Background:  Among HIV researchers and clinicians, “drug use” has long been a code word for injection drug use (IDU); this is due in part to the early decision to report AIDS cases within hierarchical categories that were interpreted as independent, non-overlapping and exhaustive. That decision was enhanced with creation of the categorical funding streams (i.e., NIDA, NIAID, NIMH). The categories revealed a class-based distinction (race, education, income) that may have further dampened a concerted response to the effects of substance use on other HIV risk behaviors. An unfortunate consequence has been the delay in fully addressing non-injection substance use as an important influence on sexual risk for HIV transmission. Until recently, substance abuse HIV prevention has focused primarily on injection (rather than drug) related behavior, centered on a comprehensive approach to injection drug use involving drug abuse treatment, syringe access, and other behavioral, social, and environmental interventions. Multiple cities now report that HIV rates in IDU have been lowered to rates equal to non-IDU. The remaining challenge is addressing sex risk, including the established role of non-injected substances (cocaine/crack, club drugs including methamphetamine, inhaled heroin, abused prescription drugs, and alcohol). 

Conclusions:  The successful introduction of buprenorphine has expanded the availability of opioid treatment and has been shown to be effective in HIV risk reduction and appropriate for those abusing prescription analgesics. While pharmacological advances for stimulant abuse have been limited, there is evidence suggesting benefits of behavioral therapies. For occasional users, brief, office-based, and other low-threshold interventions have demonstrated efficacy, whereas more extensive approaches—such as cognitive behavioral therapy, motivational interviewing, and contingency management—have been successful for dependent users. Research on mechanisms of how drugs influence sex risk will contribute to shaping the content of interventions. Moving forward, research and practice need to better embrace authentic multi-disciplinary perspectives that include greater emphasis on substance abuse issues.