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. Author manuscript; available in PMC: 2022 May 1.
Published in final edited form as: AIDS Care. 2020 Aug 24;33(5):623–632. doi: 10.1080/09540121.2020.1808163

Symptoms of Generalized Anxiety Disorder as a Risk Factor for Substance Use among Adults Living With HIV

Zachary L Mannes 1, Eugene M Dunne 2,3, Erin G Ferguson 1, Robert L Cook 4, Nicole Ennis 5
PMCID: PMC7902737  NIHMSID: NIHMS1620941  PMID: 32835502

Abstract

This study examined the association between symptoms of generalized anxiety disorder (GAD) and substance use among 932 people living with HIV (PLWH) in Florida. PLWH completed a 45-minute questionnaire assessing demographics, symptoms of GAD and depression, and use of substances including alcohol, cigarettes, marijuana, crack/cocaine, and injection drugs. The GAD-7 measured symptoms of anxiety and participants were categorized as experiencing none/mild anxiety (score 0-9) or moderate/severe symptoms (score ≥10). Adjusted binary logistic regressions assessed the association between moderate-severe GAD symptoms and substance use while controlling for covariates, including depressive symptoms. Approximately one-third (31.4%) of the sample reported experiencing moderate/severe symptoms of GAD. After controlling for covariates, PLWH with moderate/severe symptoms of GAD had greater odds of reporting current cigarette use (AOR=1.70, 95% CI=1.18-2.45 p=0.004), past 30-day hazardous alcohol consumption (AOR=1.50, 95% CI=1.04-2.16, p=0.028), and past 12-month non-injection crack/cocaine use (AOR=1.75, 95% CI=1.13-2.69, p=0.011) compared to PLWH reporting none/mild symptoms. Findings demonstrate that moderate/severe GAD symptoms were common among this sample of PLWH in Florida and were associated with use of cigarettes, crack/cocaine, and hazardous alcohol consumption. Future studies should explore interventions to reduce comorbid anxiety and substance use.

Keywords: HIV, generalized anxiety disorder, alcohol, marijuana, illicit drug use

Introduction

Co-occurring anxiety symptoms and substance use are well-documented, yet this remains an understudied topic among people living with HIV (PLWH). Substance use and misuse is becoming increasingly pertinent to the morbidity and mortality among PLWH. Nearly 75% of PLWH report consuming alcohol, with 27% engaging in hazardous alcohol use (Crane et al., 2017). Hazardous alcohol use is associated with several HIV health related outcomes, including missed clinic appointments, decreased care retention, and suboptimal antiretroviral therapy (ART) adherence (Arasteh, Jarlais, & Perlis, 2008; Chander, Lau, & Moore, 2006; Galvan et al., 2002; Monroe et al., 2016). Cigarette use is also significantly more common among PLWH compared with general medical patients, and is associated with lower life expectancy and higher mortality from cardiovascular disease and non-AIDS malignancies compared with nonsmokers (Frazier et al., 2018; Helleberg et al., 2015). Moreover, nearly 34% of adults living with HIV currently use an illicit substance; marijuana, crack/cocaine, and injection drug use are most prevalent (Nduka et al., 2015). Although injection drug use acts as a direct cause of HIV transmission, non-injection drugs such as crack/cocaine are indirectly associated with HIV transmission through engaging in unprotected sex and having a greater number of sexual partners (Baum et al., 2009; Harzke, Williams, & Bowen, 2009). Use of alcohol, marijuana, crack/cocaine, and injection drugs is also linked to ART non-adherence which can result in increased levels of HIV viral transmissibility and disease progression (Cook et al., 2017; Paolillo et al., 2017; Zhang et al., 2018). Though factors associated with alcohol and illicit drug use among PLWH are well-established, the literature examining the relationship between symptoms of generalized anxiety disorder (GAD) and substance use among PLWH is limited (Brandt et al., 2017).

Clinically significant symptoms of anxiety are prevalent in up to 82% of PLWH, with 6.5% to 22% meeting diagnostic criteria for GAD (Brandt et al., 2017; Chaudhury et al., 2016). GAD is characterized by excessive worries about a variety of topics that cause significant emotional distress, impair psychosocial functioning, and produce physical symptoms, such as restlessness, fatigue, reduced concentration, muscle tension, shortness of breath, nausea, and sleep difficulties (American Psychiatric Association, 2013). Among PLWH, significant symptoms of GAD are negatively associated with ART adherence and HIV-care appointment attendance (Mannes et al., 2018; Tucker 2003). Furthermore, though anxiety has been associated with alcohol and injection drug use among PLWH, these studies have been limited to use of bivariate analysis, and have yet to examine symptoms consistent with GAD (Comulada et al., 2010; Ibanez, Purcell, Stall, & Parsons, 2005; Stanton-Tindall et al., 2015; Gary et al., 2015). Multivariate statistics would help to further elucidate the relationship between GAD and substance use, as well as examine the independent effects of anxiety symptoms, sociodemographic characteristics, and healthcare resources on alcohol, tobacco, and illicit drug use. Moreover, Major Depressive Disorder (MDD) is the most common psychiatric comorbidity for PLWH with GAD, and is associated with substance use behavior in this population (Berg, Michelson, & Safren, 2007; Gaynes et al., 2015). Despite the co-occurring nature of these conditions, there is a relative dearth of literature examining the rates of substance use among PLWH experiencing GAD compared to MDD (Brandt et al., 2017). Given the high rates of anxiety symptoms among PLWH, delineating between the effects of GAD and MDD symptoms on substance use would likely have important treatment implications for this population.

