Changes in marijuana use and associated attitudes and health behaviors among patients in HIV care in the U.S. in the post-legalization era: a qualitative study

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INTRODUCTION
Compared to those without HIV, marijuana use among people with HIV (PWH) has been associated with worse health outcomes including increased risk of cardiovascular and lung disease (independent of smoking tobacco) (Lorenz et al., 2017;Lorenz et al., 2019), respiratory issues such as chronic bronchitis (Volkow et al., 2014), and negative impact on cognition and memory (Crean et al., 2011;Cristiani et al., 2004;Skalski et al., 2016;Thames et al., 2016).Among PWH, marijuana has also been found to have an adverse impact on health behaviors essential to survival, notably HIV-care appointments and antiretroviral adherence (Dietz et al., 2010;Kipp et al., 2017;Kuhns et al., 2016;Montgomery et al., 2019;Newville et al., 2015) with some studies finding greater negative impact with more frequent use (Bonn-Miller et al., 2014;Kuhns et al., 2016;Newville et al., 2015).Marijuana use has also been associated with higher odds of drug and alcohol use disorders among PWH (Han and Palamar, 2018).The current epidemiological literature, coupled with reports that marijuana use in the U.S. has increased in recent years (Kerr et al., 2018), possibly in concert with the relaxation and/or eradication of laws prohibiting its use in some states (Zvonarev et al., 2019), raises concern for increased morbidity among PWH.Studies have found a higher prevalence of marijuana use among PWH compared to the general population (Center for Behavioral Health Statistics and Quality, 2016;Prentiss et al., 2004;Shiau et al., 2017), with a threefold higher past-year use (34.2% versus 11.1%) and fourfold higher past-month use (24.9% versus 6.7%) (Shiau et al., 2017).
While there is a potential cause for concern regarding the impact of marijuana's broadening availability on patterns of behavior and health outcomes among PWH, marijuana may help some PWH, who report relief from a broad array of symptoms with use, including pain and anxiety (Chayama et al., 2021;Sajdeya, 2021), or those who use it as an appetite stimulant (Sajdeya, 2021).Indeed, PWH were integral to catalyzing the medicinal marijuana movement in the 1990s (Mann, 2019), and the use of marijuana for medical purposes has long been supported by some care providers (Bridgeman and Abazia, 2017).
The risks of marijuana use for PWH relative to its benefits warrant further exploration, especially in the emerging context of legalization with increased availability of regulated marijuana products, particularly for different methods of delivery (e.g., edibles vs. smoking or vaping), increased package labeling (e.g., type, THC percentage, THC/CBD ratio), and increased product potency, as one study found THC levels in marijuana increased threefold 1995-2014(ElSohly et al., 2016)).Patterns of use among PWH since legalization, as well as their perceptions of health effects compared to benefits, are poorly understood.
Through patient interviews, we sought to gain an in-depth understanding of the impact that state-level marijuana policy changes had on marijuana use behaviors, including patterns of use (e.g., frequency, modality), access, goals for use, use of other substances, and perceived health effects among PWH.

Study population and recruitment
We recruited PWH ≥ age 18 for 1:1 interviews at 3 clinics within the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) in 2019-2020: Fenway Health-Boston, MA; 1917 Clinic at the University of Alabama-Birmingham; and Madison Clinic at Harborview Medical Center/University of Washington-Seattle.
Recruitment was based on the indication of eligibility through routinely administered pre-visit electronic assessment of patientreported outcomes and measures (PROs) (Crane et al., 2007;Lawrence et al., 2010).The PRO measures include a range of health assessments including a substance use screening tool (ASSIST) which queries the frequency and modality of the past 3month marijuana use.Based on eligibility alerts from PROs, we recruited PWH at the time of their appointment or by phone afterward.We recruited a mix of daily and weekly marijuana users at all sites; in states where marijuana legalization occurred, we recruited PWH who increased their use post-legalization, those who decreased use, and those whose use remained the same.Site Institutional Review Boards approved study activity.

