Methamphetamine use is heightening risks among gay youth
Club drugs’ dull safe-sex sensibilities
A convincing body of new research suggests that a relatively recent and very important risk factor for HIV infection among men who have sex with men (MSM) is methamphetamine use. A group of illicit stimulants, dubbed "club drugs," has become such a commonplace part of the party circuit and gay club life that in some settings, treatment centers have seen a 1,000% increase in people presenting for treatment of methamphetamine abuse.1 While the club drugs have long been associated with the Pacific Rim and the West Coast, they now are ubiquitous in other Western states, the Midwest, and most recently, the East Coast, researchers say.
The designer drugs most commonly used in the gay club/party circuit are crystal methamphetamine, 3-4 methylenedioxymethamphetamine (MDMA, which also is called ecstasy), ketamine (called Special K), and gamma hydroxybutyrate (GHB).2
While HIV clinicians have long known the connection between substance abuse and HIV, especially when injectables are used, investigators are building a strong case for paying particular attention to methamphetamine and the other stimulants used by MSM. Even when these drugs are not injected, they place users at a high risk for HIV infection, new research finds.
Crystal methamphetamine can be ingested, snorted, smoked, and injected; and MSM groups use it in any and all of these ways, explains E. Michael Gorman, PhD, MPH, MSW, a chief investigator of numerous studies about methamphetamine and HIV. Gorman also is an assistant professor in the College of Social Work at San Jose (CA) State University. "With methamphetamine, as important as injection drug use is as a risk factor — and it’s an important one — it is equally important, and some might say more important, that people become uninhibited on the drug and then it becomes an issue of sexual transmission," Gorman says. "They forget; they don’t put on a condom right or don’t use a condom if they think to bring one." Evidence also shows that people using these designer drugs will tend to act in sexual ways that they normally wouldn’t choose to do, Gorman says.
For example, one HIV-positive gay man from Cincinnati described himself as an animal while high on GHB. "You’re so uninhibited and so heightened and so incredibly horny that that’s when I really did riskier behavior," says Tony Lasan, age 40. (AIDS Alert has selected a pseudonym for Lasan to protect his privacy.) Lasan had tested negative for HIV prior to his experience of using GHB while in Miami bathhouses. While on the drug, he soon found himself engaging in unprotected receptive anal intercourse, a sexual activity that he said he had never been attracted to prior to ingesting GHB. Six months after his negative test and shortly after his GHB days, he tested HIV-positive.
Lasan says he performed unprotected oral sex for 25 years and remained HIV-negative. "But it was this way-out-of-control, drug-uninhibited sex and bathhouses in Florida when I’m positive that it happened."
Ironically, research and anecdotal evidence show that methamphetamine use is ubiquitous on the gay party circuit, including at large dance venues that are sometimes sponsored by HIV outreach prevention and education organizations. Lasan says he first tried methamphetamine at a huge dance party in Atlanta more than a decade ago. The party, attracting 5,000-plus people, was a fundraiser for AIDS organizations, and condoms were distributed freely among the crowd. Unfortunately for the organizers, participants brought drugs, which also were distributed freely. In Lasan’s case, the drugs were eagerly ingested, but he can’t remember whether he used condoms during the multiple sexual encounters he had that weekend.
Body and mind risks
GHB, methamphetamine, and the other club drugs appear to place users at risk for a variety of psychological and physiological reasons. "What we see is that these drugs cause people to take more risks, cause more partnering, cause more people to have sex, create an insatiable sexual desire, and cause people to do more extreme sex than regular sex," says Perry N. Halkitis, PhD, assistant professor of psychology at New York University in New York City. Halkitis also is the co-director of the Center for HIV Educational Studies and Training, also in New York City.
"And if methamphetamine is inserted anally, this is a harsh substance that wears away at the lining of the rectum and increases the possibility of seroconversion because you’ve damaged the area where transmission can occur," Halkitis says. Halkitis has found in his research that nearly 35% of methamphetamine users report having inserted methamphetamine in their anus.
Still popular among the gay club community of the East Coast are inhalant nitrates, which cause the anal musculature to relax, making anal intercourse less painful, further contributing to increased sexual risk behavior, according to Halkitis’ latest research.
Polydrug use in the gay club/party settings has increased, and these drug combinations are substantially more dangerous when combined with alcohol, cocaine, Viagra, which also is being distributed at these venues, HIV medications, and other substances. GHB combined with alcohol, for instance, has been deadly, Halkitis says.
