Drug Use and HIV among Men Who Have Sex with Men (MSM)

1. Drug Use and HIV among Men Who Have Sex with Men (MSM) David W. Purcell, JD, PhD Prevention Research Branch Division of HIV/AIDS Prevention Centers for Disease Control and Prevention August 12, 2004

2. Presentation Objectives • Describe the prevalence of HIV, alcohol and drug use, and substance dependence among MSM as well as current trends in substance use • Describe the associations between substance use, sexual risk, and other public health problems • Describe HIV prevention approaches for substance using MSM

3. HIV Seroprevalence: Rates Among MSM (N=2881) in Four Cities % HIV+(95% CI) San Francisco 21% (17-23%) New York 13% (11-17%) Los Angeles 18% (16-24%) Chicago 15% (10-18%) TOTAL17% (15-18%) Catania, Osmond, Stall, et al. (2001). AJPH, 91, 907-914

4. HIV Seroprevalence: Race % (95% CI) African American 29% (20-40%) Native American 24% (15-39%) Hispanic 19% (13-18%) White 16% (14-18%) Asian/PI 9% ( 4-18%)

5. HIV Seroprevalence: Education % (95% CI) < High School 37% (19-59%) High School Graduate 21% (17-24%) Some College/Graduate 17% (14-20%) Masters Degree 12% ( 9-16%) Doctoral Degree 10% ( 6-15%)

6. HIV Seroprevalence: Age % (95% CI) 18-29 11% ( 7-16%) 30-39 16% (13-19%) 40-49 26% (22-30%) 50-59 19% (14-25%) 60+ 3% ( 1-10%)

7. HIV Seroprevalence: Intravenous Drug Use % (95% CI) Non-IDU 15% (13-16%) IDU < 5 years 40% (26-55%) IDU > 5 years 43% (33-53%)

8. HIV Seroprevalence: Level of Non-IV Drug Use Frequency of Use % (95% CI) 5+ Days/Week 32% (24-40%) 3-4 Days/Week 24% (18-32%) 1-2 Days/Week 22% (17-27%) Infrequent Use 16% (13-20%) Do Not Use Drugs 12% (10-14%)

9. Summary: HIV Seroprevalence • HIV remains highly prevalent among urban MSM, with nearly 1 in 5 such men currently infected • HIV infection is more prevalent among MSM of lower educational status, African American men, men who inject drugs, and men who abuse non-injection drugs • Rates of HIV infection among young men are sufficiently high to suggest that an ongoing AIDS epidemic will exist among MSM for decades to come

10. Prevalence of Substance Use:Alcohol • The pattern of alcohol use among MSM is relatively similar to heterosexual men • MSM not more likely to be problem drinkers • But MSM less likely to abstain from alcohol • In household-based sample of MSM in SF, rates of drinking and problem drinking have dropped from early 1980s to the 1990s. Stall & Wiley (1988). Drug and Alcohol Dependence, 22, 63-73 Bux (1996). Clin Psych Review, 16, 277-98

11. Prevalence of Substance Use:Non-Injection Drugs • In contrast to alcohol, the pattern of use of non-injection drugs is different from heterosexual men • More MSM use drugs • MSM use a wider variety of drugs • BUT, MSM don’t necessarily use drugs more frequently

12. Prevalence of Non-Injection Drug Use in UMHS: Past 6 Months • Alcohol 88% • Marijuana 42% • Poppers 20% • Cocaine 15% • Ecstasy 12% • Speed 10% • Current IDU 1% Stall, Paul, Greenwood et al. (2001), Addiction, 96, 1589-1601

13. Problematic Drug Use: Past 6 Months • 3+ Alcohol-Related Problems 12% (11-14%) • Frequent/Heavy Alcohol Use 8% ( 7-10%) • Frequent Drug Use 19% (17-21%) • Multiple Drug Use 18% (16-21%) Stall, Paul, Greenwood et al. (2001), Addiction, 96, 1589-1601

14. MSM (UMHS) (past 6 months) Alcohol Use Frequent/Heavy 8% Marijuana 42% Cocaine 15% Speed 10% General Population (DHHS) -- Past Year 9% 11% 2% 1% Prevalence of Drug Use among MSM versus Men in General Stall, Paul, Greenwood et al. (2001), Addiction, 96, 1589-1601

15. Prevalence of Drug Use –NHSDA (Lifetime and Past Month) Cochran, Ackerman, Mays, & Ross (2004). Addiction, 99, 989-998

16. Prevalence of Drug Dependence or Dysfunctional Use (Past Year) Cochran, Ackerman, Mays, & Ross (2004). Addiction, 99, 989-998

17. Prevalence of Injection Drug Use • MSM/IDUs constitute 8% of the AIDS epidemic • Prevalence in RDD sample = 1% • Prevalence in treatment studies = 41%-56% • Prevalence among HIV+ MSM • 16% lifetime • 7% past year • Challenging population to reach and treat due to multiple and complex identities