Patient interviews
A multidisciplinary team of HIV care providers and researchers designed an interview guide querying key areas of interest regarding marijuana use, with a focus on changes in perceptions of marijuana products, and patterns of use pre-and post-legalization.Topic areas included: 1) goals for use; 2) product access; 3) patterns of use, including frequency, method of delivery, and factors affecting use; 4) user experience; 5) relationship to use of other substances; 6) control of use including cessation; 7) perceptions of health impact, and 8) social dimensions of use.Interviews were ~60 min and were conducted by trained qualitative researchers either by phone or in person.We offered $50 compensation.

Interview coding
Two trained qualitative researchers coded transcripts using Dedoose software (Sociocultural Research Consultants LLC, 2014).We coded interview content upon receipt of each transcript based on the aforementioned topic areas.Within each topic area, two coders independently used an opencoding process to identify the theme within the interview excerpt.We then sought consensus on existing themes, facilitated by the qualitative project leader, and evaluated theme frequency.
We evaluated for thematic saturation, the point at which no new themes emerge from additional interviews, after coding the 15th and 25th interviews.The qualitative project leader summarized emergent themes found within the coded categories.We conducted four additional interviews upon finding saturation after the 25th; we then determined that no new themes had emerged and ceased recruitment.

Goals for use
Relaxation and sleep were the most-cited goal for use (66%), followed by a desire to increase appetite (41%), relief of stress/anxiety (31%), pain relief (28%), fun/ recreation (28%), reduce cravings for another substance (17%), and treat physical symptoms other than pain (10%); 69% of participants cited use for more than one purpose.Legalization did not modify goals for use.For nearly a quarter of participants, however, general goals for use changed over time and life course, independent of legalization, from recreational use to treatment of symptoms: From age 18 or 19; it was just purely recreational, very sporadic…then I started taking [the HIV cocktail]; it was the first time I started using cannabis for an entirely different reason.I would get so nauseated and weak and tired.It was a different cocktail then… that's when my usage became way more regular.(Male, 54, MA) I don't smoke as much as before, 'cause I don't smoke enough to get f--ked up.It's more of a medical and an emotional thing…the use became…a way of help[ing] me take care of my mental health.And of helping me eat (Male, 33, MA).
I smoke [just] so much until the pain goes away and that's it.But, I mean, getting loaded or high--no, no more (Transgender female, 51, WA).
Five participants indicated that a primary goal of their marijuana use was to help manage cravings for another substance, namely methamphetamine and/or alcohol: Weed helps with my [meth] cravings a lot.It throws my mind off.It doesn't make me think about it.I could wanna do some meth, and then I could smoke some weed and just completely get lost in the [TV] show or find something interestingmy mind can be deterred from it way easier than if I'm just sober (Male, 39, WA).

Fredericksen et al. 3
Pot helps me keep my alcohol in check.If I just drink and then don't smoke pot, I drink way too much.But if I smoke some pot, I'll drink a lot less (Male, 49, WA).
When I stopped drinking completely, it would be cannabis that probably saved me because that was when I switched …all I did was smoke.And that was plenty.I preferred it.I remembered my life, and I didn't destroy anyone else's…so that's when everything switched (Male, 54, MA).

Product access, including price
For states in which marijuana products were legal, participants overwhelmingly reported easy access to dispensaries.Most already had well-established contacts from whom to purchase marijuana before legalization.
Several participants reported that they were glad to stop using street-based dealers: I used to get it from the street people, you know?Now I just go to the dispensaryit's a lot better.'Cause when you used to go to just on the street, sometimes I used to get burned….whenI get home in my apartment, it's, like, 'What the hell?'[The 'weed'] was a wet newspaper.I don't buy weed from anybody in the street no more (Transgender female, 51, WA).
However, some participants reported price barriers and continued purchasing through their dealers: The dispensary….don'tgive you your money's worth...you can always get more from your friend (Male, 52, WA).
In AL, where recreational marijuana sale/use is not legalized, most claimed marijuana was still "easy" to get, occurring through dealers.However, one participant echoed others in disliking the feeling of obligation to be social with a dealer.
Back when I was younger, I was more social.Now I'm older…I have to find somebody that's not trying to talk to me [like a friend] because…it ruins the business aspect of it (Male, 49, AL).

