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HIV, Mental Health, and Substances – Public Health or Politics?

Ever since the days of Prohibition in the 1920’s, or the 1938 camp film, “Reefer Madness”, substances and American politics have clashed in a way that goes far beyond the actual health risks of alcohol or “recreational” drugs and into a moralistic quagmire that leaves people confused and conflicted about just what to believe. I have seen this frequently in my work as a therapist with people who are living with HIV and have issues, or even just questions, about substance use, abuse, and addiction.

This was true with my client, Cliff. Cliff was a 42-year-old man living with HIV who admitted to using marijuana regularly, which he reported improved his appetite and reduced his nausea. He was careful not to drive after using it, and his use was about 2-3 times per week. But he often felt guilty, knowing that his purchase, possession, and use of marijuana was illegal, when he held a responsible job where he enforced many legal and ethical corporate policies. He was especially disturbed by the recent television campaign that implies that buying a marijuana joint is akin to supporting terrorism, as he found this insulting and inaccurate for a practice he knew from his own experience to cause relatively little harm to either his personal or professional functioning.

Certainly, other clients have described in vivid detail the extremely harmful effects that the misuse of alcohol and drugs can cause. But what bothered Cliff was that alcohol has contributed to such social ills as automobile accidents, industrial accidents, domestic violence, lost professional productivity, child abuse, premature illness, and certainly deaths, yet it is legal to possess, buy and use for anyone of a legal drinking age. Marijuana, in contrast, remains illegal; it is a substance that lands some people (disproportionately the poor and people of color) in jail. I had a client who admitted committing a murder who didn’t serve time in jail. This disparity reveals that politics, not public health, are at issue. And these negative politics can negatively impact the self-image of Cliff and many like him.

Research has shown that many more people use alcohol and/or some recreational drugs than get addicted to them, and that there is a difference in the health risk and other harm when comparing some drugs (such as marijuana, Ecstasy, or mushrooms) with others (such as heroin, crystal methamphetamine, or crack cocaine). While the relative harm each causes differs, American public health programs have a tendency to lump them all together as equally harmful in a way that confuses people’s understanding of how to protect their health. Also, many of my clients were not aware that mixing some “street” drugs with their HIV medications is dangerous to their health – for example, using Ritonavir or Kaletra (which contains Ritonavir), can greatly increase the concentration of Ecstasy in the blood, risking overdose that has resulted in at least one death. Using GHB or Ketamine with alcohol, or Viagra with nitrate inhalants (“poppers”), is also very dangerous. However, because American political policies generally prevent funding for the official study of how “street” drugs interact with any legal medications (not just those for HIV), and usually prevent the use of warning labels against such interactions, the victims of these accidents didn’t have the scientific, public health education warnings that might have saved lives.

Another client, Jeff, argued that it takes just one person to try Ecstasy, for example, and see a dozen of her friends do the same, and not die or have extremely adverse effects from it, for the entire federal public health message to lose credibility in her mind, because she wasn’t told the truth that some people can use and not experience great harm if certain harm reduction health precautions are followed. Jeff knew what these precautions were to prevent the overdose and dehydration that can cause deaths from his own research from educational resources such as or

All of the politicized messages about substances makes my work harder with clients, because in addition to the physical and psychological aspects of substances, I need to help them overcome issues of shame and stigma, which they are already usually facing as people living with HIV. The Western European approach to educating people about substances (which takes for granted that some people will use them despite the health risks and their illegality) emphasizes educating the public frankly about the health hazards without sweeping all the informational white dust under the rug. They include harm reduction instructions for safer use that could prove life-saving if followed – not condoning illegal drug use, but educating the public on the safety issues for those who do. This seems like a much more healthy, realistic, and credible approach to the behaviors that are already occurring in society in large numbers. Perhaps American public health programs should take notes from our friends across the Atlantic. The stigma around HIV is bad enough, when the focus should be on the health and mental health aspects of treating the disease without judgment. The same could be said of substances.

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