Supporting antiretroviral therapy uptake and adherence: the SUPA research programme and RCT

Background : HIV-AIDS if not treated can lead to low quality of life and life expectancy is short, it is necessary to support the effort, care and treatment and prevention of transmission HIV-AIDS disease. Adherence therapy is crucial in supporting the success of antiretroviral therapy treatment. Method: This research was conducted with the observational method with cross sectional approach. Data collection techniques by way of interviews using structured questionnaires. Samples taken as many as 70 HIV-AIDS patients received Antiretrovial therapy. Analysis of data by using univariate analysis, bivariate analysis with Chi Square test and multivariate analysis using logistic regression analysis. Results : This study showed an association between perception of the benefits of treatment with antiretroviral therapy adherence (p value = 0000), self-efficacy with treatment adherence (p value = 0000), experience side effects with compliance with antiretroviral therapy antiretroviral therapy (p = 0.005), knowledge about treatment with antiretroviral adherence (p = 0000), the availability of drugs with antiretroviral therapy adherence (p = 0018), supported by case managers with adherence antiretroviral therapy (p = 0030). The variables that are not associated with antiretroviral therapy adherence is the perception of severity, perception of barriers, ease of access to services, family support, peer support, support team physician HIV-AIDS. Independent variables, the most dominant influence on antiretroviral therapy adherence is the knowledge of antiretroviral therapy (exp (B) = 68,098), and than experience side effects (exp (B) = 12.248) and the availability of drugs (exp (B) = 10,260). Keywords: HIV, AIDS, patients, adherence, antiretroviral, therapy.

BackgroundIncreasing HIV rates among young Latino sexual minority men (YLSMM) warrant innovative and rigorous studies to assess prevention and treatment strategies. Ecological momentary assessments (EMAs) and electronic pill dispensers (EPDs) have been used to measure antiretroviral therapy (ART) adherence repeatedly in real time and in participants’ natural environments, but their psychometric properties among YLSMM are unknown.ObjectiveThe study’s objective was to assess the concurrent validity, acceptability, compliance, and behavioral reactivity of EMAs and EPDs among YLSMM with HIV.MethodsA convenience sample of 56 YLSMM with HIV with suboptimal ART adherence, aged 18‐34 years, was recruited into a 28-consecutive-day EMA study. Concurrent validity was analyzed by comparing median ART adherence rates and calculating Spearman correlations between ART adherence measured by EMA, EPD, and baseline retrospective validated 3-item and single-item measures. Acceptability was assessed in exit interviews asking participants to rate EMA and EPD burden. Compliance was assessed by computing the percent lost to follow-up, the percent of EMAs missed, and the percentage of days the EPD was not opened that had corresponding EMA data self-reporting adherence to ARTs. Behavioral reactivity was assessed by computing the median change in ART adherence during the study period, using generalized mixed models to assess whether the cumulative number of EMAs completed and days of EPD use predicted ART adherence over time, and by asking participants to rate perceived reactivity using a Likert scale.ResultsEMA ART adherence was significantly correlated with baseline validated 3-item (r=0.41, P=.003) and single-item (r=0.52, P<.001) measures, but correlations were only significant for participants that reported EMA was not burdensome. Correlations for EPD ART adherence were weaker but significant (r=0.36, P=.009; r=0.34, P=.01, respectively). Acceptability was high for EMAs (48/54, 89%) and EPDs (52/54, 96%) per self-report. Loss to follow-up was 4% (2/56), with the remaining participants completing 88.6% (1339/1512) of study-prompted EMAs. The percentage of missed EMA surveys increased from 5.8% (22/378) in week 1 of the study to 16.7% (63/378) in week 4. Of 260 days when EPDs were not opened, 68.8% (179) had a corresponding EMA survey self-reporting ART adherence. Reactivity inferred from the median change in ART adherence over time was 8.8% for EMAs and −0.8% for EPDs. Each completed EMA was associated with 1.03 odds (95% CI 1‐1.07) of EMA ART adherence over time, and each day of EPD use with 0.97 odds (95% CI 0.96‐0.99) of EPD ART adherence over time. Self-reported perceived behavioral reactivity was 39% for EMAs and 35% for EPDs.ConclusionsThis study provides evidence of concurrent validity with retrospective validated measures for EMA- and EPD-measured ART adherence among YLSMM, when participant burden is carefully considered, without significant behavioral reactivity. While acceptability and compliance of EMAs and EPDs were high overall, noncompliance increased over time, suggesting respondent fatigue.

Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist. To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients. Retrospective cohort study. Multi-state Medicaid database (Thomson Reuters MarketScan®). Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed. Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables. In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63-0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12-3.29). Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.

Childhood sexual abuse (CSA) has been shown to be more prevalent among populations living with HIV. Antiretroviral therapy (ART) adherence is crucial for populations living with HIV as it significantly increases the likelihood of attaining and maintaining viral suppression. Previous findings on the association between CSA and ART adherence have been mixed. The current mixed-methods systematic review aimed to identify quantitative and qualitative studies from CINAHL, PsycInfo, PubMed, and Web of Science examining the relationship between CSA and ART adherence. Authors were also contacted if relevant data were unpublished. Studies had to be published from January 1, 2000 to April 1, 2019, written in English, and examined CSA as an exposure and ART adherence as an outcome. Four domains were combined: 1) childhood sexual abuse; 2) child; 3) antiretroviral; and 4) adherence. Eight quantitative and two qualitative studies were retained. The results showed that four quantitative studies found no association while the other four found factors such as timing of victimization, mental health and gender influenced the association between CSA and ART adherence. Themes emerging from the qualitative studies included use of ART evoking memories of CSA; CSA impacting mental health; and mental health treatment improving ART adherence. Mixed insights included the intricate links between CSA and ART adherence and the role of external factors on the relationship. ART adherence intervention programs may be needed for people who have experienced CSA. However, future studies are needed that will examine the association between CSA and ART adherence and include subgroup analyses.

People living with HIV (PLWH) have a higher risk of experiencing sexual assault compared to populations without HIV. Prior studies have shown independent associations between sexual assault, depression, and antiretroviral therapy (ART) adherence. However, research analyzing the potential mediating effects of depressive symptoms between sexual assault and ART adherence, and the associated age and sex disparities, especially among PLWH in the Southern United States, is lacking. Therefore, the current study sought to determine whether depressive symptoms mediate the association between sexual assault and ART adherence and to evaluate the associated age and sex disparities among PLWH in South Carolina. Data were collected from 337 individuals who received HIV care from an immunology center in South Carolina. Crude and adjusted path analysis models stratified by age and sex were used to determine the association between sexual assault, depressive symptoms, and ART adherence. Depressive symptoms were associated with ART adherence among adults aged 18-34 (β = - 0.281, p = .018) and 35-49 (β = - 0.185, p = .005), and men (β = - 0.205, p = .011). Sexual assault was associated with depressive symptoms (β = 0.211, p = .001) and with ART adherence (β = - 0.172, p = .010) among adults 35-49. Among men (β = - 0.238; p = .029) and women (β = - 0.344, p = .001), sexual assault was associated with ART adherence; among women, sexual assault was associated with depressive symptoms (β = 0.280, p = .006). Depressive symptoms mediated the association between sexual assault and ART adherence among adults 35-49 (β = - 0.039, p = .035). Interventions addressing depressive symptoms may improve ART adherence among adults aged 18-34 and 35-49 and men. Programs also addressing depressive symptoms and using trauma-informed approaches may improve ART adherence, especially among middle-age populations, men, and women.

Childhood sexual abuse (CSA) is linked to substance use and lower antiretroviral therapy (ART) adherence. However, studies examining the mediational role of substance use between CSA and ART adherence are lacking. Therefore, the aim of this study was to determine the potential mediational role of substance use between CSA and ART adherence among older adults living with HIV (OALH) (n = 91). Mediation analyses assessed the direct and indirect relationships between CSA, substance use, and ART adherence. Statistically significant differences existed in substance use by gender (male vs. female: 12.3 vs. 9.97) and ART adherence by race (Black vs. White: 98.2% vs. 99.6%) and employment. CSA was associated with ART adherence (β = -3.27, p < .001) and substance use (β = 2.14, p = .035), but substance use was not associated with ART adherence, and did not mediate the pathway between CSA and ART adherence in the adjusted model. Trauma-informed interventions may lower substance use among OALH with CSA.

