National studies1,2 indicate that rates of alcohol use during pregnancy have remained stable in the US since 2002, whereas rates of prenatal cannabis and prescription opioid use have increased. However, little is known about changes in substance use during pregnancy and post partum in subpopulations that are particularly vulnerable to poor outcomes. People living with HIV have a higher risk of adverse perinatal outcomes compared with those without HIV infection. Substance use can further increase the risk of adverse outcomes during pregnancy and post partum for people living with HIV, including suboptimal viral control and perinatal transmission of HIV infection.
Using data from the Surveillance Monitoring for Antiretroviral Toxicity Study (SMARTT) of the Pediatric HIV/AIDS Cohort Study, Yee and colleagues3 examined trends in use of cannabis, alcohol, and opioids during pregnancy and 1 year post partum in a large sample of people living with HIV (mean age, 29 years; 64% non-Hispanic Black and 28% Hispanic) who gave birth between 2007 and 2019 at 22 US sites. Results indicated that the risk of cannabis use during pregnancy and post partum and co-use of cannabis and alcohol post partum increased significantly from 2007 to 2019. In contrast, risk of alcohol and opioid use during pregnancy and alcohol use post partum were stable over time (postpartum opioid use was not measured). Yee and colleagues3 also assessed whether the risk of cannabis and alcohol use during pregnancy and post partum varied with state legalization of cannabis for recreational or medical use. They found that the risk of cannabis use during pregnancy or post partum did not differ by recreational cannabis legalization status; however, risk of cannabis use during pregnancy and post partum was higher among people living with HIV who were pregnant after vs before medical cannabis became legal in their state. Notably, risk of alcohol use during pregnancy was lower among people living with HIV who were pregnant after vs before medical cannabis was legalized.
The increasing prevalence of cannabis use during pregnancy and post partum among people living with HIV seen in the study by Yee et al3 is concerning and deserves attention. Prenatal cannabis use has been associated with adverse fetal, neonatal, and neurodevelopmental outcomes. Postpartum cannabis use may also have unintended consequences for children, such as poisoning through unintentional ingestion, secondhand smoke exposure, or risks associated with driving or providing care for children while using cannabis. The American College of Obstetricians and Gynecologists strongly recommends that people abstain from cannabis use during pregnancy, yet a previous study4 suggested that some see cannabis as a safe and natural substance that can be used to mitigate depression, stress, and morning sickness.
Cannabis has long been used among people living with HIV in an effort to manage medication adverse effects, mental health conditions, and chronic comorbidities, which are more prevalent among people living with HIV than among those without HIV infection.5 Furthermore, people living with HIV often have unmet social needs, including unstable housing and poverty. Both HIV-related and substance use outcomes can be improved when those structural factors are addressed, demonstrating the importance of holistic care that considers the complex health and psychosocial needs of pregnant and postpartum people living with HIV. Clinicians should be aware of the increasing risk of prenatal cannabis use among people living with HIV, screen patients for prenatal cannabis use, and advise patients not to use cannabis during pregnancy. However, patient-centered care also requires empathetic and nonjudgmental conversations about prenatal substance use; individualized assessment of reasons for use, social needs, and treatment preferences; and shared decision-making about safer alternatives. Risk of cannabis use among postpartum people living with HIV may also reflect deficiencies in ongoing and supportive care during the postpartum period when patients’ needs are often overlooked. Greater attention to the mental health symptoms of patients during the postpartum period, with appropriate linkage to resources and services, may also help reduce postpartum cannabis use.
In addition to the increasing risk of cannabis use, Yee and colleagues4 found that state legalization of medical (but not recreational) cannabis was associated with increased risk of cannabis use during pregnancy and post partum and decreased risk of alcohol use during pregnancy. Those findings are somewhat consistent with recent data from a repeated cross-sectional study6 of women in 4 US states in the Pregnancy Risk Monitoring System, which found that legalization of recreational cannabis use was associated with increases in preconception and postpartum cannabis use but not prenatal cannabis use. However, while the results of the analysis on cannabis legalization by Yee et al3 are provocative, causal interpretation is limited by the cross-sectional nature of the analyses and the small sample size of pregnancies in states with legal recreational cannabis during the study period.
Additional research is critically needed to examine the association of cannabis policies with the prevalence and frequency of cannabis use—as well as how cannabis is ingested (eg, smoking, vaping, edibles, or high-potency concentrates)—during pregnancy and post partum, including among people living with HIV. Evaluation of local and state-level policies is essential because, in many states, local governments can regulate cannabis sales beyond what is allowed by state law (eg, by banning retailers or limiting which products can be sold) and access to retail cannabis varies significantly within states that have legalized cannabis. Modes of cannabis administration are rapidly evolving, and data on their relative harms during pregnancy are limited; such information could help guide patient-practitioner discussions and shared decision-making about safer use. Studies are also needed to better understand the broader association of public health and cannabis policies with prenatal and postpartum substance use, including whether people may increasingly substitute cannabis for other substances that are harmful to the fetus, such as alcohol, after legalization.
Criminalization of cannabis has been a major driver of mass incarceration and racial inequity in the US. Legalization of cannabis could reduce criminalization-related harms, particularly among Black people, who are at substantially higher risk of arrest for cannabis possession than White people. On the other hand, legalization could also exacerbate racial inequities in adverse perinatal outcomes if there is a disproportionate increase in cannabis use during pregnancy and post partum in racial and ethnic minority populations. The sample in the study by Yee et al3 was primarily Black and Latina, reflecting the substantially higher risk of HIV infection among Black and Latinx people compared with White people in the US. Yee et al3 adjusted for race and ethnicity in their analyses, precluding the exploration of racial or ethnic disparities in cannabis use during pregnancy and post partum. In future studies of substance use during pregnancy and post partum, stratification by race and ethnicity and measurement of exposure to systemic racism7 can better elucidate disparities and opportunities for structural intervention to improve health equity.
Yee and colleagues3 have identified an increasing risk of prenatal and postpartum cannabis use among people living with HIV. Clinicians should routinely screen for cannabis use in this population and provide patient-centered care to reduce potential harms. Further research is needed to understand factors that contribute to prenatal and postpartum cannabis use, the association of cannabis legalization with health outcomes and equity, and strategies to improve health services and outcomes for pregnant and postpartum people living with HIV.
Published: December 3, 2021. doi:10.1001/jamanetworkopen.2021.37588
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Young-Wolff KC et al. JAMA Network Open.
Corresponding Author: Kelly C. Young-Wolff, PhD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94162 (email@example.com).
Conflict of Interest Disclosures: Dr Young-Wolff reported receiving grants from the National Institute on Drug Abuse (NIDA) during the conduct of the study and outside the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by K01 award DA043604 from the NIDA (Dr Young-Wolff).
Role of the Funder/Sponsor: The NIDA had no role in the analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Agatha Hinman, BA, Division of Research, Kaiser Permanente Northern California, Oakland, provided editorial assistance. She was not compensated for her work.
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