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Crystal Meth Use High (6%) Among Gay Men in the North Carolina: hi rates of HIV, anal sex without condom use, STDs, sex with females, Viagra use
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"Characteristics of a Sample of Men Who Have Sex with Men, Recruited from Gay Bars and Internet Chat Rooms, Who Report Methamphetamine Use"
AIDS Patient Care and STDs. August 2007, 21(8): 575-583.
Scott D. Rhodes, Ph.D., M.P.H.
Department of Social Sciences and Health Policy, Division of Public Health Sciences, and the Maya Angelou Research Center on Minority Health, Wake Forest University Health Sciences, Winston-Salem, North Carolina.
Kenneth C. Hergenrather, Ph.D., M.S.Ed., M.R.C.
Department of Counseling/Human and Organizational Studies, Graduate School of Education and Human Development, The George Washington University, Washington, D.C.
Leland J. Yee, Ph.D., M.P.H.
Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
Emily Knipper, B.S.
Department of Social Sciences and Health Policy, Division of Public Health Sciences, and the Maya Angelou Research Center on Minority Health, Wake Forest University Health Sciences, Winston-Salem, North Carolina.
Wake Forest University School of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Aimee M. Wilkin, M.D., M.P.H.
Section on Infectious Diseases, and Infectious Diseases Specialty Clinic, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Morrow R. Omli, M.A.Ed.
Department of Psychiatry, Division of Addiction Medicine, University of Florida College of Medicine, Gainesville, Florida.
"......it has been asserted that methamphetamine use may be associated with feelings of isolation and loneliness among MSM in urban cities......more than 1 in 20 of participants in this large sample of MSM reporting using methamphetamines in the past 30 days....
.....Overall, 5.9% of participants reported using methamphetamine during the past 30 days. When comparing data collection mode, 8.4% (n=59) of bar participants and 2.0% (n=9) of online participants reported methamphetamine use within the past 30 days (p
.....CHARACTERISTICS ASSOCIATED WITH METHAMPHETAMINE USE WITHIN A SAMPLE OF MSM IN NORTH CAROLINA (Table 1):
67% were 20-29 yrs old. 86% had oral sex with multiple partners in past 3 months, 85% insertive-anal sex with multiple partners in past 3 months; 62.7% inconsistent condom use during anal sex in past 3 months; 76% ever had STD; 17% sex with a female partner within past 2 years; 79% HIV-positive; 85% used Viagra, Cialis or Levitra in past 30 days; 54% internet is most frequently used to meet sex partners.....
....CHARACTERISTIC INDEPENDENTLY ASSOCIATED WITH SELF-REPORTED METHAMPHETAMINE USE WITHIN THE PAST THIRTY DAYS AMONG A SAMPLE OF MSM IN NORTH CAROLINA (Table 2):
3.2 times more likely to have inconsistent condom use during anal sex in past 3 months, 2.8 times more likely to have had an STD ever, 4.1 times more likely to have HIV, and 6.1 times more likely to have used erectile dysfunction drugs in past 3 months (Viagram Cialis, Levitra).....
....Clearly, MSM in the south have a high rate of use when compared to the general U.S. adult population; in 2004, 0.2% within the general U.S. adult population reported methamphetamine use during the same past-30-day recall period.....
....Studies of methamphetamine use in other regions of the United States have reported use rates from approximately 10% during the past 6 months among Asian American and Pacific Islander MSM16 to 36% during the past 12 months among MSM attending circuit parties,37 which are an ongoing series of gay-oriented parties thrown in metropolitan areas throughout the year.... the only other study to use this recall period was a study of HIV-positive clinic patients in San Francisco that found an 19.6% methamphetamine use rate among MSM...."
ABSTRACT
Crystal methamphetamine is a highly addictive stimulant that initially gained popularity in the western region of the United States and has spread to all regions of the country. This study was designed to identify factors associated with methamphetamine use among men who have sex with men (MSM) in North Carolina. Participants were recruited in five gay bars and in five geographically defined Internet chat rooms concurrently in 2005 to complete a brief assessment of drug use and other risk behaviors. Of the 1189 MSM who completed the assessment, mean age was 29 years. Two thirds self-identified as black/African American or other minorities, and 25% as bisexual. Nearly 6% reported using methamphetamines during the past 30 days.
