Substance abuse and its associated factors among HIV/AIDS patients at Dessie Comprehensive Specialized Hospital, Northeast Ethiopia, 2025

INTRODUCTION

Substance use, including alcohol, tobacco, khat, and illicit drugs, has been a long-standing human practice dating back to ancient times.^1,2 Psychoactive substance use can lead to dependence syndrome cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use. Substance use is a broad term that covers taking of all substances within which there are stages.³ Globally, an estimated 37.9 million people were living with HIV in 2020.⁴ In Ethiopia, the adult prevalence is approximately 1.2%, but among this population, substance use is disproportionately high, with studies suggesting that 20% to 50% of people living with HIV (PLHIV) engage in substance use.^5-7 This dual burden of HIV and substance use disorder (SUD) creates a cyclical problem: substance use exacerbates mental health conditions, increases risky behaviors, and drives social isolation through worsened stigma and discrimination.⁸ Individuals living with HIV are often at increased risk for substance use disorders (SUDs) and it adversely affect their adherence to antiretroviral therapy (ART), lead to poor health outcomes and increase the potential for transmission to others.⁹ Substance use can worsen health problems, complicate treatment regimens, and lead to co-infections and other chronic health issues.³ Substance use among HIV/AIDS patient’s increases healthcare costs, worsens health outcomes by impairing ART and immunity, raises HIV transmission risk through risky behaviors, and intensifies stigma and social isolation. It also contributes to unemployment and reduced productivity.^10,11

Adolescent substance abuse varies by substance type and region. Reported ranges are 11.3–60% for alcohol, 9.7–74% for khat, and 2–56.5% for tobacco. In eastern Africa, youth regular alcohol use was 52% and occasional use was 15%.¹¹ Substance use among people living with HIV/AIDS is increasing, and global estimates project growth from about 1.3 billion to 1.7 billion people by 2025.^4,30 Prevalence is 53% in developed countries and 6%–29.8% in Africa.^8,12 Across studies, prevalence ranges from 2% in Ethiopia to 56% in Nigeria.^13,14 Pooled lifetime prevalence across 53 studies was 21.0%, highest in Southern Africa (25.0%) and lowest in West Africa (17.0%); Zambia (40.0%) was highest and Sierra Leone (4.0%) lowest.^15-17 In sub-Saharan Africa, pooled adolescent prevalence is 41.6%, highest in Central Africa 55.5%, then East Africa 48.99%, and West Africa 38.3%.¹⁸ In Ethiopia, 18.4% in Mezan Tepi, 31.8% alcohol use disorder in Hawassa, and an Addis Ababa study linking higher HIV rates with alcohol consumption among ages 15–24.^18-21

Factors associated with substance use among people living with HIV/AIDS include socio-demographic characteristics such as age, sex, marital status, residence, educational status, and income, as well as individual factors like stress, depression, and ART adherence.^{10,11,15,22-27} Social and environmental influences such as having poor social support, family and friends’ substance use history, prevailing social norms, and availability of substances also contribute.^{11,15,19,23,28-33} Substance use is a major public health issue, especially with stigma and limited healthcare access. The study aims to assess prevalence and factors at Dessie Comprehensive Specialized Hospital to guide integrated interventions and improve adherence, outcomes, and stigma reduction.

METHODS

Study design, setting and period

A facility based cross sectional study design was conducted at Dessie Comprehensive Specialized Hospital (DCSH) from November 25 to December 25, 2025. DCSH is a healthcare facility located in Dessie, a city in the Amhara region of Ethiopia. Dessie located about 400 km from Addis Ababa, the capital city of Ethiopia. DCSH provides service for more than five million people of South Wollo and neighboring zones and regions.

In addition to the general services, the hospital also provides ART follow-up care services since 2005. Currently, more than 10,000 patients are on active follow-up, of who over 7832 started highly active antiretroviral treatment (HAART).

Study participants

The source population included all HIV patients receiving care and treatment at DCSH. The study population consisted of HIV patients receiving care at DCSH who were available during the data collection period. Patients who were critically ill during data collection were excluded.