But it’s the link to HIV and suspected increases in HIV incidence among MSM that most worries researchers studying the phenomenon. "What we’re finding is that an occasional use of methamphetamine in gay populations is a significant predictor of HIV infection, but when you move up the level of use to dependence, then methamphetamine is an outrageous predictor of infection," says Steve Shoptaw, PhD, principal investigator with the Friends Research Institute in Los Angeles, and an associate research psychologist at the University of California in Los Angeles (UCLA).
At a Los Angeles substance abuse treatment center, researchers found that 62% of the gay and bisexual men who showed up for methamphetamine treatment were HIV-positive.2 "We were shocked by our numbers," Shoptaw says.
On the West Coast where the heroin injection drug using (IDU) population has traditionally had very low HIV prevalence, with rates in Seattle, and Los Angeles of less than 5%, the opposite is true of injection methamphetamine use, Gorman says. "The Seattle/King County Health Department in Washington state had been looking at this, and in one study, they found that 60% of gay IDUs who use methamphetamine were HIV-positive," Gorman says. "Meth users, or at least gay users in Seattle, had at least as high an HIV prevalence as heterosexual heroin users in New York City."
Methamphetamine use and its tie to HIV among MSM is a trend found outside the U.S. borders, as well. Researchers in Vancouver, Canada surveyed 495 MSM in 2001 and found that 25% had reported crystal meth use in the previous year. Those who had used the drug also were more likely than those who had not used the drug to be polydrug users and had engaged in other risky behavior, including both injection drug use and unsafe sex practices.3
"We’ve seen an increasing incidence of HIV in this population of MSM, and a lot of that has to do with changes in behavior, namely associated with a real increase in barebacking," says Robert Hogg, PhD, a principal investigator of the Vancouver study and the manager of the HIV/AIDS Drug Treatment Program at the British Columbia Centre for Excellence in HIV/AIDS in Vancouver.
Vancouver investigators survey patients annually, and each year, the methamphetamine use has increased, coinciding with an increase in HIV incidence over the same period of time, Hogg says. "There’s a group of men who have decided for a variety of reasons — cultural, as well as other reasons — that they will not use condoms when engaging in anal intercourse," Hogg adds. "And obviously, club drugs or other drugs play a role in how they engage in risk behavior."
A Brisbane, Australia study also notes a dramatic increase in methamphetamine use in the past five years. The study found that among users who injected methamphetamine, there was low needle sharing. However, the meth IDUs did place themselves at risk of HIV infection through water used to liquidize crystal meth, tourniquets, and drug-mixing vessels potentially contaminated with blood.4
Five years ago, if you asked New York City street pushers, outreach workers, substance abuse experts, and others if methamphetamine use was a problem, the answer would have been that it didn’t exist in the city. However, that answer would have been dead wrong, because the drug had already begun to take a hold on the gay and bisexual community in clubs and party circuit venues, and now it’s everywhere, says Michael C. Clatts, PhD, a medical anthropologist and associate professor of public health in the department of sociomedical science at Columbia University in New York City. Clatts also is the director of the Institute for International Research on Youth at Risk at the National Development Research Institutes, also in New York City. He had taken part in a study that sought information about methamphetamine use in the late 1990s.
"They all swore that there was no methamphetamine in New York in 1997 and 1998, and then we followed up and did ethnographic interviews in gay clubs in New York City and found a very different story," Clatts says. "Methamphetamine was widely available in many forms, and the majority of the use was not injected, although there was injection present."
References
1. Gorman EM, Pach AP, Nelson K, et al. Ecological perspectives regarding club drug and methamphetamine use among U.S. men who have sex with other men: Prevention, outreach, and research implications. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 2002. Abstract: ThPeE7862.
2. Gorman EM, Carroll RT. Substance abuse and HIV: Considerations with regard to methamphetamines and other recreational drugs for nursing practice and research. J Assoc Nurses AIDS Care 2000; 11(2):51-62.
3. Weber AE, Chan K, Schilder A, et al. HIV risk profile of crystal methamphetamine users in a cohort of young men who have sex with men. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 2002. Abstract: MoPeC3454.
4. Hunter AP, Davey J, Davies A. Developing safe injecting procedures for methamphetamine using recreational IDUs through peer research. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 2002. Abstract ThPeE7861.
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