In multivariable analysis, MSM who reported using methamphetamines were more likely to report higher education; health insurance coverage; inconsistent condom use during anal sex within the past 3 months; a history of sexually transmitted disease (STD) infection; positive HIV serostatus; and use of medications designed to treat erectile dysfunction.
A lack of data exists on methamphetamine use among MSM in the southeastern United States, particularly in nonurban regions. Because the southeastern United States carries a disproportionate HIV, AIDS, and STD burden, our findings underscore the need for further research and intervention.
INTRODUCTION
CRYSTAL METHAMPHETAMINE is a highly addictive stimulant that initially gained popularity in the western region of the United States and has spread to all regions of the country.1 Methamphetamine use has been associated with increased sexual arousal and prolonged sexual activity (commonly known as "sex marathons").2-4
Methamphetamine use has been found to impair judgment, decrease inhibitions, promote feelings of invincibility, increase impulsivity, and enhance sexual sensitivity. In turn, these yield increased potential for disease transmission through decreased use of condoms, increased numbers of sexual partners, engagement in anal sex with both men and women, and rougher sexual behaviors (e.g., sex marathons and "fisting") that may result in tears in epidermis or mucous membrane tissue that facilitate exposure to, and transmission of, HIV and sexually transmitted diseases (STDs).5 Additionally, MSM who use methamphetamines have been found to be significantly more likely to report decreased condom use during anal sex, increased sex in exchange for money or drugs, and sex with injection drug users. Besides the drug's psychological
effects and the associations with sexual risk behaviors, studies have indicated an association of methamphetamine use with sexually transmitted disease (STD) outcomes, including syphilis and HIV infection among MSM.1,3,6-14
Prior studies of methamphetamine use have generally focused on MSM in predominantly dense urban areas, particularly in the western and northeastern United States.2,10,15-17 Although a few studies have examined use among MSM in the south,18-20 descriptions of methamphetamine use within the more rural and suburban parts of the southern United States remains missing from the literature.21 We assessed the prevalence and identified correlates of methamphetamine use within a sample MSM in North Carolina, a state that consistently leads the nation in reported cases of HIV/AIDS and other STDs.22-24
This analysis is based on data collected concurrently in 2005 using two collection modes: (1) targeted intercept interviewing through outreach in predominately gay bars and (2) targeted online assessment through outreach in Internet chat rooms designed to facilitate social and sexual networking among MSM.
RESULTS
A sample of 1189 male participants was collected from two data collection modes; 62.3% completed the assessment in gay bars (n =741) and 37.7% completed the assessment online (n =448). The overall sample was demographically diverse with 34.5% self-identifying as black or African American (n =408); 32.1% as white (n 380); 24.6% as Hispanic or Latino (n =291); 6% as Native Hawaiian or Pacific Islander (n=71); 1.7% as American Indian or Alaska Native (n=20); and 1% as Asian (n=12).
All participants reported having had sex with men during the past 2 years. Mean age was 29.12 (+/-8.9; range, 18-62) years. Nearly half of the sample (46%) reported a high school diploma or GED or less; and 23.9 reported having a college degree or higher. One fifth of participants reported their annual income less than $10,000 per year; 24.4% reported their annual income to be $40,000 or
more. Nearly three fourths (73.7%) self-identified as gay, 25% as bisexual, 1.3% as heterosexual or straight. Overall, 5.9% of participants reported using methamphetamine during the past 30 days. When comparing data collection mode, 8.4% (n=59) of bar participants and 2.0% (n=9) of online participants reported methamphetamine use within the past 30 days (p
Thirteen characteristics were associated with methamphetamine use after adjusting for mode of data collection as presented in Table 1. MSM who reported using methamphetamines within the past 30 days were significantly more likely to report:
--greater than high school education;
--health insurance coverage;
--oral, receptive-anal, and insertive-anal sex with multiple partners during the past 3 months;
--inconsistent condom use during anal sex within tthe past 3 months;
--sex with a female partner within the past 2 years;
--a history of STD infection;
--positive HIV serostatus;
--use of drugs for sexual enhancement;
--and use of Internet as the most frequent location to meet male sexual
partners.