Further research is needed to continue to examine the association between GAD symptoms and health behaviors pertinent to optimizing HIV health. Thus, this study aimed to examine the association between symptoms of GAD and substance use (i.e., cigarettes, hazardous alcohol consumption, marijuana, crack/cocaine, and injection drugs) among a sample adults living with HIV within the state of Florida. We hypothesized that individuals experiencing moderate/severe GAD symptoms would demonstrate a greater likelihood of reporting past 30-day hazardous alcohol consumption and cigarette use, and past 12-month use of marijuana, crack/cocaine, and injection drugs compared to adults reporting none/mild symptoms of anxiety.

Materials and Methods

Participants and Procedure

The sample (N = 932) was comprised of participants from the Florida Cohort, a study that aims to understand biopsychosocial determinants of health among PLWH receiving care within the state of Florida. Participants were recruited from 2014-2018 across several county health departments and community clinics and settings throughout Florida (Gainesville, Ft. Lauderdale, Lake City, Miami, Orlando, Sanford, and Tampa). A convenience sampling method was utilized such that all PLWH aged 18 and older presenting to the Florida Cohort recruitment settings were eligible to participate. Upon receiving care or services at the aforementioned sites, PLWH were informed about the study by clinic staff or via brochures available in the clinic. Interested participants were then provided with additional information and administered a prescreening questionnaire to assess for literacy skills. Following written informed consent, PLWH completed a 45-minute questionnaire on paper or via laptop that assessed information related to demographics, HIV-associated medical information, anxiety and depression symptomatology, and substance use. Participants received $25.00 after study completion. The Institutional Review Boards of the University of Florida, Florida International University, and Florida Department of Health approved this study.

Measures

Symptoms of Generalized Anxiety Disorder:

The Generalized Anxiety Disorder 7-item Assessment (GAD-7) measured GAD symptoms over the past two weeks. Items are scored on a Likert scale, with responses ranging from “0” (not at all) to “3” (nearly every day). The GAD-7 has shown to be a valid and effective tool to screen for GAD and has been utilized to assess anxiety in PLWH (Shacham et al., 2012; Spitzer et al., 2006). Scores on the GAD-7 were dichotomized into none/mild symptoms of anxiety (score 0-9) and moderate/severe symptoms (score ≥10); this cut-off has exhibited good sensitivity (89%) and adequate specificity (82%) for a clinical diagnosis of GAD (Shacham et al., 2012; Spitzer et al., 2006).

Substance Use:

The Florida Cohort assessed self-reported substance use. Participants reported whether they smoked cigarettes in the past 30 days, and if they used any other substances in the past 12 months including alcohol, marijuana, crack/cocaine, and injection drugs. Hazardous drinking criteria was designated as consuming more than 14 drinks per week or ≥5 drinks per occasion at least monthly in the past year for men, and more than 7 drinks per week or ≥4 drinks per occasion at least monthly for women (US Preventative Task Force, 2004; Vagenas et al., 2015). Marijuana use, crack/cocaine use, and injection drug use (i.e., injection heroin, stimulants, crack/cocaine) within the past 12 months was dichotomized as no use vs any use.

Depressive Symptoms:

Self-reported depressive symptomatology over the past two weeks was assessed with the Patient Health Questionnaire (PHQ-8), a highly reliable measure of depression that has been used with PLWH (Do et al., 2014; Strine et al., 2008). Depression was defined by a participants’ endorsement of the presence of either depressed mood or anhedonia and at least 5 of the 8 symptoms “more than half the days” during the past two weeks. Individuals reporting 2-4 symptoms, including depressed mood or anhedonia “more than half the days,” were classified as those with “other depression” (Kroenke et al., 2009). Depression is associated with substance use and misuse among adults living with HIV (Crane 2017; Lightfoot et al., 2005; Palfai et al., 2013; Pilowsky et al., 2011).

Sociodemographics:

Participants reported on their age, race/ethnicity, sex, educational attainment, marital status, sexual orientation, and insurance status. For the purpose of our analyses, participants were categorized into the following age groups: 18-34, 35-44, 45-54, and ≥55. Race/ethnicity was categorized into Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic Other. Sex was based on participant’s sex at birth (male or female). Education was categorized into three groups; less than high school, high school, and more than high school. Marital status was dichotomized into single/divorced/widowed/separated versus married/living with a long-term partner. Participants were categorized based on their reported sexual orientation (i.e., heterosexual, gay/lesbian, bisexual). Participants were also dichotomized into groups pertaining to whether or not they currently had any health insurance, including Ryan White or ADAP (AIDS Drug Assistance Program). Age, male sex, lower educational attainment, race/ethnicity, non-married status, lack of insurance, and MSM status have been associated with substance use/misuse and utilization of substance abuse treatment services among PLWH (Crane et al., 2017; Gamarel et al., 2016; Goldstein et al., 2005; Goulet et al., 2007; Mimiaga et al., 2013; Zaller et al., 2017).

Statistical Analyses

All analyses were conducted using IBM SPSS Version 25 (SPSS, Version 25; IBM, Armonk, NY). Univariate descriptive statistics were utilized to describe sample characteristics, including sociodemographics, anxiety and depression symptomatology, and substance use. Chi-square analyses were used to assess statistical significance of any differences in substance use behaviors based on GAD symptom severity (i.e., none/mild vs moderate/severe). Substances demonstrating significant differences (p < 0.05) between GAD groups in bivariate analysis were further examined in multivariate analyses. In order to ascertain the association between the primary independent variable, GAD symptoms and the substance use outcomes of past 30-day hazardous alcohol consumption and cigarette use, and past 12-month use of marijuana, crack/cocaine, and injection drugs, binary logistic models were fit to include GAD symptoms and covariates supported by the literature (i.e., depressive symptoms, age, race/ethnicity, sex, education, marital status, sexual orientation, insurance status). Adjusted odds ratios with 95% confidence limits were presented, and participants who reported none/mild anxiety were designated as the referent group in analyses.

