capture experiences across other geographic or socioeconomic contexts. Second, this was a secondary analysis of two parent studies that were not originally designed with ART diversion as their primary focus. Although this approach yielded valuable insights into diversion dynamics, a larger study designed specifically around ART diversion could explore additional dimensions in greater depth, including regional variation, healthcare system factors, or differences across medication types. Together, these limitations clarify the scope of our findings while highlighting opportunities for future research to further refine and extend the Economies of Diversion model.

Implications

Looking forward, both empirical and applied research can build on these insights. Table 2 (below) summarizes actionable study implications organized by the three core processes of the Economies of Diversion model (commodification, navigation, reorientation) onto specific clinical, policy, and structural strategies. Organized by setting, the table highlights how addressing material needs (commodification) through economic supports and upstream social protections can reduce diversion; how autonomy-affirming and harm-reduction practices (navigation) in clinical and pharmacy contexts can sustain adherence; and how shifting from punitive to structurally competent policies (reorientation) can rebuild trust and facilitate participants’ transition away from diversion. In doing so, it translates participants lived experiences into multi-level recommendations for equitable HIV care. Implications are grounded in harm reduction principles and informed by participant insights on ART diversion as a pragmatic approach to navigating unmet needs within inequitable systems.

Table 2.

Implications for HIV care, policy, and structural intervention across settings: application of the economies of diversion model

Category	Key Insight	Implication	Setting
Commodification	ART functions as currency when material and symbolic needs are unmet (e.g., housing, food, substances, and pleasure).	Integrate economic supports (transportation stipends, housing referrals, financial navigation) into HIV care programs as harm reduction strategies that reduce the need for diversion.	Clinical
Commodification	Economic precarity drives the informal economy of diversion.	Invest in upstream social protections (e.g., public housing, guaranteed income pilots) to ameliorate chronic poverty among Black and Latino PLWH.	Policy + Structural
Commodification	Diversion signals impeded needs, not moral failure.	Reframe diversion as a structural equity issue that requires multi-level solutions rather than individual blame.	Cross-Setting
Navigation	Provider surveillance (e.g., DOT, blister packs) disrupts both adherence and diversion management.	Adopt harm reduction, autonomy-affirming clinical approaches (e.g., shared decision-making, flexible adherence plans) and expand pharmacy incentives that respect participants’ agency.	Clinical
Navigation	Pharmacy-based legal incentives reduce diversion and support adherence.	Scale up pharmacy-based financial incentive models (e.g., cash, gift cards, or transport vouchers) as harm-reduction–informed alternatives to illicit diversion.	Clinical
Navigation	Transitioning to long-acting injectables (LAIs) may disrupt informal diversion income streams.	Pair LAI roll-outs with economic supports (e.g., cash transfers, housing subsidies, job training) as harm reduction strategies to offset lost diversion income and support continued engagement in care.	Clinical + Structural
Reorientation	Criminalization deepens mistrust without addressing the root causes of ART diversion.	Shift from punitive policies to structurally competent, harm reduction approaches that recognize diversion as a pragmatic response to unmet needs.	Policy
Reorientation	As stability improves (housing, income, social supports), participants shift away from diversion.	Develop participant-informed interventions that combine economic empowerment, emotional support, and culturally tailored education to support transitions out of diversion.	Cross-Setting

While developed in the context of ART diversion, the Economies of Diversion model holds potential for understanding other systems of drug diversion shaped by structural inequity (e.g., insulin, opioids, benzodiazepines, stimulants). Its emphasis on the dynamics of diversion, including commodification, navigation, and reorientation, offers a transferable framework for examining how individuals respond to unmet needs in ways that may conflict with institutional expectations or medical guidelines. As such, the model can inform structural interventions and equity-focused strategies across healthcare systems managing the distribution of high-value or tightly regulated medications.

Conclusion

In this IIT-ICM informed phenomenological study with Black and Latino PLWH living within the context of chronic poverty, we identified three interrelated processes (commodification, navigation, reorientation) which we characterize as “Economies of Diversion” model, which shows how ART diversion operates as a structurally driven survival economy. Ultimately, nuanced and compassionate understanding of ART diversion is needed, one that acknowledges its role in the survival economies of Black and Latino PLWH experiencing chronic poverty. Rather than treating ART diversion as a barrier to care, it should be seen as a signal of unmet material and emotional needs alongside an enduring commitment to viral suppression. Economic empowerment interventions, when coupled with autonomy affirming, harm-reduction clinical practices and structurally competent policy design, offer a path forward not only to reduce diversion but to promote long-term engagement in HIV care on terms that affirm both health and self-determination.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

SRC, RM, and MG conceptualized the purpose and design of the study. SRC wrote the first draft of the article with regular feedback from RM and MG. SRC and RM co-led the qualitative analysis. MG acquired the funding for this study. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The study was sponsored by the National Institute on Drug Abuse (NIDA, R01DA040480) at the National Institutes of Health, supported by the Center for Drug Use and HIV Research (CDUHR) at the NYU School of Global Public Health (P30DA011041; Holly Hagan, Ph.D., Principal Investigator). Analyses for this study were additionally supported by grants from the National Institute of Mental Health (NIMH, P30MH43520, T32MH019139) awarded to the HIV Center for Clinical and Behavioral Studies at Columbia University and the New York State Psychiatric Institute.

Declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical Approval

Procedures were approved by the Institutional Review Board at the New York University Silver School of Social Work.

Consent to Participate

Participants gave informed consent for study activities.