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We examined the independent effect of alcohol and combined effects of drug and alcohol use on antiretroviral (ART) utilization, adherence, and viral suppression in an urban cohort of HIV-infected individuals.In an observational clinical cohort, alcohol use, active drug use, and adherence were prospectively assessed at 6-month intervals. We classified hazardous alcohol use as >7 drinks/week or >3 drinks/occasion in women, and >14 drinks/week or >4 drinks/occasion in men and active drug use as any use in the previous 6 months. Our outcomes included ART utilization, 2-week adherence, and viral suppression. We used generalized estimating equations to analyze the association between independent variables and outcomes. Analyses were adjusted for age, sex, race, years on ART, and clinic enrollment time.Between 1998 and 2003, 1711 individuals participated in 5028 interviews. 1433 of these individuals received ART accounting for 3761 interviews. The prevalence of any alcohol use at the first interview was 45%, with 10% classified as hazardous drinkers. One-third of the sample used illicit drugs. In multivariate analyses adjusting for age, sex, race, active drug use, years on ART, and clinic enrollment time, hazardous alcohol use was independently associated with decreased ART utilization (AOR, 0.65; 95% CI: 0.51 to 0.82), 2-week adherence (AOR, 0.46; 95% CI: 0.34 to 0.63), and viral suppression (AOR, 0.76; 95% CI: 0.57 to 0.99) compared to no alcohol use. Concurrent injection drug use (IDU) exacerbated this negative effect on ART use, adherence, and suppression.Hazardous alcohol use alone and combined with IDU was associated with decreased ART uptake, adherence, and viral suppression. Interventions targeting alcohol use may improve HIV outcomes in individuals with hazardous alcohol use.