Patterns of use, including frequency, method delivery, and factors affecting the use
One-third of participants living in states where marijuana is legal (MA, WA) reported a change in their patterns of use since legalization.Among this subset, all but one noted an increase in the frequency of use, and one noted only a brief increase in use.For these participants, ease of accessibility was a key factor in this increase: The availability and the legalization [of marijuana]…was a [The joints'] CBD content was a little bit higher…and so I wanted to see how I do with them, and I wanted them to…help me sleep (Male, 49, WA).
I think I had access to whatever they want to call all the different strains now.The difference between then and now is now I know which one is which…I never realized that some of it was different feeling because…my prime goal back at that point was to get rid of nausea, and all of them work for that.Does not matter strain.But some of them would make you more nervous or more paranoid, and others would relax and calm you, and you didn't know why (Male, 54, MA).

Relationship to use of other substances
When asked about the use of other substances along with marijuana, a few patients reported using it to magnify the effects of alcohol.However, multiple participants also reported using marijuana to reduce alcohol intake: I feel like I can maintain a plateau easier and with less substances when I drink, both drink beer and do pot (Male, 58, WA).
I have found that, you know, when I have taken like a tincture or had an edible or so before I go to like a bar event, or go out for drinks or dinner or something, that I don't have to have as much alcohol to feel a buzz...I like that sort of balance.I also like the fact that just having, even if it's a glass of wine or, one cocktail or two, kind of helps me get into that space.You feel the high.It sort of speeds it along a little bit.It also puts me in a mindset to say, okay, I'm in a good place, so I'm going to just coast on this for a bit.I may sip on my drink versus ordering another one.So, I've learned to kind of create a balance where I keep myself in check, especially in a social setting (Male, 39, MA).
One participant reported using marijuana for sleep and to increase their appetite after a long session of methamphetamine use: When I was doing meth, if I was coming down and I was done I know I needed to sleep then I would smoke some weed.And I need to eat and I need to calm myself down.I would smoke some weed.And get myself back together (Male, 39, WA).
One participant also reported marijuana use to augment prescription opioids for pain relief: It's really a combined usage of my medicines that I get from a doctor and the cannabis that create livable pain levels (Female, 60, WA).

Control of use including cessation
Over half of the participants had not tried to 'control' their use (n=16 Control of use appeared to be especially easy for edibles: It's one edible… I've never taken one and then had another and another one (Male, 58, WA).
For one participant this was aided by the product labeling: I try to do a 'dosage' -which is why I like these dispensaries…everything is kind of portioned out.I try to do a dosage of around 10 milligrams, usually.Sometimes if I really want an extra boost, I'll do 15.Maybe even 20.…I feel like that gives me just the right balance of everything (Male, 39, MA).
Others measured use by units (e.g., blunts) or by rationing a set amount: My main thing is smoking blunts …I have one when I get home from work.Definitely before I go to bed I'll smoke another one and that's it (Male, 29, MA).
I try to ration it, you know?And not really smoke it all up in one day, I try, so I probably smoke one blunt today then one blunt tomorrow (Female, 41, AL).
I just made sure that whatever I get last week for that month, so I roll it small, then skinny, and then when I'm out, I'm out (Male, 60, AL).
One participant described waiting between hits to control their intake: The weed, you know, it varies-the quality.So, I wait between hits to see what's happening instead of rushing and smoking a lot in 20 minutes (Male, 49, MA).
Another continued to smoke until they had met a specific goal: There isn't something that marks the end of smoking, that you're, like, 'Okay, I smoked this much.I'm gonna stop now,'…you'll just smoke until the pain goes away (Transgender female, 51, WA).
Attempts to stop using marijuana varied in style and motivation.Seventy-six percent had made prior attempts to stop or cut down.Two participants successfully stopped smoking marijuana but continued to use it in other forms.Several others had stopped and started again for a disparate variety of reasons which included pregnancy/child-rearing, employment search or maintenance, respiratory health problems, and attempting to get sober in general from multiple substances.