Methamphetamine use was not found to be significantly associated with self-identified sexual orientation, race/ethnicity, or meeting sexual partners most frequently in gay bars or through friends.
In the multivariable model, greater than high school education, equal to or greater than $20,000 annual income, health insurance coverage, inconsistent condom use during anal sex within the past 3 months, history of STD infection; positive HIV serostatus; and use of drugs for sexual enhancement were associated with an increased likelihood of reporting methamphetamine use, as presented in Table 2.
TABLE 1. CHARACTERISTICS ASSOCIATED WITH METHAMPHETAMINE USE WITHIN A SAMPLE OF MSM IN NORTH CAROLINA
67% were 20-29 yrs old. 86% had oral sex with multiple partners in past 3 months, 85% insertive-anal sex with multiple partners in past 3 months; 62.7% inconsistent condom use during anal sex in past 3 months; 76% ever had STD; 17% sex with a female partner within past 2 years; 79% HIV-positive; 85% used Viagra, Cialis or Levitra in past 30 days; 54% internet is most frequently used to meet sex partners.
TABLE 2. CHARACTERISTIC INDEPENDENTLY ASSOCIATED WITH SELF-REPORTED METHAMPHETAMINE USE WITHIN THE PAST THIRTY DAYS AMONG A SAMPLE OF MSM IN NORTH CAROLINA
MSM in North Carolina who reported using methamphetamine in the past 30 days were 3.2 times more likely to have inconsistent condom use during anal sex in past 3 months, 2.8 times more likely to have had an STD ever, 4.1 times more likely to have HIV, and 6.1 times more likely to have used erectile dysfunction drugs in past 3 months (Viagram Cialis, Levitra).
DISCUSSION
Our study found that nearly 6% of MSM reported using methamphetamines within the past 30 days. Clearly, MSM in the south have a high rate of use when compared to the general U.S. adult population; in 2004, 0.2% within the general U.S. adult population reported methamphetamine use during the same past-30-day recall period.36 However, comparing the rate found in this sample of MSM to rates found among other samples of MSM is often difficult because of differences in sampling frame and time period. Studies of methamphetamine use in other regions of the United States have reported use rates from approximately 10% during the past 6 months among Asian American and Pacific Islander MSM16 to 36% during the past 12 months among MSM attending circuit parties,37 which are an ongoing series of gay-oriented parties thrown in metropolitan areas throughout the year. By assessing use during the past 30 days, our study attempted to reduce recall bias and identify those who may be more likely to use methamphetamines currently. Similarly, the only other study to use this recall period was a study of HIV-positive clinic patients in San Francisco that found an 19.6% methamphetamine use rate among MSM.38
Demographic differences (higher educational level and having health insurance coverage) between MSM who use methamphetamines and those who do not may provide guidance to inform intervention efforts. For instance, because MSM who use methamphetamines also are more likely to have health insurance,
clinical care settings may be potential locations for intervention. Careful screening and intervention by health care providers may be effective in reaching these men. Provider-delivered, client-centered strategies that have been tested and shown to positively impact HIV-seropositive patient risk behavior39 may
be a adaptable to identify and meet the prevention needs of MSM who use methamphetamines. Use of clinic-based interactive computer- based delivery of patient education also may be a potential option to educate MSM who use methamphetamines to the risks and provide them with "cues to action." We also
found that MSM who use methamphetamines may be at increased risk for HIV and STD exposure and transmission. MSM who used methamphetamines had over 3 times the odds of reporting inconsistent condom use during anal sex within the past 3 months. Thus, these men are clearly putting themselves and their partners at risk for HIV and STDs. Furthermore, MSM who reported using methamphetamines within the past 30 days had nearly 3 times the odds of reporting ever having had an STD and over 4 times the odds of reporting being HIV positive.