18. Current Trends in Drug Use for MSM • Party drugs, circuit parties • Poly-drug use in sexualized settings including GHB, ketamine, ecstasy, poppers, cocaine, methamphetamine • Methamphetamine or “crystal” • Increasing coverage in mainstream press • (e.g., “Beast in the Bathhouse” in NY Times; Jan., 2004) • Public forums and public marketing campaigns pointing out the dangers of crystal • Internet usage for PNP (party and play)

19. STD Clinic Sample, % reporting Viagra Use MSM 31% Heterosexual 7% MSM in San Francisco, % reporting Viagra Use HIV-positive 42% HIV-negative 19% Unknown 12% Current Trends: Viagra Use Chu et al (2003). JAIDS, 33, 191-3 Kim et al (2002). AIDS, 16, 1425-8

20. Conclusions: Prevalence of Substance Use and Abuse Among MSM • MSM appear to use a broader variety of drugs and are more likely to be poly-drug users than heterosexual men • Certain drugs are much more popular among MSM, particularly “party” drugs or sexually-related drugs • Higher rates of use do not appear to translate into more substance abuse (but marijuana, maybe meth?) • Cultural shifts in the popularity of different drugs and settings present intervention challenges

21. Conclusions: Potential Explanations for Prevalence Differences • Different patterns of use from adolescence, may be due to specific stressors related to sexuality • Substance use at sexual initiation may become an established pattern that is difficult to change • Bars and dance clubs are important cultural and social settings supporting substance use • Certain “party drugs” are often used specifically to enhance the sexual experience

22. Substance Use, Sexual Risk, and other Public Health Problems

25. Substance Use, Sexual Risk, and other Public Health Problems • SU and sexual risk are linked in some way, either directly (causally) or as a marker variable • Use of particular substances (party drugs) is related to HIV seroconversion • Substance use is related to other public health issues for MSM and these may be synergistic

26. Associations between Substance Use and Sexual Risk • Global Associations: • Use of substance X is related to risk behavior • Situational Associations: • Use of substance X before/during sex is related to risk behavior • Event-Level Analysis: • Use of substance X during particular sexual episodes is related to risk behavior Leigh & Stall (1993). American Psychologist, 48, 1035-45

27. Global and Situational Associations between Substance Use and Sexual Risk • Most global or situational studies find univariate associations between use of a variety of substances and sexual risk • Multivariate associations in these studies usually show that use of one or a few party drugs is associated with sexual risk: • cocaine, crystal, poppers, ecstasy, GHB, ketamine, and sometimes alcohol

28. Event-Level Associations between Substance Use and Sexual Risk • Findings for both alcohol and non-injections substances have been mixed : • Substance use was not related to risk; condoms used more with casual partners and by HIV-negative men, regardless of SU • Use of poppers, amphetamines, and cocaine and heavy alcohol consumption was related to serodiscordant UA among 4000+ HIV-negative MSM • Gillmore et al (2002). AIDS and Behavior, 6, 361-70 • Colfax et al., (2004). Am J Epidemiology, 159, 1002-12

29. Importance of the Link between Substance Use and Sexual Risk • While there remains some debate about causality: • MSM who use substances or use substances before/ during sex engage in more risk behavior, although data are mixed for event-level studies • Particular “club or party” drugs have much stronger associations with sexual risk • In addition, substance user are more likely to: • Be HIV-positive • Become HIV-positive in longitudinal studies

30. Viagra Use and Seroconversion • 7,145 anonymous, male repeat HIV testers with HIV seroconversion as the outcome of interest • HIV incidence significantly higher among Viagra users than among non-users • Multivariate predictors of seroconversion: • MSM, amphetamine use, Viagra use, non-white race, age 30-39 • marijuana had a protective effect for seroconversion L. Loeb et al. (July, 2004). Intl AIDS Conf Abstract, Bangkok, Thailand

31. Prevalent Public Health Problems Among MSM • HIV, Hepatitis A & B, other STDs • Substance Use, including Tobacco Use • Childhood Sexual Abuse and violence • Suicide • Drug Abuse • Depression and other mental health issues • Interpersonal and stranger violence • Sexual compulsivity

32. Number of Health Problems and Vulnerability to HIV in MSM Stall, Mills, Williamson et al. (2003). AJPH, 93, 939-42

33. Intertwining Epidemics: “Syndemics” • Syndemic: two or more epidemics, interacting synergistically, contributing to excess burden of disease in a population • HIV is not the only epidemic among MSM – these other problems are important and also may increase HIV risk • This is consistent with mental health literature showing 25-58% of substance users also have another DSM-IV diagnosis (Brems et al., 1997).

