Alcohol and other drug use among HIV-affected adolescents and young adults in Zambia: a qualitative study of multilevel drivers and preferences for prevention and treatment approaches.

Background: Alcohol and other drug (AOD) use is a growing public health problem among AYA and young adults (AYA) globally. AYA who are affected by HIV in low-and-middle-income countries (LMICs) may have high risk for AOD use problems, yet the context of AOD use remains an understudied area in this population. Methodology: In this qualitative study, we conducted 16 focus group discussions with HIV-affected AYA (ages 16-24), caregivers, and healthcare workers, and eight key informant interviews with mental health experts in Lusaka, Zambia. Thematic analysis with open coding explored multi-level determinants of AOD use among HIV-affected AYA, as well as perceptions of intervention approaches. Results: The study included N = 40 AYA, N = 50 caregivers, N = 40 lay healthcare workers, and M = 41 professional healthcare workers. Substance use among AYA was commonly initiated as a coping mechanism for trauma and perpetuated by withdrawal symptoms. Perceived benefits included enhanced cognitive (boys) or sexual (girls) performance. Interpersonal factors, including peer pressure, bullying, and lack of family support contributed to initiation and continuation of use. Structurally, limited access to recreational facilities, poverty, unemployment, and widespread availability of inexpensive substances facilitated use. At the health system level, the absence of standardized treatment guidelines, insufficient AYA-specific services, and pervasive stigma surrounding AOD care impeded access to services. Current prevention efforts were seen as limited by targeting HIV alone, having limited accessibility, and favoring girls in implementation. Conclusion: Findings underscore the need for integrated HIV and AOD services, gender-responsive and trauma-informed interventions, and structural approaches addressing youth unemployment and service accessibility.