In Ghana, poor treatment adherence among persons living with HIV (PLHIV) affects the effective treatment and management of HIV/AIDS. A key limitation in addressing the antiretroviral therapy (ART) adherence challenge is the skewed nature of the existing literature on the topic, as much of the research on ART adherence has focused on patient-reported experiences, failing to capture the perspectives of healthcare providers involved in ART delivery. We ascertained healthcare providers' perspectives on ART adherence among PLHIV and their proffered recommendations for improved ART retention in the Volta Region of Ghana. A total of eighteen healthcare providers offering ART services to PLHIV in the Volta Region of Ghana were purposefully recruited from five HIV sentinel sites and interviewed. The data was thematically analyzed using ATLAS.ti. The health workers' experiences were categorized under seven thematic areas. These included difficulties in accessing healthcare providers, improvements in adherence to treatment, people who have interrupted treatment often being new clients, general improvements in health outcomes, financial challenges, persistent stigmatization, and varied levels of family awareness about clients' status. The reasons for treatment interruption were categorized into fifteen areas. These factors included appointment intervals, healthcare workers, medication shortages, long waiting times, clients' distance from the facility, forgetfulness, drug characteristics, financial challenges, stigmatization, drug side effects, lack of donor support, alternative treatment choices, misconceptions about HIV cures, and the location of the ART clinic within the health facility. Participants recommended making health facilities/ART sites accessible to communities, increased advocacy on HIV by PLHIV, extended appointment intervals, continuous availability of antiretroviral drugs (ARVs), community support in the treatment of HIV, improved counseling, public education on HIV to reduce stigmatization, government support, home dispensing of ARVs, regulating the activities of traditional herbalists and faith-based healers, and the encouragement of religious bodies in ART adherence education for improved ART uptake. The ART-related challenges identified by the healthcare providers should be addressed by both the Ghana Health Service and the Ghana AIDS Commission to improve ART uptake and adherence in the Volta Region and across the country if Ghana is to end the HIV pandemic by 2030, as set by UNAIDS.

BackgroundIn Ghana, poor treatment adherence among persons living with HIV (PLHIV) affects the effective treatment and management of HIV/AIDS. A key limitation in addressing the antiretroviral therapy (ART) adherence challenge is the skewed nature of the existing literature on the topic, as much of the research on ART adherence has focused on patient-reported experiences, failing to capture the perspectives of healthcare providers involved in ART delivery.ObjectiveWe ascertained healthcare providers’ perspectives on ART adherence among PLHIV and their proffered recommendations for improved ART retention in the Volta Region of Ghana.MethodsA total of eighteen healthcare providers offering ART services to PLHIV in the Volta Region of Ghana were purposefully recruited from five HIV sentinel sites and interviewed. The data was thematically analyzed using ATLAS.ti.ResultsThe health workers’ experiences were categorized under seven thematic areas. These included difficulties in accessing healthcare providers, improvements in adherence to treatment, people who have interrupted treatment often being new clients, general improvements in health outcomes, financial challenges, persistent stigmatization, and varied levels of family awareness about clients’ status. The reasons for treatment interruption were categorized into fifteen areas. These factors included appointment intervals, healthcare workers, medication shortages, long waiting times, clients’ distance from the facility, forgetfulness, drug characteristics, financial challenges, stigmatization, drug side effects, lack of donor support, alternative treatment choices, misconceptions about HIV cures, and the location of the ART clinic within the health facility. Participants recommended making health facilities/ART sites accessible to communities, increased advocacy on HIV by PLHIV, extended appointment intervals, continuous availability of antiretroviral drugs (ARVs), community support in the treatment of HIV, improved counseling, public education on HIV to reduce stigmatization, government support, home dispensing of ARVs, regulating the activities of traditional herbalists and faith-based healers, and the encouragement of religious bodies in ART adherence education for improved ART uptake. The ART-related challenges identified by the healthcare providers should be addressed by both the Ghana Health Service and the Ghana AIDS Commission to improve ART uptake and adherence in the Volta Region and across the country if Ghana is to end the HIV pandemic by 2030, as set by UNAIDS.