Sampling size determination and procedure

A sample size of 422 was determined using the single population proportion method, with 50% assumed prevalence, 95% confidence level, 5% margin of error, and 10% non-response. After considering all primary and secondary objectives and adding 10% incomplete data, the largest required sample was 422. Finally, 422 HIV/AIDS patients on follow-up were selected from ART clinic visitors using systematic random sampling. A sampling interval of 18 (k=18) was used to choose the study participants.

Data collection instrument and procedures

After reviewing various literatures, data collection tool was prepared.^7,10,19,21 Data were collected using interviewer-administered structured questionnaires. Two health science students conducted the interviews under supervision of the principal investigator. Before data collection, all data collectors received one day of training on study objectives, how to administer the questionnaire, obtaining verbal assent, participants’ right not to join, and how to handle unclear questions.

Variables of the study

In this study, the dependent variable was substance use, categorized as yes or no. The independent variables included socio-demographic characteristics (age, sex, educational status, place of birth, income, and type of work), individual factors (perceived risk of substance use, perceived benefits, age at HIV diagnosis, ART adherence, stress, and depression), social influences (family support, family substance use history, friends’ substance use history, and social norms), and environmental factors (availability and accessibility of substances).

Operational definitions

Substance use- substances are any non-medical chemicals (including Khat, cigarette, alcohol, shisha etc.) that affect brain activity artificially and induce temporary happiness.

Data processing and analysis

Data were entered and cleaned in statistical package for the social sciences (SPSS) version 26. Descriptive statistics (frequencies, proportions, percentages) summarized the variables. Associations between substance use and independent factors were assessed using logistic regression. Variables with p<0.25 were selected for multivariable logistic regression at 95% confidence. Multivariable analysis identified statistically significant factors (p<0.05), and odds ratios were used to interpret associations. Model fit was evaluated using the Hosmer and Lemeshow goodness-of-fit test.

Data quality management and control

Data were collected by trained health science students. Questionnaires were translated from English to Amharic and back to English for consistency, and the Amharic version was used in interviews. The tools were pretested on 5% of HIV patients at Dessie Health Center ART clinic before the main study.

After collection, the principal investigator coded each questionnaire. Data were entered using double entry to reduce errors, and 5% of the entered data were rechecked against the original questionnaires. Frequency was used to check for missed values and outliers. The researcher reviewed completed questionnaires daily for completeness and consistency, taking corrective action when needed.

RESULTS

Socio-demographic characteristics

A total of 419 patients were included in the final analysis, yielding a response rate of 99.3%. The mean age of participants was 41.23 years, and 226 (53.9%) were female. The largest age group consisted of those over 45 years 193 (46.1%), followed by the 35–44 years 106 (25.3%).

Regarding monthly income, most participants 174 (41.5%) earned between 1,647 and 4,537 Birr, nearly half of the respondents 197 (47.0%) were married. In terms of education, the largest proportion had completed primary school 144 (34.4%), followed by secondary education 103 (24.6%). Finally, most participants 270 (64.4%) resided in urban areas (Table 1).

Social and other factors prevalence of substance uses among HIV/AIDS

This study indicated that significant portion of respondents were government employees 100 (23.9%). Regarding to educational status of partners, 222 (53.0%) participants did not specify or were missing information. Among those who responded, 33 (7.9%) indicated their partners couldn’t read or write, 54 (12.9%) had partners who completed only primary school, 47 (11.2%) said their partners could read and write without formal schooling. More than half of the participants 232(55.4%) reported that substance use was a positive social norm. Regarding peer influence, 101 (24.1%) stated that their best friend used substances, whereas the majority, 318 (75.9%), reported their best friend did not. Similarly, sibling influence appeared relatively low, with 325 (77.6%) reported that their siblings did not use substances, implying only 94 (22.4%) had a sibling with a history of substance use (Table 2).

Individual level factors affect prevalence of substance uses among HIV/AIDS

Nearly all respondents (414, 98.8%) are on ART. Most have lived with HIV for over five years (324, 77.3%). About a quarter (101, 24.1%) have other chronic illnesses. Adherence to ART medication schedules varied: the majority, 281 (67.1%), reported always adhering to their ART schedule, followed by 105 (25.1%) who adhered most of the time, 22 (5.3%) who adhered sometimes, and 11 (2.6%) who adhered rarely (Table 3).