34. Syndemics: Intervention Implications • Public health issues among MSM are intertwined with each other and with HIV risk • Need for a “whole-person” approach • HIV risk reduction or drug treatment programs may need to be designed to work in synch with a broader gay men’s health movement, and such approaches should be tested

35. HIV Prevention Approaches for Substance Using MSM

36. HIV Prevention Approaches for Substance Using MSM • For HIV prevention with SU-MSM, two different cultures collide: • Substance abuse treatment as the focus • HIV prevention as the focus

37. Substance Abuse Treatment as the Focus • Traditionally abstinence-based philosophy • Inpatient & outpatient services supplemented by community groups such as AA and NA • Drug treatment as HIV prevention (Paul et al, 1996) • HIV prevention seen as an additional activity • Treatment extending to partners and social networks of substance using MSM • Semaan, Des Jarlais, et al. (2002). JAIDS, 30, S73-S93 • Sorenson et al. (2000). Drug & Alcohol Dep, 59, 17-31

38. HIV Prevention as the Focus • Traditionally harm reduction philosophy • Programs developed or delivered by CBOs on safe sexual behavior and safer drug use • Approaches at multiple levels: • Individual and small group settings • Peer-based approaches • Community-building interventions/structural • Social marketing and internet approaches

39. HIV Prevention Interventions for MSM • Recent meta-analysis of all HIV prevention interventions for MSM: • 34 studies identified • 23 studies in the United States, 11 elsewhere • Most studies (22) reported in the past 8 years • 2 studies focused on substance using MSM in Tx • Neither had a significant summary effect size • But both have important lessons for programs Herbst et al (under review) CDC PRS Project

40. HIV Prevention Interventions for SU-MSM • Interventions in treatment settings • Stall et al (1999) • Shoptaw et al (2002) • General HIV prevention interventions • None found to be effective so far • Project MIX (CDC-funded; 2002-2007) • Current RCT of a 6-session HIV risk-reduction intervention for substance using MSM in 4 cities in the US

41. Stall et al., 1999 • Men were recruited as they were enrolling in treatment – put in early recovery group (ERG) • After the ERG, participants were assigned to a standard-of-care recovery group or to recovery groups enhanced with specific exercises for sexual risk reduction • Assessments at baseline and every 3 months for one year Stall et al. (1999). J Stud Alcohol, 60, 837-45

42. Outcomes: Stall et al., 1999 • Sexual risk reduction seen in both groups • Change occurred between baseline and first follow-up which occurred after the ERG but before the intervention groups started • No change at next 2 follow-ups (6 & 9 months) • Increase in risk at final follow-up, but rate of unprotected sex still lower than baseline

43. Who Has Trouble Changing Behavior? • Men most likely to relapse to or continue risky sex reported the following behaviors or attitudes at baseline: • Higher rates of sexual behavior • Greater number of sexual partners • Greater enjoyment of unprotected sex • Higher levels of combining substance use and sex • Sex-drug link needs to be addressed in programs for these men as their likelihood of success is lower than other MSM

44. Lessons from Stall et al., 1999 • Risk reduction occurred based on early drug treatment alone, with no additional benefit from either treatment group • “new playmates, new playgrounds”? Men may be associating with lower risk networks • Maintenance of risk reduction – ongoing support • Moving from avoidance coping to situations where behavioral skills are needed to maintain lower risk?

45. Lessons from Stall et al., 1999 • Risk reduction can be introduced earlier in the treatment process • High rate of drop out at every step of treatment • Similar to HIV prevention efforts • Remaining clients may be more “ready” for change • Lower threshold treatment for broader coverage

46. Shoptaw et al., 2002 • Randomized Controlled Trial of 4 treatment options for MSM methamphetamine abusers (DSM-IV validated substance abuse Dx) • Contingency Management only ($ for clean urine) • Relapse Prevention only (based on CBT) • CM + RP • RP + gay friendly concepts/culture (also focused on reducing sex and drug risks related to HIV) Shoptaw (2002). Int’l AIDS Conf. Presentation, Barcelona, Spain

47. Sample Characteristics:Shoptaw et al., 2002 • Drug Use • 41% injectors • 8.3 years of use/ 3.4 years of heavy use • 9.6 days of meth use in month before admission • Health • 61% HIV positive at admission • Mood disorders = 28%; Antisocial = 14% • Suicide attempts: 30% HIV+; 17% HIV-

48. Outcomes: Shoptaw et al., 2002 • Drug use • Conditions with contingencies and the gay condition outperformed the “RP only” condition during the 16 weeks of treatment • Follow-up – reductions across all group • Sexual risk • Gay friendly group reduced sexual risk more than other 3 groups during treatment • Follow-up – reductions across all groups

49. Next Steps and Challenges • To date, interventions in treatment – we need: • Interventions in TX that are stronger than TX alone • Interventions for out-of-treatment substance users • In any case, treatment and prevention programs reach a small portion of SU-MSM • Drop-outs from programs are sexually riskier – we need lower threshold interventions

50. Intervention Implications of Episodic Substance Use Among MSM • Addiction/dependency model may be less relevant • Interventions should: • Prevent infrequent users from becoming abusers • Address effects of episodic use on risk • Directly reduce substance use during sex • Address indirect risk such as degradation of safe sex skills when high • Many MSM are HIV+ by the time they get to Tx