Conflicting evidence exists on the impact of cannabis use on antiretroviral therapy (ART) adherence among people with human immunodeficiency virus (PWH). We leveraged data collected among older PWH to characterize longitudinal associations between cannabis use and ART adherence. AIDS Clinical Trials Group (ACTG) A5322 study participants were categorized as <100% (≥1 missed dose in past 7 days) or 100% (no missed doses) ART adherent. Participants self-reported current (past month), intermittent (past year but not past month), and no cannabis (in past year) use at each study visit. Generalized linear models using generalized estimating equations were fit and inverse probability weighting was used to adjust for time-varying confounders and loss to follow-up. Among 1011 participants (median age, 51 years), 18% reported current, 6% intermittent, and 76% no cannabis use at baseline; 88% reported 100% ART adherence. Current cannabis users were more likely to be <100% adherent than nonusers (adjusted risk ratio [aRR], 1.53 [95% CI, 1.11-2.10]). There was no association between ART adherence and current versus intermittent (aRR, 1.39 [95% CI, .85-2.28]) or intermittent versus no cannabis use (aRR, 1.04 [95% CI, .62-1.73]). Among a cohort of older PWH, current cannabis users had a higher risk of <100% ART adherence compared to nonusers. These findings have important clinical implications as suboptimal ART adherence is associated with ART drug resistance, virologic failure, and elevated risk for mortality. Further research is needed to elucidate the mechanisms by which cannabis use decreases ART adherence in older PWH and to advance the development of more efficacious methods to mitigate nonadherence in this vulnerable population.

Depression consistently emerges as a significant predictor of poor antiretroviral therapy (ART) adherence among adult people living with human immunodeficiency virus (PLHIV). However, a gap exists regarding how social support and depressive symptoms can interact to influence ART adherence among adult PLHIV in South Africa (SA). To investigate the interaction between social support and depressive symptoms on ART adherence among adult PLHIV. A tertiary hospital in Durban, KwaZulu-Natal province of SA. Utilising a quantitative cross-sectional research design along with time location sampling technique (TLS); the study recruited 201 adult patients enrolled in an ART programme. The results indicated that depressive symptoms were significantly associated with ART adherence with and without the interaction (B = -0.105; odds ratios [OR] 0.901; 95% confidence intervals [CI] = 0.827, 0.981; p = 0.016), while social support was not significantly associated with ART adherence (B = 0.007; OR 1.007; 95%CI = 0.989, 1.025; p = 0.475). However, a statistically significant interaction was found between social support and depressive symptoms (B = -0.006; OR 0.994; 95%CI = 0.989, 1.000; p = 0.037) on ART adherence. Based on the results, depressive symptoms significantly influenced ART adherence. However, social support did not buffer the adverse effects of clinical depression associated with poor ART adherence. This study provides an evidence-based approach to address gaps in the mental health and social well-being of PLHIV in the context of ART adherence.