Results

Sociodemographics, Clinical Characteristics, Mental Health, and Substance Use

The sample (N = 932) had a mean age of 46.65 years (SD = 11.21). The racial/ethnic breakdown was as follows: Hispanic (20.3%), non-Hispanic Black (55.2%), non-Hispanic White (20.8%), and non-Hispanic others (3.8%). The majority of participants were male (66.0%). A similar percentage of the sample obtained less than a high school degree (34.3%), high school diploma (29.6%) and postsecondary education (36.1%). Approximately 15.0% of the sample endorsed symptom criteria for major depression or other depression, while 31.4% reported moderate/severe symptoms of GAD. On the specific items of the GAD-7, 35.1%, 28.2%, 29.2%, 28.7%, 24.9%, 30.1%, 24.8% of the sample reported “worrying too much about different things”, “feeling nervous anxious or on edge”, “not being able to stop or control worrying”, “trouble relaxing”, “being so restless that it’s hard to sit still”, “being easily annoyed or irritable”, and “feeling afraid as if something awful might happen” at least half of the days during the past two weeks, respectively. GAD and depressive symptoms were significantly associated (χ 2 = 173.22, p < 0.001) with 14.7% and 22.4% of participants reporting symptoms of “other depression” and “major depression” also reporting moderate/severe GAD symptoms respectively (Table 1).

Table 1.

Demographics, insurance status, GAD & depressive symptoms (N = 932)

Variable Category Total
(N=932)
Age 18-34 158 (17.0)
35-44 182 (19.5)
45-54 371 (39.8)
≥55 221 (23.7)
Sex Male 615 (66.0)
Female 317 (34.0)
Race/Ethnicity Hispanic 189 (20.3)
Non-Hispanic, White 194 (20.8)
Non-Hispanic, Black 514 (55.2)
Non-Hispanic, Other 35 (3.8)
Education <High School 319 (34.3)
High School diploma or equivalent 275 (29.6)
>High School 335 (36.1)
Marital Status Married/Living with a long-term partner 179 (19.3)
Divorced/Widowed/Separated/Single 750 (80.7)
Sexual Orientation Heterosexual 473 (53.7)
Gay 320 (36.3)
Bisexual 88 (10.0)
Insurance Status Uninsured 53 (5.9)
Insured 847 (94.1)
GAD Symptoms None-Mild 617 (68.6)
Moderate-Severe 282 (31.4)
Depressive Symptoms No 747 (85.2)
Other Depression 67 (7.6)
Major Depression 63 (7.2)
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Note. N may vary according to missing data.

The Association between Moderate to Severe Symptoms of GAD and Substance Use

In regard to substance use, over half (51.3%) reported currently smoking cigarettes, while nearly one third (33.5%) of participants reported hazardous alcohol consumption. Use of marijuana, crack/cocaine, and injection drugs during the past 12 months were reported by 37.1%, 18.9%, and 7.0% respectively. Bivariate analyses indicated that participants reporting moderate-severe GAD symptoms were significantly more likely to report current cigarette use (χ2 =10.52, p=0.001), hazardous alcohol consumption (χ2 =9.47, p=0.002), and use of marijuana (χ 2 =4.07, p=0.044), crack/cocaine (χ2 =11.92, p=0.001), and injection drugs (χ2 =8.08, p =0.004), compared to participants who reported none-mild anxiety (Table 2).

Table 2.

Bivariate Associations between GAD Symptom Severity and Substance Use (N=932)

Variable Category None-Mild
Anxiety		 Moderate-
Severe
Anxiety		 Total p
Cigarette Use No 313 (52.2) 107 (40.3) 420 (48.5) 0.001
Yes 287 (47.8) 159 (59.7) 446 (51.5)
Hazardous Alcohol Use No 394 (68.2) 156 (57.4) 550 (64.7) 0.002
Yes 184 (31.8) 116 (42.6) 300 (35.3)
Marijuana Use No 359 (65.5) 144 (58.1) 503 (63.2) 0.044
Yes 189 (34.5) 104 (41.9) 293 (36.8)
Non-injection Crack/Cocaine Use No 491 (83.4) 197 (73.2) 688 (80.2) 0.001
Yes 98 (16.6) 72 (26.8) 170 (19.8)
Injection Drug Use No 557 (94.6) 239 (89.2) 796 (92.9) 0.004
Yes 32 (5.4) 29 (10.8) 61 (7.1)
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Note. N may vary according to missing data. Bold values indicate significance at p < 0.05

The associations between GAD symptoms and substances demonstrating significant group differences (p<0.05) in bivariate analysis (i.e. cigarettes, hazardous drinking, marijuana, crack/cocaine, and injection drugs) were further examined utilizing adjusted binary logistic regressions controlling for age, race/ethnicity, sex, education, marital status, sexual orientation, insurance status, and depressive symptoms. Prior to covariate adjustment, participants reporting moderate-severe symptoms of GAD demonstrated greater odds of cigarette use (OR=1.62, 95% CI=1.20-2.17, p=0.001), hazardous alcohol consumption (OR=1.59, 95% CI=1.18-2.14, p=0.002), marijuana use, (OR=1.37, 95% CI=1.01-1.86, p=0.044), crack/cocaine use (OR=1.81, 95% CI=1.29-2.58, p=0.001), and injection drug use (OR=2.11, 95% CI=1.25-3.57, p=0.005) compared to participants reporting none-mild symptoms of GAD.

