Despite the central role of substance use in the acquired immunodeficiency syndrome (AIDS) epidemic, the role of individual substances on human immunodeficiency virus (HIV) disease progression has been a complicated puzzle. Cook and colleagues studied the impact of crack cocaine use among 1686 HIV-positive women in the Women's Interagency Cohort Study between 1996 and 2004, the era of highly active antiretroviral therapy (HAART). Outcomes examined included the following measures of HIV disease progression: death, AIDS-defining illness, CD4 count, and HIV viral load.

To identify the impact of crack cocaine specifically, researchers controlled for potential confounders including age, race/ethnicity, education, income, tobacco, heroin and injection drug use, baseline HIV viral load and CD4 cell count, year of HIV diagnosis, study site, HAART adherence, depressive symptoms and problem drinking. Analyses were based on patterns of use: 1203 women (71.4%) were nonusers of crack cocaine, 429 (25.4%) were intermittent users, and 54 (3.2%) were persistent users (use reported at every study visit).

• Persistent users had a significant increase in death, AIDS-defining illness, and HIV viral load and a decrease in CD4 count compared with nonusers.
• Intermittent users had an increase in AIDS-defining illnesses compared with nonusers and had intermediate CD4 counts and HIV viral loads.
• Lack of access to health care was not a factor; 100% of participants reported seeing a health-care provider within the past 6 months.

Comments by Norma Finkelstein, PhD, LICSW
This study details the independent relationship between crack cocaine use and the progression of HIV disease in women. Although multi-sited in 6 urban cities, the study sample was primarily composed of African-American women (80%), which makes its generalizability to other populations at least questionable. Nevertheless, treatment practitioners working with HIV-infected female crack cocaine users should let clients know about the specific effects of crack on their HIV disease, and intensify treatment as needed to help them achieve abstinence.