Young African American men who have sex with men (AAMSM) experience disproportionately high HIV incidence and are less likely to achieve viral suppression compared to White men who have sex with men, an outcome that relies on antiretroviral therapy (ART) adherence. We created My Personal Health Guide, a talking relational agent-based mobile health app to improve ART adherence among young AAMSM. The objective was to determine the efficacy of My Personal Health Guide on improving ART adherence among young AAMSM living with HIV. We implemented a randomized controlled trial among young (aged 18-34 years) AAMSM with nonoptimal ART adherence throughout the United States between February 2020 and September 2023, predominantly through social media and by word of mouth, provider referral, and fliers in selected health care settings. Participants were randomized in a 1:1 ratio using permuted blocks of 8 to the intervention, My Personal Health Guide, or the attention control arm. ART adherence was assessed with Wilson's 3-item self-reported adherence measurement and dichotomized at ≥80%. Logistic regression models using backward selection were used to evaluate the efficacy of My Personal Health Guide on ≥80% ART adherence at 1-month follow-up. Among the 253 AAMSM at baseline, most (n=180, 71.1%) self-reported being ≥80% adherent to ART, over half (n=145, 57.3%) resided in the Southern United States, but all US regions were represented, nearly half (n=175, 42.3%) had some college education, over one-third (n=96, 37.9%) had less than optimal literacy, and approximately one-quarter (n=61, 24.1%) experienced housing insecurity in the past 6 months. The sample for analysis of the My Personal Health Guide app efficacy was 131 (intervention=76 and control=55). The odds of being ≥80% adherent to ART at 1-month follow-up were 3.97 (95% CI 1.26-12.55) times greater among participants randomized to the My Personal Health Guide app compared to the controls, after adjusting for ART adherence at baseline, treatment adherence self-efficacy, and ever being incarcerated. Additionally, for every 1-point increase in the HIV Treatment Adherence Self-Efficacy Scale, the odds of ≥80% ART adherence increased by 3% (odds ratio 1.03, 95% CI 1.00-1.06). Participants randomized to receive My Personal Health Guide reported nearly 4 times greater odds of being ≥80% adherent to ART compared to the attention control group at 1-month follow-up. To our knowledge, this is the first randomized controlled trial demonstrating improved medication adherence using a relational agent-based behavioral intervention. These findings provide evidence of short-term efficacy of My Personal Health Guide to improve ART adherence among young AAMSM. We recommend further research on the inclusion of relational agents in behavioral research, especially in populations affected by stigma and nonoptimal health literacy, where this nonhuman supportive and educational approach may be complementary to health care systems. ClinicalTrials.gov NCT04217174; https://clinicaltrials.gov/study/NCT04217174.

We sought to (a) replicate and (b) extend (via the addition of alcohol use) Cha et al.'s cross-sectional multi-component model of ART adherence on the relationship between social support, depression, self-efficacy beliefs, and antiretroviral therapy (ART) adherence, among HIV patients in Tshwane, South Africa. Using purposive sampling, 304 male and female ART recipients were recruited. ART adherence was assessed using three manifest indicators: total adherence ratio, the CASE adherence index and 1-month adherence measure. Data were analysed using structural equation modeling. In our replicated model, social support had both direct and indirect relationships with ART adherence, and inclusion of alcohol use improved prediction of ART adherence. Direct and indirect effects of alcohol use on ART adherence emerged: adherence self-efficacy beliefs partially mediated the latter path. Findings highlight the importance of integrating into ART promotion interventions, the reduction of alcohol use, provision of social support, and enhancement of adherence self-efficacy beliefs.

BackgroundEvidence suggests that economic, social, and psychological circumstances brought about by the COVID-19 pandemic may have a serious impact on behavioral health. Men who have sex with men (MSM) are disproportionally impacted by HIV and stimulant use, the co-occurrence of which heightens HIV transmission risk and undermines nationwide treatment strategies as prevention efforts for ending the HIV epidemic. There is a paucity of information regarding the potential impact of the COVID-19 pandemic on the substance use and HIV medication adherence in this key vulnerable population—MSM who use stimulants and are living with HIV.ObjectiveThe aim of this qualitative study was to identify ways in which the COVID-19 pandemic has affected stimulant use and antiretroviral therapy (ART) adherence among a sample of MSM living with HIV.MethodsTwo focus groups were conducted in August 2020 via videoconferencing technology compliant with the Health Insurance Portability and Accountability Act. Potential participants from an established research participant registry at State University of New York Downstate Health Sciences University were invited and screened for study participation on the basis of inclusion criteria. A semistructured interview guide was followed. A general inductive approach was used to analyze the data. Findings in two general areas of interest, the impact of the COVID-19 pandemic on stimulant use and ART adherence, emerged directly from the raw data.ResultsA total of 12 ethnically diverse participants over the age of 25 years took part in the study. Results were heterogeneous in terms of the effects of the pandemic on both stimulant use and ART adherence among MSM living with HIV. Some men indicated increased or sustained stimulant use and ART adherence, and others reported decreased stimulant use and ART adherence. Reasons for these behavioral changes ranged from concerns about their own health and that of their loved ones to challenges brought about by the lack of daily structure during the lockdown phase of the pandemic and emotion regulation difficulties.ConclusionsThe COVID-19 pandemic has had a differential impact on stimulant use and ART medication adherence among MSM living with HIV. The reasons for behavioral change identified in this study may be salient intervention targets to support ART medication adherence and lower stimulant use among MSM in the aftermath of the of the COVID-19 pandemic, as well as beyond.