After controlling for covariates, PLWH with moderate/severe symptoms of GAD had greater odds of current cigarette use (AOR = 1.71, 95% CI = 1.18–2.46 p = 0.004), hazardous alcohol consumption (AOR = 1.50, 95% CI = 1.04–2.16, p = 0.028), and non-injection crack/cocaine use (AOR = 1.75, 95% CI = 1.13–2.69, p = 0.011). Moderate/severe GAD symptoms were not significantly associated with marijuana use (AOR = `1.28, 95% CI = 0.87–1.86, p = 0.202), or injection drug use (AOR = 1.70, 95% CI = 0.86–3.34, p = 0.125) after controlling for covariates. Depressive symptoms were not significantly associated with any substance use after controlling for covariates and GAD. Please refer to Table 3 for additional information related to covariates and substance use.

Table 3.

Logistic Regression Analyses Examining the Association between GAD Symptom Severity and Substance (N=932)

Variable Cigarettes
AORa (CI)		 p Hazardous
Drinking
AORa (CI)		 p Marijuana
AORa (CI)		 p Crack/
Cocaine
AORa (CI)		 p Injection
Drugs
AORa (CI)		 p
GAD
None-Mild (Referent)
Moderate-Severe 1.71 (1.18-2.46) 0.004 1.50 (1.04-2.16) 0.028 1.28 (0.87-1.86) 0.202 1.75 (1.13-2.69) 0.011 1.70 (0.86-3.34) 0.125
Depression
No (Referent)
Other Depression 1.35 (0.73-2.49) 0.532 1.15 (0.64-2.07) 0.630 1.74 (0.94-3.20) 0.075 1.50 (0.77-2.88) 0.225 1.23 (0.43-3.52) 0.696
Major Depression 0.86 (0.45-1.66) 0.334 1.06 (0.57-1.99) 0.833 1.50 (0.77-2.92) 0.232 1.14 (0.56-2.33) 0.712 1.65 (0.62-4.39) 0.312
Age
18-34 (Referent)
35-44 1.17 (0.72-1.92) 0.511 0.71 (0.43-1.17) 0.188 0.66 (0.40-1.10) 0.114 1.25 (0.66-2.34) 0.484 0.73 (0.29-1.83) 0.505
45-54 1.10 (0.71-1.70) 0.658 0.87 (0.56-1.35) 0.537 0.55 (0.35-0.88) 0.013 1.52 (0.87-2.68) 0.139 0.82 (0.37-1.80) 0.631
55+ 1.05 (0.64-1.72) 0.828 0.97 (0.59-1.61) 0.935 0.37 (0.21-0.63) <0.001 1.44 (0.75-2.75) 0.262 0.77 (0.29-2.00) 0.599
Sex
Male (Referent)
Female 0.75 (0.51-1.10) 0.145 0.90 (0.61-1.32) 0.596 0.64 (0.42-0.97) 0.040 0.77 (0.48-1.25) 0.298 0.60 (0.25-1.44) 0.257
Race/Ethnicity
Non- Hispanic, Black (Referent)
Non-Hispanic, White 0.88 (0.60-1.30) 0.535 1.10 (0.74-1.64) 0.634 1.09 (0.73-1.63) 0.684 0.63 (0.39-1.03) 0.065 2.51 (1.21-5.23) 0.014
Hispanic 0.69 (0.46-1.04) 0.076 0.85 (0.56-1.30) 0.461 0.52 (0.33-0.82) 0.005 0.47 (0.27-0.83) 0.008 2.08 (0.96-4.48) 0.061
Non-Hispanic, Other 1.13 (0.52-2.44) 0.754 1.31 (0.60-2.88) 0.496 1.35 (0.61-3.00) 0.461 0.75 (0.27-2.07) 0.576 1.78 (0.38-8.46) 0.464
Education
< High school (Referent)
High school 0.86 (0.59-1.27) 0.466 0.66 (0.45-0.98) 0.041 1.29 (0.86-1.95) 0.213 0.98 (0.62-1.57) 0.960 1.13 (0.54-2.37) 0.734
>High school 0.37 (0.25-0.55) <0.001 0.46 (0.31-0.69) <0.001 0.83 (0.54-1.27) 0.405 0.65 (0.40-1.07) 0.093 1.48 (0.54-4.07) 0.153
Marital Status
Divorced, Widowed, Separated (Referent)
Married, Long-term Partner 0.98 (0.67-1.43) 0.941 1.24 (0.83-1.85) 0.279 1.02 (0.68-1.53) 0.903 1.35 (0.81-2.27) 0.245 1.19 (0.55-2.58) 0.646
Sexual Orientation
Heterosexual (Referent)
Gay 0.79 (0.52-1.18) 0.254 1.10 (0.72-1.68) 0.629 1.04 (0.67-1.61) 0.850 1.34 (0.81-2.22) 0.247 1.69 (0.77-3.71) 0.186
Bisexual 1.48 (0.86-2.55) 0.153 1.18 (0.69-2.03) 0.537 1.59 (0.90-2.80) 0.108 1.23 (0.64-2.34) 0.524 1.48 (0.54-4.07) 0.445
Insurance Status
Yes (Referent)
No 1.08 (0.57-2.04) 0.804 0.69 (0.37-1.30) 0.261 1.00 (0.51-1.99) 0.978 0.57 (0.27-1.18) 0.136 0.75 (0.26-2.17) 0.602
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Note. Bold values indicate significance at p < 0.05. Controlled for depressive symptoms, age, sex, race/ethnicity, education, marital status, sexual orientation, and insurance status.