In this analysis, MSM who reported using methamphetamines also had over 6 times the odds of using medications designed to treat erectile dysfunction. Because methamphetamine use is associated with both heightened libido (or at least perceived heightened libido) and impotence,5,17 MSM who use methamphetamines may be using medications designed to treat erectile dysfunction to prevent impotence. This combination may be dangerous as methamphetamines provide a feeling of euphoria and stamina for sustained sexual activity and medications designed to treat erectile dysfunction provide the ability to maintain an erection for hours, thus resulting in tears in epidermis or mucous membrane tissue that facilitate exposure to, and transmission of, HIV and STDs. Furthermore, the interactive effects of these drug combinations are not well documented; however, treatment for methamphetamine intoxication is complicated if medications designed to treat erectile dysfunction have been taken and the patient has not shared this with his provider. Screening for the use of medications designed to treat erectile dysfunction may provide indication of methamphetamine or other illicit drug use among MSM for whom other reasons for using medications for erectile dysfunction do not exist. Because of the ease of accessing medications designed to treat erectile dysfunction, further research should explore the contributions of various sources for accessing medications
for erectile dysfunction and use rates among MSM, including accessing prescriptions and filling those prescriptions online. To date, there is little empirical data describing how medications for erectile dysfunction are accessed.
Moreover, online strategies to reach MSM who use methamphetamines may be an effective approach to reduce disease exposure and transmission (and reinfection); however, the development, implementation, and evaluation of
online intervention strategies to reduce HIV and STD risk currently are limited.26,27,40 Given research suggesting that MSM online may be different
from those available in physical spaces (e.g., gay bars and clubs, bathhouses),41-46 creative and innovative online approaches must be developed and tested to reach the online community.
This study is not without limitations. The associations are based on cross-sectional data; additional studies using longitudinal designs will be necessary to evaluate the significance and stability of these findings over time. Furthermore,
the results of this study may not apply to the general populations of MSM. However, the degree of fit between a sample and a target population about which generalizations can be made is a common challenge in many studies;
in fact, most studies of sexual behavior among MSM are based on nonrandom, self-selected samples.44,46-48 Moreover, by combining two datasets and adjusting for data collection mode, we may be closer to an approximation of what the true prevalence and associations may be among MSM.
Although both data collection modes used a self-administered format to minimize bias, these results remain based on self-reported data with their potential limitations. Techniques found to increase validity of self-reported behavior were applied.49-51 Finally, although the bar-based data collection had a 95%
response rate as reported,20 accurate response rates for the chat room-based data collection could not be calculated because of the unknown number of chatters (potential participants) who read the general public chat room
messages but chose not to reply or participate. Comparing the number of chatters in the chat room to the number who completed the assessment
would not be accurate because chatters engaged in private chats may not attend to messages in the public room; thus the denominator may be artificially high.
CONCLUSIONS
It has been established that substance use among MSM in the southern United States is a strong facilitator of sexual risk behaviors including anal sex with multiple partners and nondisclosure of positive HIV serostatus,52 however, to date, methamphetamine use in nonurban areas of the southern United States, particularly among MSM, has not been well explored or described. Given that the southern United States comprises a region of the country carrying disproportionate HIV, AIDS, and STD burden, our findings suggest the potential role methamphetamine use plays in the intersecting HIV and STD epidemics in the south. Ongoing and improved monitoring of methamphetamine use rates is needed. Currently, insufficient sexual orientation and behavioral data are collected on national and regional prevalence surveys, making comparisons across subgroups and over time difficult.48
Future studies should explore the meaning of methamphetamine use for MSM, the contexts in which use occurs, and how these differ by subgroup. For example, it has been asserted that methamphetamine use may be associated with feelings of isolation and loneliness among MSM in urban cities17; whether the same motivations for use are found among MSM in more rural areas of the south is unknown. Contexts of use have included bars, sex clubs, and bathhouses; however, contexts must be different in the South and
other rural areas where these venues are less common or nonexistent. Furthermore, understanding the differences among gay men and non-self-identifying MSM is clearly needed. The complex factors involved in accurately
determining methamphetamine rates and the associations with use underscore the need for further research. With more than 1 in 20 of participants in this large sample of MSM reporting using methamphetamines in the past 30 days, prevention, intervention, and treatment efforts are urgently needed and must be prioritized.
MATERIALS AND METHODS
Targeted intercept interviewing As has been described elsewhere,21 teams recruited a sample of MSM in five predominately gay male bars in central North Carolina in 2005. Eligible participants were ages 18 years or older and reported living within one of several zip codes within a combined statistical area (CSA)
in central North Carolina. Participants were assured that data collected would remain anonymous. Each bar patron was screened for participation regardless of assumed sex, gender, or sexual orientation by a trained bilingual recruiter
who explained the study, determined whether the participant had previously completed the assessment, and assessed the sobriety of potential respondents using established criteria to ensure informed consent.25 Assessments were self-administered and completed in secluded areas of the bars. All data collected were double-entered and cross-validated.
