Russia has over 1.2 million HIV infections and Europe's highest HIV incidence. Although its HIV epidemic is intertwined with high alcohol consumption rates, the interaction between alcohol use and HIV care in Russia is understudied. Five hundred eighty-six HIV-positive persons were recruited using social network methods in St. Petersburg. Fifty-nine percent of males, and 45% of females, drank regularly. Thirty percent of alcohol users reported binge drinking (males: ≥ 5 drinks; females ≥ 4 drinks) in the past week. Alcohol use was associated with lower HIV care engagement and having a detectable viral load. Multivariate analyses showed that any alcohol consumption, number of alcohol drinks consumed, and having a binge drinking day in the past week were associated with male gender, use of illicit drugs, drug injection, smaller social network size, lower social supports, being unmarried, and reporting condomless intercourse with non-main partners. Interventions to improve HIV care in Russia must comprehensively address the use of alcohol and substances that interfere with care engagement.