Discussion

The purpose of this study was to examine the association between symptoms of GAD and substance use among adults living with HIV. Results from this study partially supported our hypothesis that adults reporting moderate/severe GAD symptoms would demonstrate greater odds of cigarette use, hazardous alcohol use, and crack/cocaine use compared to those reporting none/mild symptoms. Though moderate/severe symptoms of GAD were associated with use of marijuana and injection drugs in bivariate analyses, this association attenuated and was non-significant after adjusting for relevant covariates. Moderate/severe symptoms of GAD were prevalent, with approximately one-third of participants meeting this threshold of symptomology. These self-reported findings are consistent with data from a recent systematic review suggesting that approximately 33% of PLWH meet criteria for an anxiety disorder when using self-report questionnaires compared to about 22% when using clinical interviewing (Brandt et al., 2017).

Anxiety among PLWH is important to consider given the substantial stress associated with managing a chronic health condition, the need for strict adherence to medication regimens, and frequent medical appointments. Additional stressors common among HIV populations include economic disparities and HIV-related stigma (Moskowitz et al., 2009). Chronic stress negatively impacts quality of life, and has been found to accelerate HIV-disease progression as measured by CD4+ count (Remor et al., 2007). Despite advances in antiretroviral medications, mental health and substance use comorbidities remain high among persons living with HIV. Interestingly, depressive symptoms were not significantly associated with substance use in the multivariate model. This finding is contrary to the literature that indicates an association between greater depressive symptoms and substance use among PLWH (Crane et al., 2017; Lightfoot et al., 2005; Palfai et al., 2014; Pilowsky et al., 2011). However, it is plausible that patients reporting significant depressive symptoms were underrepresented in the current sample. Most patients in the current study were recruited via clinic contact, which yields a sample representative of patients currently retained in care. However, PLWH who suffer from major depressive disorders are more difficult to retain in HIV care (Zuniga et al., 2016). Nonetheless, greater attention is needed to improving mental healthcare for PLWH to continue to advance HIV medicine towards the goal of eliminating HIV transmission (Abrams & Strasser, 2015).

The present study highlights a critical link between mental health and substance use among PLWH. Specifically, participants with symptoms consistent with moderate/severe GAD were more likely to report hazardous alcohol consumption and use of cigarettes and crack/cocaine. This is particularly significant, as alcohol and cocaine are associated with high risk sexual behavior, which can further transmission of HIV. Specifically, the disinhibiting effect of excessive alcohol consumption increases risk of sexual encounters with casual partners and unprotected sex (Scott-Sheldon et al., 2016). Crack cocaine is also associated with risky sexual behavior, including sex trade for money or drugs (Booth et al., 1993). Lastly, tobacco use is becoming increasingly problematic, as effective antiretroviral medications allow persons living with HIV to live longer and healthier lives. However, among those who are chronic tobacco users, late-life chronic illnesses (e.g., lung cancer, COPD) are becoming a common cause of mortality (Reddy et al., 2017).

Given the association between GAD symptoms and substance use in the present study, it is plausible that persons living with HIV are using substances as a form of self-medication (Quitkin et al., 2972; Robinson et al., 2009). In fact, studies with non-HIV samples with co-occurring disorders find that participants frequently endorse the use of substances to manage anxiety symptoms and patients with social anxiety describe drinking alcohol as an effective tension reduction strategy (Carrigan et al., 2003; Thomas et al., 2003). Not surprisingly, individuals who self-medicate with alcohol and drugs tend to experience an exacerbation of mental health symptoms (Robinson et al., 2009). The increased mental health burden highlights the need for comprehensive psychological screening when working with patients with co-occurring anxiety and substance use disorders. Longitudinal studies with non-HIV samples indicate that relying on alcohol or drugs to self-manage symptoms of anxiety greatly increases the risk of new-onset substance use disorders (Robinson et al., 2011).

Among the most commonly reported symptoms of GAD in this sample were worrying and feelings of anxiety. Given this, it is critical that appropriate anxiety management recommendations are provided, which may include cognitive behavioral therapy and/or psychotropic medications (Stefan et al., 2019). Cognitive behavioral therapy with a focus on exposure and response prevention strategies is effective for patients with anxiety disorders and has promising results in the context of comorbid substance use concerns (Lee & Oei, 1993). An integrated cognitive behavioral therapy approach specifically adapted for patients living with HIV demonstrated a reduction in anxiety symptoms while improving HIV medication adherence (Brandt et al., 2017). Regarding psychotropic medication, common medications used to treat anxiety disorders include benzodiazepines, venlafaxine, and buspirone (American Psychiatric Association, 2012). However, it is critical that prescribing clinicians consider drug-drug interactions and potential side effects if such psychotropic medications are prescribed. Finally, collaborative care models or co-location of services, in which medical, mental health, and other ancillary services (e.g. substance use treatment, case management) partner to provide care, may be useful to address anxiety and substance use among PLWH (Mizuno et al., 2019). This is supported by the Ryan White HIV/AIDS Program AIDS Education and Training Centers (AETCs) National Curriculum, which emphasizes the necessity of clinician screening efforts and integration of mental health care into HIV primary care (Budak & Cournos, 2020).

Several limitations and strengths should be considered when interpreting the results of this study. First, the temporality of the findings cannot be established due to the cross-sectional design, which is particularly salient given the bidirectionality of mental health symptoms and substance use. The current study utilized self-report of mental health symptoms and substance use, which may have introduced biased responding (e.g., under- or over-reporting), and accuracy of participant answers may have been further influenced by study compensation and the convenience sampling method used for participant recruitment. The PHQ-8 and the GAD-7 are considered reliable and valid self-report measures for assessing depressive and anxiety symptoms respectively, and their scoring methods map onto diagnostic criteria of the DSM-5. Nonetheless, such stand-alone measures cannot replace clinical interviewing for diagnosing mental health conditions and use of the GAD-7 prohibited a more refined understanding of the emotional, cognitive, and behavioral symptom domains of anxiety. Future research may consider a more nuanced understanding of anxiety symptoms, as well as use of the Structured Clinical Interview for DSM-5 (SCID-5) or medical chart reviews to confirm mental health diagnoses (First et al., 2015). The high degree of co-occurring anxiety and depressive symptoms may have also reduced our ability to detect significant unique variance attributable to the PHQ-8, especially given the high correlations between the GAD and PHQ measures (Kroenke et al., 2016). Lastly, marijuana and illicit substance use measurement was limited to any past 12-month use, and authors did not assess polysubstance use and were unable to delineate between differences in frequency or quantity of use, which are all important areas of future research. Despite these limitations, this study demonstrated a significant association between symptoms of anxiety and substance use among a large, diverse cohort of PLWH enrolled in care. Moreover, this investigation is among the first to assess the relationship between GAD symptoms and substance use while accounting for potential confounding variables, including depressive symptoms. This study builds on previous research demonstrating the adverse effects of GAD symptoms on important HIV-related health behaviors.