Perceptions of health
Participants sought information about marijuana use and its health effects from a variety of sources.Approximately half of the participants (n=14) reported getting information from the internet, 12 from their health care provider, 10 from friends, and 7 from their marijuana dispensary; 10 participants reported using more than one source of information.
The majority of participants (62%) believed marijuana use was beneficial to their health.Of these, 9 believed it was helpful for appetite and 7 for pain.Eight participants described a psychological benefit of reducing anxiety, "calming down", and/or "helping control thoughts".Five believed the effects could be primarily negative, but these statements were typically couched in uncertainty: …you're putting a foreign substance in your body.Even though it's natural, there's gotta be some type of downfall I'm sure.Never really thought about it.I have thought about my lungs and stuff, and maybe trying to switch to edibles or something, but I haven't had a problem with my lungs and weed (Male, 59, MA).I don't really feel the effects yet.But you know, who knows.Ten years now I could be coughing up a lung… (Male, 29, MA).
Eight participants believed that the health effects depend on the modality of use, favoring edibles as healthier: I don't smoke it…I feel it's not as much of a threat to certain parts of my well-being by just ingesting it (Male, 39, MA).
There is one negative to the smoking over the years…the coughing, which is why I tend to be more attracted to the edibles now (Male, 54, MA).
The edibles would be better.You don't have to eat but one cookie and you're good for half a day.Weed you're smoking throughout the day pretty much, at least I am (Female, 60, WA).
One participant echoed others in the belief that marijuana was more neutral or inert as a substance relative to other substances: [Marijuana] is a positive…as it enters and leaves you.I can't say that about the hydrocodone or the Tylenol or the HIV cocktail, and all the poisons literally that I have to take to stay alive.Cannabis is the only one that doesn't do anything bad (Male, 54, MA).Six participants did not perceive a relationship between marijuana use and their health.

Social dimensions of use
In states where marijuana use was legalized, participants noted feeling liberated from the stigma of possessing or using marijuana: The stigma is gone.There is zero fear…it's just so much nicer to know that you can just casually walk into any place that sells these things and everything is legal, so it's comfortable (Male, 54, MA).
I feel like suddenly it's become super commercial and super well-branded and I go to the dispensary and there's so much excitement around there.I feel like I'm at a lounge in a night club.Walking in and out [of a dispensary] for me a different experience than feeling like I'm…going to get caught for having it, I'm in possession (Male, 52, MA).
My friends started using [marijiuana]…they didn't want anything to do with it when it was illegal.The legality also has made me feel more relaxed around using it.Not that I'm super paranoid, but…I don't have to hide it as much…before it was more of a secretive type of thing (Male, 58, WA).Independent of smoking tobacco, large longitudinal cohort studies have found that compared to those without HIV, long-term marijuana smoking was linked to lung disease; in a study of middle-aged men, heavy marijuana use was a risk factor for cardiovascular disease (Lorenz et al., 2017;Lorenz et al., 2019).Several studies demonstrated the impact of marijuana use on cognitive functioning.One found that moderate-to-heavy marijuana users with HIV performed worse in learning/memory function compared to those without HIV (Thames et al., 2016); another found worse cognitive function among symptomatic PWH compared to asymptomatic PWH and those without HIV (Keihani et al., 2019).A 17-year longitudinal study comparing people with and without HIV who used marijuana showed cognitive processing differences to be poorer among PWH, though authors questioned the clinical relevance of the differences found (Okafor et al., 2019).These studies suggest substantial risks associated with long-term marijuana use among PWH with of which our interview participants were largely unfamiliar.PWH may wish to weigh these against the shorter-term, symptom-relief benefits they describe.
While findings point generally to adverse cumulative health effects of marijuana use among PWH, opportunities for more granular inquiries exist, particularly surrounding long-term effects of specific routes of administration, such as 'vaping', edibles, and tinctures, and evaluation of the health impacts of prolonged, frequent use of higher potency products.Additional exploration is also warranted for the efficacy of marijuana use as a potential harm reduction tool for reducing the use of alcohol and/or other 'harder' substances, such as methamphetamine; the results of such studies to date have been inconclusive (National Academies of Sciences, 2017) or positive but limited in sample size (Socias et al., 2017).A better understanding of long-term impacts, particularly weighted against the benefits of short-term symptom alleviation and harm reduction, will help empower PWH and their health providers to consider more tailored, informed decisions regarding marijuana use.