Objective:We are failing to reach 95–95–95 for adolescents living with HIV (ALHIV). Sexual abuse and intimate partner violence (IPV) may impact antiretroviral therapy (ART) adherence, with high rates of 17.4 and 29.7%, respectively, across the southern sub-Saharan African region. However, evidence on their associations with adolescent ART adherence remains limited, with only three cross-sectional studies globally.Design:A prospective cohort of ALHIV (sample N = 980, 55% female individuals, baseline mean age 13.6 years) were recruited from 53 health facilities in South Africa's Eastern Cape Province and responded to a structured questionnaire at 18-month and 36-month follow-up (2015–2016, 2017–2018).Methods:A repeated-measures random effects model assessed multivariable associations of self-reported sexual abuse and IPV with past-week ART adherence, controlling for individual, socioeconomic, and HIV-related factors. Past-week adherence was defined based on currently taking ART and not having missed any doses in the past 7 days (including weekends). We further fitted a moderation model by sex.Results:Fifty-one percent of adolescents reported consistent ART adherence at both time points. Exposure to IPV was associated with lower odds of self-reported ART adherence (aOR 0.39, 95% CI 0.21–0.72, P = 0.003), as was sexual abuse (aOR 0.54, 95% CI 0.29-0.99, P = 0.048). The marginal predicted probability of ART adherence for adolescents with no exposure to either IPV or sexual abuse was 72% (95% CI 70–74%) compared with 38% (95% CI 20–56%) for adolescents with exposure to both IPV and sexual abuse. Moderation results showed similar associations between sexual violence and ART adherence by sex.Conclusion:Sexual violence prevention and postviolence care may be essential components of supporting adolescent ART adherence. Integration of HIV and violence prevention services will require accessible services and simple referral systems.

PurposeMarijuana use is common among people living with HIV (PLWH), but its association with antiretroviral therapy (ART) adherence is unclear. This study examined the association between reason for marijuana use and ART adherence in a sample of adults living with HIV.Patients and methodsParticipants (N=703) recruited from seven community health centers in Florida completed a 45-minute questionnaire assessing demographics, symptoms of anxiety and depression, ART adherence, and substance use, including reasons for marijuana use. ART adherence was defined as the proportion of days in the last 30 days participants did not miss any medication and dichotomized as optimal (≥95%) and suboptimal (<95%). Multivariate logistic regression analysis assessed the association between therapeutic marijuana use to manage HIV symptoms (ie, improve appetite/gain weight, induce sleep, relieve nausea/vomiting, relieve pain, relieve anxiety/depression/stress) versus recreational marijuana use and ART adherence.ResultsApproximately one third (33.2%) of the participants reported using marijuana in the past 3 months. Of marijuana users, 21.8% reported using marijuana only for therapeutic purposes to manage HIV-associated medical symptoms, while 78.2% reported recreational use. After controlling for covariates, therapeutic use of marijuana was not associated with ART adherence (AOR =1.19, 95% CI =0.60–2.38, p=0.602) while recreational marijuana users showed significantly greater odds of suboptimal ART adherence compared to nonusers (AOR =1.80, 95% CI =1.18–2.72, p=0.005).ConclusionOur results suggest differences in ART adherence between individuals who report recreational versus therapeutic marijuana use. Continued research examining the health implications of marijuana use among adults living with HIV is important as legalization of recreational and medical marijuana proliferates in the United States.