Individuals living with HIV experience higher rates of mental health and substance use comorbidities compared to the general population. The present study advances the literature by demonstrating GAD symptoms as a risk factor for substance use among PLWH, and highlights the possibility of self-medication of anxiety symptoms in this population. Future studies should explore the relationship between anxiety and substance use among PLWH using longitudinal methods to better explain the hypothesized self-medication processes, while research should also consider this association and explore best clinical practices to mitigate the negative consequences of substance use among this population, most notably adherence to antiretroviral medications. Stress management interventions including psychological therapies (e.g., CBT) and mind-body interventions (e.g., mindfulness) may be particularly useful in treating anxiety symptoms and co-occurring substance use.

Acknowledgments

The authors would like to thank the participants in the Florida Cohort Study for their contribution to this study.

Funding Sources

This work was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) under grant number U24AA022002, U24AA022003 and National Institute on Drug Abuse (NIDA) under grant number 1K23DA039769.

Footnotes

Declaration of Interest Statement

The authors declare that they have no conflict of interest.

References

  1. Abrams EJ, & Strasser S (2015). 90-90-90–Charting a steady course to end the paediatric HIV epidemic. Journal of the International AIDS Society, 18, 20296. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Arasteh K, Des Jarlais DC, & Perlis TE (2008). Alcohol and HIV sexual risk behaviors among injection drug users. Drug and alcohol dependence, 95(1), 54–61. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. American Psychiatric Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub. [Google Scholar]
  4. American Psychiatric Association, A.P. (2012). HIV and Anxiety. https://www.psychiatry.org/psychiatrists/practice/professional-interests/hiv-psychiatry/resources
  5. Baum MK, Rafie C, Lai S, Sales S, Page B, & Campa A (2009). Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users. Journal of Acquired Immune Deficiency Syndromes, 50(1), 93–99. [DOI] [PubMed] [Google Scholar]
  6. Beck AT, & Clark DA (1997). An information processing model of anxiety: Automatic and strategic processes. Behaviour Research and Therapy. 35(1), 49–58. [DOI] [PubMed] [Google Scholar]
  7. Berg CJ, Michelson SE, & Safren SA (2007). Behavioral aspects of HIV care: adherence, depression, substance use, and HIV-transmission behaviors. Infectious Disease Clinics of North America, 21(1), 181–200. [DOI] [PubMed] [Google Scholar]
  8. Booth RE, Watters JK, & Chitwood DD (1993). HIV risk-related sex behaviors among injection drug users, crack smokers, and injection drug users who smoke crack. American Journal of Public Health, 83(8), 1144–1148. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Brandt CP, Paulus DJ, Garza M, Lemaire C, Norton PJ, & Zvolensky MJ (2018). A novel integrated cognitive-behavioral therapy for anxiety and medication adherence among persons living with HIV/AIDS. Cognitive and behavioral practice, 25(1), 105–118. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Brandt C, Zvolensky MJ, Woods SP, Gonzalez A, Safren SA, & O’Cleirigh CM (2017). Anxiety symptoms and disorders among adults living with HIV and AIDS: A critical review and integrative synthesis of the empirical literature. Clinical psychology review, 51, 164–184. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Budak JZ, Cournos F (2020, June 17). National HIV curriculum: screening for mental disorders. https://www.hiv.uw.edu/go/basic-primary-care/screening-mental-disorders/core-concept/all#models-integrating-screening-mental-disorders-neurocognitive-disorders-into-hiv-primary-care. [Google Scholar]
  12. Chaudhury S, Bakhla A, & Saini R (2016). Prevalence, impact, and management of depression and anxiety in patients with HIV: A review. Neurobehavioral HIV Medicine, 7, 15–30. [Google Scholar]
  13. Chander G, Lau B, Moore RD. Hazardous alcohol use: a risk factor for non-adherence and lack of suppression in HIV infection. Journal of acquired immune deficiency syndromes (1999). 2006;43(4):411. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Cook RL, Zhou Z, Kelso-Chichetto NE, Janelle J, Morano JP, Somboonwit C, … & Cohen RA (2017). Alcohol consumption patterns and HIV viral suppression among persons receiving HIV care in Florida: an observational study. Addiction science & clinical practice, 12(1), 22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Comulada WS, Rotheram-Borus MJ, Pequegnat W, Weiss RE, Desmond KA, Arnold EM, … & Chesney MA (2010). Relationships over time between mental health symptoms and transmission risk among persons living with HIV. Psychology of Addictive Behaviors, 24(1), 109. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Crane HM, McCaul ME, Chander G, Hutton H, Nance RM, Delaney JA, … & Mimiaga M (2017). Prevalence and factors associated with hazardous alcohol use among persons living with HIV across the US in the current era of antiretroviral treatment. AIDS and Behavior, 21(7), 1914–1925. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Do AN, Rosenberg ES, Sullivan PS, Beer L, Strine TW, Schulden JD, . . . Skarbinski J (2014). Excess burden of depression among HIV-infected persons receiving medical care in the United States: data from the medical monitoring project and the behavioral risk factor surveillance system. PLoS One, 9(3), e92842. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. First MB, Williams JBW, Karg RS, Spitzer RL: Structured Clinical Interview for DSM-5—Research Version (SCID-5 for DSM-5, Research Version; SCID-5-RV). Arlington, VA, American Psychiatric Association, 2015 [Google Scholar]
