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A Matter of Substance: Integrating SUD Treatment and HIV Care

Clinical Thought
Clinical Thought
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Released: October 16, 2026

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The rapport that HIV care providers inherently build with patients makes the HIV clinic an ideal setting for also providing substance use disorder (SUD) treatment, ultimately improving outcomes for both conditions. In this case-based commentary, learn how I screen for SUD and how I use the information from screening to build a treatment plan.

Glenn J. Treisman
Glenn J. Treisman, MD, PhD
SUD Treatment and HIV Care


Case Scenario
A 40-year-old woman living with HIV has returned to the clinic after 2 missed follow-up visits. She asserts that her chronic pain is out of control. Her chart shows a history of oxycodone prescription. She does not appear intoxicated.

Although the woman in this case study appears sober at presentation, her extreme pain, recent missed follow-up visits, and history of oxycodone prescription should prompt screening for substance use disorder (SUD), even in the HIV clinic. SUD is more prevalent among people living with HIV than in the general population.

Compared to people without addictions, people with addictions tend to have worse HIV outcomes and long‑term physical and mental health outcomes. As such, HIV healthcare professionals (HCPs) should be prepared to screen for SUD if people exhibit warning signs of SUD during routine HIV visits.

SUD Screening
I find that knowing the person well and being familiar with their circumstances is key for effective SUD screening. This makes the HIV clinic an excellent setting for SUD screening, as there tends to be more consistent care continuity here. When an individual presents with potential signs of SUD, I begin by taking a thorough history.

Initial factors to consider include whether they have other psychiatric disorders, like depression or personality disorders. Then, you have to determine what substances they are using, why they are using them, how long they have been using them, and how much they are using.

Other key questions to answer include:

  • How do they get the substance, and how are they affording it?  
  • Are they exchanging the substance for sex or other things?
  • Are they putting themselves at risk or stealing money to get the substance?
  • Who else knows they are using the substance?
  • Who could be an advocate for them, if anybody?
  • What precipitated their current substance use, and what is keeping it going?
  • When have they been sober?

Once these patterns have been established, you can begin to formulate a recovery plan with the patient. Their history can reveal what would or would not work for their recovery, based on what they have tried in the past. You are looking to construct a pathway from where the person is to where the person could be sober and in recovery.

Integrating Care
Substance users come in and out of care a lot. They have disrupted lives. They frequently turn from clinic to clinic and place to place in an effort to keep their addiction going. Integrating SUD treatment with HIV management helps give people with SUD another option for staying engaged in treatment and recovery. It improves HIV antiretroviral adherence as well.

For SUD with mild to moderate severity, where substance use occurs only several times a week, SUD treatment is feasible and appropriate to integrate with HIV care. When beginning SUD treatment, HCPs may need to see the patient frequently: every week to every month.

People with more severe SUD who have more frequent substance use may require detoxification in an inpatient facility. So do people whose substance use is less frequent if they use substances like alcohol or benzodiazepines, as withdrawal from these substances can be life‑threatening.

The more disordered a person is because of their substance use, the more you should consider referral to specialist care. For example, if a person is throwing up blood every morning, or presents with low-grade liver failure, they should be checked into specialist care right away, even if the only substance they are using is alcohol.

Ins and Outs
Knowing the appropriate route to get somebody into specialist care is just as important as being able to provide outpatient SUD treatment. This requires knowledge of where to refer people and how to hand off to social workers to avoid loss to follow-up. I find that if you just send a patient over and tell them to go see the social worker, they will likely disappear, so I recommend a “warm handoff,” where you or another HCP meets with the patient and the social worker as a team. I find that nurses excel at this role.

In all, successful integration of SUD treatment and HIV care depends on knowing your patients well and consistency in care. The trust and rapport that HIV care providers build with their patients is the ideal setting for also providing SUD treatment, ultimately improving outcomes for both conditions.

Your Thoughts
How would you initiate a discussion about SUD for the patient in the case scenario? What would be your first step in engaging her in care? Leave a comment to join the discussion!