Targeted online assessment
Two trained self-identified gay men recruited participants in five Internet chat rooms designed to facilitate social and sexual networking among MSM in central North Carolina in 2005. These chat rooms had been identified by the research
team in another ongoing study.26 The recruiters were online in random 2-hour shifts. After entering a predetermined chat room, both followed a standard protocol to recruit chat-room participants. Eligible participants were ages 18 years or older and reported living within one of several zip codes within the same CSA included in the targeted intercept interviewing mode. After they were found eligible, potential participants were given the web address of the online assessment that was functionally similar to the paper-pencil assessment that was used in the bar-based targeted intercept interviewing. Further detail about this online data collection can be found elsewhere.27
Measurement
Data were collected using a brief risk assessment, which was developed by a local community-based participatory research (CBPR) partnership whose members comprised representatives from the local gay community; two local AIDS service organizations (ASOs); local gay bars; a foundation supporting lesbian, gay, bisexual, and transgender (LGBT) health; the leading Spanish-language newspaper and radio station in North Carolina whose owners have prioritized HIV education and prevention through media outreach; and two county public health departments, among others, who have partnered with Wake Forest University Health Sciences (WFUHS). This partnership serves as a catalyst for identifying priorities and approaches to meet local HIV/AIDS prevention
and care needs.26,28-34 The process was iterative with members negotiating and agreeing on a version of the assessment that was sufficient to collect necessary data yet concise to ensure completion by the target community.
Much effort went into the process of developing the assessment in order to ensure its rapid completion by participants. The final assessment was based on self-report, using predefined response options with binary, categorical, or Likert-scale response options to facilitate readability and administration.
Demographic characteristics were assessed, including age in years, gender (i.e., "male" "female," and "transgender," which included "male to female" and "female to male"), educational attainment, health insurance coverage, and estimated annual income. Race/ethnicity was assessed using the item, "How would you
describe your race or ethnic background?" Response options included, "American Indian or Alaskan Native," "Asian," "African American or black," "Hispanic or Latino," "Native Hawaiian or Other Pacific Islander," "White,"
and "Other." Participants who selected "Other" were asked to specify how they would describe their race or ethnic background. Sexual orientation was assessed using the item, "How would you describe your sexuality?" Response options included: "Bisexual," "Gay," "Heterosexual or Straight," "Transgender," and "Other." Participants who selected "Other" were asked to specify how they would
describe their sexuality.
Behaviors assessed included sexual behavior with men and women; numbers of sexual partners; engagement in oral, receptive-anal, and insertive-anal sex; condom use during oral, receptive-anal, and insertive-anal sex during the past 3 months; and condom use during oral, receptive-anal, and insertive-anal sex with men met online.
Self-reported history of STDs, including gonorrhea, syphilis, chlamydia, herpes, hepatitis A, hepatitis B, and genital warts; and HIV counseling, testing, and diagnosis also were assessed. Participants were asked whether they had ever used, and to estimate the past 30-day frequency use of, methamphetamine, cocaine, crack, heroin, and ecstasy.
Lifetime and past 30-day frequency use of medication designed to treat erectile dysfunction and often used for sexual enhancement (i.e., Viagra, Pfizer, New York, NY; Cialis, Eli Lilly and Company, Indianapolis, IN; and Levitra, Bayer HealthCare Phamaceuticals, Wayne, NJ) and of amyl nitrate ("poppers") also were assessed.
Participants ranked the three most frequent locations that they met most male sexual partners in the past 12 months, including: "Adult Bookstores," "Friends," "Gay Bars and Clubs," "Gyms or Health Clubs," "Internet or Chat
Rooms," "Non-Gay Bars and Clubs," "Public Places Such As Parks or Restrooms," "School," "Social Organizations or Volunteer Service Activities,"
"Vacation/Business Trips," and "Work."
A final item assessed whether a participant had completed the assessment previously in either mode.
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