  19. Frazier EL, Sutton MY, Brooks JT, Shouse RL, & Weiser J (2018). Trends in cigarette smoking among adults with HIV compared with the general adult population, United States-2009–2014. Preventive medicine, 111, 231–234. [DOI] [PubMed] [Google Scholar]
  20. Galvan FH, Bing EG, Fleishman JA, London AS, Caetano R, Burnam MA, et al. The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study. J Stud Alcohol. 2002;63(2):179–86. [DOI] [PubMed] [Google Scholar]
  21. Gamarel KE, Brown L, Kahler CW, Fernandez MI, Bruce D, Nichols S, & Adolescent Medicine Trials Network for HIV/AIDS Intervention. (2016). Prevalence and correlates of substance use among youth living with HIV in clinical settings. Drug and alcohol dependence, 169, 11–18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Garey L, Bakhshaie J, Sharp C, Neighbors C, Zvolensky MJ, & Gonzalez A (2015). Anxiety, depression, and HIV symptoms among persons living with HIV/AIDS: the role of hazardous drinking. AIDS care, 27(1), 80–85. [DOI] [PubMed] [Google Scholar]
  23. Gaynes BN, O’Donnell J, Nelson E, Heine A, Zinski A, Edwards M, … & Pence BW (2015). Psychiatric comorbidity in depressed HIV-infected individuals: common and clinically consequential. General hospital psychiatry, 37(4), 277–282. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Goldstein RB, Rotheram-Borus MJ, Johnson MO, Weinhardt LS, Remien RH, Lightfoot M, … & NIMH Healthy Living Trial Group. (2005). Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus. Medical care, 401–410. [DOI] [PubMed] [Google Scholar]
  25. Goulet JL, Fultz SL, Rimland D, Butt A, Gibert C, Rodriguez-Barradas M, … & Justice AC (2007). Do patterns of comorbidity vary by HIV status, age, and HIV severity?. Clinical infectious diseases, 45(12), 1593–1601. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Harzke AJ, Williams ML, & Bowen AM (2009). Binge use of crack cocaine and sexual risk behaviors among African-American, HIV-positive users. AIDS and Behavior, 13(6), 1106. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Helleberg M, May MT, Ingle SM, Dabis F, Reiss P, Fätkenheuer G, … & Justice AC (2015). Smoking and life expectancy among HIV-infected individuals on antiretroviral therapy in Europe and North America. AIDS (london, England), 29(2), 221. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Ibañez GE, Purcell DW, Stall R, Parsons JT, & Gomez CA (2005). Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who also inject drugs. Aids, 19, S49–S55. [DOI] [PubMed] [Google Scholar]
  29. Khan Y, Glazier RH, Moineddin R, & Schull MJ (2011). A Population‐based Study of the Association Between Socioeconomic Status and Emergency Department Utilization in Ontario, Canada. Academic Emergency Medicine, 18(8), 836–843. [DOI] [PubMed] [Google Scholar]
  30. Kroenke K, Spitzer RL, Williams JB, Monahan PO, & Löwe B (2007). Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and DetectionAnxiety Disorders in Primary Care. Annals of internal medicine, 146(5), 317–325. [DOI] [PubMed] [Google Scholar]
  31. Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, & Mokdad AH (2009). The PHQ-8 as a measure of current depression in the general population. Journal of affective disorders, 114(1), 163–173. [DOI] [PubMed] [Google Scholar]
  32. Kroenke K, Wu J, Yu Z, Bair MJ, Kean J, Stump T, & Monahan PO (2016). The patient health questionnaire anxiety and depression scale (PHQ-ADS): initial validation in three clinical trials. Psychosomatic medicine, 78(6), 716. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Lee NK, & Oei TP (1993). Exposure and response prevention in anxiety disorders: Implications for treatment and relapse prevention in problem drinkers. Clinical Psychology Review, 13(6), 619–632. [Google Scholar]
  34. Lightfoot M, Rogers T, Goldstein R, Rotheram-Borus MJ, May S, Kirshenbaum S, … & Gore-Felton C (2005). Predictors of substance use frequency and reductions in seriousness of use among persons living with HIV. Drug and alcohol dependence, 77(2), 129–138. [DOI] [PubMed] [Google Scholar]
  35. Mannes ZL, Hearn LE, Zhou Z, Janelle JW, Cook RL, & Ennis N (2018). The association between symptoms of generalized anxiety disorder and appointment adherence, overnight hospitalization, and emergency department/urgent care visits among adults living with HIV enrolled in care. Journal of behavioral medicine, 1–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Mimiaga MJ, Reisner SL, Grasso C, Crane HM, Safren SA, Kitahata MM, … & Mayer KH (2013). Substance use among HIV-infected patients engaged in primary care in the United States: findings from the Centers for AIDS Research Network of Integrated Clinical Systems cohort. American journal of public health, 103(8), 1457–1467. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Mizuno Y, Higa DH, Leighton CA, Mullins M, & Crepaz N (2019). Is co-location of services with HIV care associated with improved HIV care outcomes? A systematic review. AIDS care, 31(11), 1323–1331. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Monroe AK, Lau B, Mugavero MJ, Mathews WC, Mayer KH, Napravnik S, … & McCaul ME (2016). Heavy Alcohol Use Is Associated With Worse Retention in HIV Care. Journal of acquired immune deficiency syndromes (1999), 73(4), 419–425. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Moskowitz JT, Hult JR, Bussolari C, & Acree M (2009). What works in coping with HIV? A meta-analysis with implications for coping with serious illness. Psychological bulletin, 135(1), 121. [DOI] [PubMed] [Google Scholar]