STRENGTHS AND LIMITATIONS
This study is one of the few that evaluate beliefs surrounding marijuana use among PWH.We note that this study is limited to PWH who use marijuana at least weekly.Beliefs, behaviors, and perceptions of the impact of marijuana use may differ substantially among PWH who use marijuana less frequently.However, we believe the focus on frequent marijuana users placed a greater focus on those at higher risk of experiencing adverse health effects from marijuana use.

Conclusion
Among a sample of PWH who use marijuana, the broad variety and availability of products following legalization increased use for a third of participants from affected states and consistently described as offering a means for facilitating decision-making for targeted therapeutic use, including as an aid for sleep, anxiety, appetite, and pain, as well as minimization of craving alcohol and 'harder' substances.While many participants described attempts to decrease or stop use driven by a variety of motivations, concern over the long-term impact of use was limited to respiratory effects, with no concerns regarding potential cognitive impacts or effects from the use of edible marijuana.

Table 1 .
Interview participant characteristics: patients with HIV who use marijuana.difference.Before, I wasn't using it much.There was nowhere to get it, right?(Male, 54, WA) Several noted the novelty of experimenting with new products.Participants appreciated the transparency of ingredient labeling (e.g., indica/sativa, THC percentage, THC/CBD ratio) which encouraged experimentation with different types.There are lot more choices.The information they provide is you know the THC, the CBD, what type of strain it is if it's Indica, Sativa or hybrid.The information that they provide is so much more than when it was medical.'ve had some strains that affect me really bad…so having that information is helpful.I can get me something where the THC is below 20 percent…I can have some more control over what I'm buying, what's actually in it, how much THC or CBD is in it (Male, 49, WA).
Center for AIDS Research Network of Integrated Clinical Systems.hugeBefore,[youdidn't]know if it's gonna be strong, I don't know if it's gonna be good weed, or, you know, I don't know if it's gonna be Indica or could be something else… (Transgender female, 51, WA).Since it was legalized I like to explore different types of strains and flavors, especially when it comes to edibles (Male, 33, MA).They've went crazy with really diversifying their products and what they offer.I think that in itself is amazing.You don't have to smoke it if you don't want to smoke it.You can try this [edible] and it might have the same effect.It's just better for people or patients that need it, or that can't smoke it (Male, 29, MA).I'm not one that's very keen with…any kind of thing I have to inhale…a friend of mine shared some [edibles] with me and I liked the feeling.And so that's where it kind of took off for me, when more dispensaries became available, I decided to explore it on my own and really understand 'what do I like' and figure it out from there (Male, 39, MA).
Fredericksen et al.  5don't get high every day or I don't feel the need to get high every day.I guess it's become more of a habit, but it's not something hard to break and go for a period of not using (Male, 52, MA).
).Few reported any interest in stopping marijuana use.PWH generally reported their use as easy to control: I would say it's easy for me to regulate [my use of] it.I