Psychosocial and environmental factors affect prevalence of substance uses among HIV/AIDS

Many participants, 342 (81.6%), reported no HIV-related stigma or discrimination. About 52 (12.4%) of the respondents stated they lacked support from family or friends. For stress/anxiety, responses were mixed: 30.3% sometimes, 23.4% rarely, 22.0% often, and 24.3% reported never feeling stressed or anxious. Regarding feelings of depression, 116 (27.7%) of respondents experienced it rarely, 111 (26.5%) reported sometimes (Table 4).

Prevalence and type of substance use among HIV/AIDS

Prevalence of substance use among HIV/AIDS

Overall, 20.8% of participants currently use substances (Figure 1). Khat was the most prevalent at 64.2%, followed by alcohol at 29.8%, while only 3.8% of participants reported using cigarettes and 1.9% used other drugs.

Factor associated with substance uses among HIV/AIDS

In bivariate analysis factor such as sex, marital status, educational status, partner’s educational status, family history of substance use, sibling history of substance use, friend history of substance use, history of substance use, ART adherence, depression, and anxiety were selected for multivariable logistic regression because they had a p<0.2. Statistical significance in the multivariable model was considered at p<0.05. Males were significantly more likely to use substances than females (AOR=4.075, 95% CI: 1.793–9.263).

Individuals with friends who had a history of substance use were also more likely to use substances (AOR=6.758, 95% CI: 2.946–15.504). The strongest association was observed in individuals with a personal history of substance use at AOR of 24.085 (95% CI: 9.207–63.003). Depression was also significantly associated with substance use; individuals who often experienced depression were 12.76 times more likely to engage in substance use (AOR=12.760, 95% CI: 1.674–97.253) (Table 5).

*p≤0.05, **p≤0.01, **p<0.0001

DISCUSSION

The study found a 20.8% prevalence of substance abuse among HIV patients, which can worsen ART adherence, treatment outcomes, and quality of life, and may be driven by factors like stress, stigma, lack of support, and coping behaviors. This finding aligns with findings from similar settings done in Mezan Tepi, Ethiopia, and Nigeria (22.8%).^19,34

It recommends integrating substance screening, counseling, and treatment into HIV care. Khat was the most prevalent available substance (64.2%), followed by alcohol (29.8%). Despite cultural acceptance, both substances are linked to negative health and HIV-related outcomes, so integrated, culturally sensitive interventions are needed.

Males were about four times more likely than females to use substances. This suggests a gender-based disparity in risk and coping behaviors, emphasizing the need for gender-sensitive screening and interventions within HIV programs.^15,22,32,35 Individuals with friends who used substances had six times higher odds of substance use compared to those whose friends did not use substances among HIV patients. This finding highlights the strong role of peer influence and social networks, suggesting that interventions should also target friends/families and social environments.^{23,32,33,35,36}

A history of substance use strongly predicts on-going use, suggesting substance use is relapsing and can hinder ART adherence and health outcomes. This aligns with research viewing addiction as a chronic, relapsing condition, with higher relapse risk under stress. Therefore, integrate substance use disorder care with HIV treatment.^18,33,37

Depression was significantly associated with substance use. Depression may lead people to self-medicate, creating a cycle where substance use harms ART adherence and health, so integrated mental health support is essential in HIV care.^9,32 The significant association between depression and substance use emphasizes the need for integrated mental health support in HIV care settings, where addressing both mental health issues and substance use can improve treatment adherence and overall patient well-being.

CONCLUSION

In conclusion, this study shows high substance abuse among HIV patients, driven by availability, peer influence, gender differences, mental health (especially depression), and prior use. Male patients and those with substance-using friends or personal history face greater risk, affecting ART adherence and health. Integrated care combining HIV, mental health, and substance treatment is needed to improve outcomes, reduce transmission risk, and enhance quality of life. Health professionals should integrate routine screening and brief interventions for substance use and mental health (e.g., depression) into HIV care, with training for early referral. NGOs should strengthen community-based prevention, peer support, and harm-reduction services. Policymakers must fund integrated HIV–mental health–substance programs, reduce stigma, and expand access. Researchers should conduct longitudinal studies on these intersections.

ACKNOWLEDGEMENTS

Authors would like to thank study participants, data collectors, hospital staff and administrators, and Dessie Health Science College for their support.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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