  40. Nduka C, Uthman O, Kimani P, & Stranges S (2015). Drug abuse in people living with HIV in the era of highly active antiretroviral therapy: A systematic review and meta-analysis. Journal of Addiction Research and Therapy, 6(255), 2 [Google Scholar]
  41. Palfai TP, Cheng DM, Coleman SM, Bridden C, Krupitsky E, & Samet JH (2014). The influence of depressive symptoms on alcohol use among HIV-infected Russian drinkers. Drug and alcohol dependence, 134, 85–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Paolillo EW, Gongvatana A, Umlauf A, Letendre SL, & Moore DJ (2017). At Risk Alcohol Use is Associated with Antiretroviral Treatment Nonadherence Among Adults Living with HIV/AIDS. Alcoholism: Clinical and Experimental Research, 41(8), 1518–1525. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Pilowsky DJ, Wu LT, Burchett B, Blazer DG, & Ling W (2011). Depressive symptoms, substance use, and HIV-related high-risk behaviors among opioid-dependent individuals: results from the Clinical Trials Network. Substance Use & Misuse, 46(14), 1716–1725. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Quitkin FM, Rifkin A, Kaplan J, & Klein DF (1972). Phobic anxiety syndrome complicated by drug dependence and addiction: a treatable form of drug abuse. Archives of General Psychiatry, 27(2), 159–162. [DOI] [PubMed] [Google Scholar]
  45. Reddy KP, Kong CY, Hyle EP, Baggett TP, Huang M, Parker RA, … & Walensky RP (2017). Lung cancer mortality associated with smoking and smoking cessation among people living with HIV in the United States. JAMA internal medicine, 177(11), 1613–1621. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Remor E, Penedo FJ, Shen BJ, & Schneiderman N (2007). Perceived stress is associated with CD4_ cell decline in men and women living with HIV/AIDS in Spain. AIDS Care, 19(2), 215–219. [DOI] [PubMed] [Google Scholar]
  47. Robinson J, Sareen J, Cox BJ, & Bolton J (2009). Self-medication of anxiety disorders with alcohol and drugs: Results from a nationally representative sample. Journal of anxiety disorders, 23(1), 38–45. [DOI] [PubMed] [Google Scholar]
  48. Ruiz MA, Zamorano E, García-Campayo J, Pardo A, Freire O, & Rejas J (2011). Validity of the GAD-7 scale as an outcome measure of disability in patients with generalized anxiety disorders in primary care. Journal of affective disorders, 128(3), 277–286. [DOI] [PubMed] [Google Scholar]
  49. Scott-Sheldon LA, Carey KB, Cunningham K, Johnson BT, Carey MP, & MASH Research Team. (2016). Alcohol use predicts sexual decision-making: a systematic review and meta-analysis of the experimental literature. AIDS and Behavior, 20(1), 19–39. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Shacham E, Morgan JC, Önen NF, Taniguchi T, & Overton ET (2012). Screening anxiety in the HIV clinic. AIDS and Behavior, 16(8), 2407–2413. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Spitzer RL, Kroenke K, Williams JB, & Löwe B (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of internal medicine, 166(10), 1092–1097. [DOI] [PubMed] [Google Scholar]
  52. Staton-Tindall M, Harp KL, Minieri A, Oser C, Webster JM, Havens J, & Leukefeld C (2015). An exploratory study of mental health and HIV risk behavior among drug-using rural women in jail. Psychiatric rehabilitation journal, 38(1), 45. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Stefan S, Cristea IA, Szentagotai Tatar A, & David D (2019). Cognitive-behavioral therapy (CBT) for generalized anxiety disorder: Contrasting various CBT approaches in a randomized clinical trial. Journal of Clinical Psychology, 75, 1188–1202. [DOI] [PubMed] [Google Scholar]
  54. Strine T, Williams JBW, & Mokdad A (2008). The PHQ-8 as a Measure of Current Depression in the General Population. [DOI] [PubMed] [Google Scholar]
  55. Tucker JS, Burnam MA, Sherbourne CD, Kung FY, & Gifford AL (2003). Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection. The American journal of medicine, 114(7), 573–580. [DOI] [PubMed] [Google Scholar]
  56. US Preventive Services Task Force. (2004). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Annals of Internal Medicine, 140(7), 554. [DOI] [PubMed] [Google Scholar]
  57. Vagenas P, Azar MM, Copenhaver MM, Springer SA, Molina PE, & Altice FL (2015). The impact of alcohol use and related disorders on the HIV Continuum of care: a systematic review. Current HIV/AIDS Reports, 12(4), 421–436. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Wilson IB, Lee Y, Michaud J, Fowler FJ, Rogers WH. Validation of a new three-item self-report measure for medication adherence. AIDS Behav. 2016;20(11):2700–2708. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Zhang Y, Wilson TE, Adedimeji A, Merenstein D, Milam J, Cohen J, … & Golub ET (2018). The Impact of Substance Use on Adherence to Antiretroviral Therapy Among HIV-Infected Women in the United States. AIDS and Behavior, 22(3), 896–908. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Zuniga JA, Yoo-Jeong M, Dai T, Guo Y, & Waldrop-Valverde D (2016). The role of depression in retention in care for persons living with HIV. AIDS Patient Care and STDs, 30(1), 34–38. [DOI] [PMC free article] [PubMed] [Google Scholar]

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