# Presentation: 672030

## 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

## 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

**Notes:**
I want to do three broad things today – I want to describe the prevalence of HIV, alcohol and drug use, and substance dependence among MSM

Then I will describe the associations between drug use and risky sexual behavior among MSM

And finally, I will describe HIV prevention approaches for substance using MSM

## 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%)
**TOTAL**		**17%**		(15-18%)

**Catania, Osmond, Stall, et al. (2001). **_**AJPH, 91**_**, 907-914**

**Notes:**
Very high rates of infection – compared to overall rate in the US, which is less than 1⁄2 of one percent.  These rates are consistent with the most severely affected countries in Africa

Data I will be referring to in a few sections of my talk will be from the Urban Men’s Health Study – led by Joe Catania and Co-PI was Ron Stall.  So let me tell you a little bit about it 

This was a large study that used RDD to screen over 65,000 households looking for MSM in 4 cities

You can see the final N was almost 3000 men, and 78% of eligible households participated in the interview
Interviews averaged 75 minutes in length, and refusal rates for key variables were < 1%

Orasure testing to confirm HIV status in a sub-sample of respondents
Assessed a broad range of health problems faced by urban MSM

## 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%)

**Notes:**
Seroprevalence varies by race

## 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%)

**Notes:**
Less educated men are more likely to be HIV+

## 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%)

**Notes:**
High rates even at relatively young ages, 

Rates of HIV start rising among MSM in their late teens and by their early 20s hit 10% according to data from the Young Men’s Survey’s funded in 7 cities in the US

## HIV Seroprevalence: Intravenous Drug Use

- 						 _%_	 (_95% CI)_
- Non-IDU				15% 	 (13-16%)
- IDU < 5 years			40%	 (26-55%)
- IDU > 5 years			43%	 (33-53%)

**Notes:**
Having been an injector was high related to being HIV+ -- and there was no difference based on length of injection, although if they had made a category with a much shorter time of injection they would have likely found less HIV.

## 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%)

**Notes:**
And more frequent use of non-injection drugs was related to being HIV+.

So you can see, among heavy drug users, like the types we might see in drug treatment, rates of infection of about one-third could be expected, and even higher among men who are also drug injectors.

## 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

## 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**

**Notes:**
Early bar-based samples estimated 33% of gay men were alcohol abusers

More recent studies indicate MSM are not more likely to be alcohol abusers than heterosexual men

But, MSM seem less likely to abstain

Rates of drinking and problem drinking have dropped from early 1980s to 1990s.  When population-based comparison studies have been done, rates of alcohol use and abuse have decreased among MSM (possibly cohort effects [HIV] or effects of history)

## 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

## 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

## 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

## Prevalence of Drug Use among MSM versus Men in General

**	****	****           ****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%

- Stall, Paul, Greenwood et al. (2001), _Addiction, 96_, 1589-1601

## Prevalence of Drug Use –NHSDA (Lifetime and Past Month)

|  | MSM-Life | MSW-Life  | MSM-1M | MSW-1M |
| --- | --- | --- | --- | --- |
| Any Drug | 72.8% | 54.6% | 16.3% | 9.9% |
| Marijuana | 64.6% | 52.3% | 13.9% | 8.4% |
| Cocaine | 37.2% | 19.5% | 3.9% | 1.2% |
| Hallucin. | 34.7% | 18.0% | 1.6% | 0.7% |
| Inhalants | 30.8% | 9.8% | 0.0% | 0.6% |
| Analgesics | 15.9% | 7.9% | 0.0% | 1.0% |
| Tranq. | 13.9% | 5.4% | 0.4% | 0.6% |

**Cochran, Ackerman, Mays, & Ross (2004). **_**Addiction, 99**_**, 989-998**

**Notes:**
This slide shows data that was published this month in Addiction.
It was a secondary data analysis from the 1996 National Household Survey on Drug Abuse and it compares men based on their sexual behavior in the past year (having male partners or only female partners).  The N for MSM was fairly small (98) while the N for MSW was 3922.

They then compare lifetime rates of substance use (in the first 2 columns) and substance use in the past month (2nd 2 columns) between MSM and MSW.  The red highlighted figures indicate significant differences between groups.

You can see that MSM were more likely to use a variety of drugs over their lifetime – but there were few differences for recent use – the only significant one being cocaine.

## Prevalence of Drug Dependence or Dysfunctional Use (Past Year)

|  | MSM-DD | MSW-DD  | MSM-DU | MSW-DU |
| --- | --- | --- | --- | --- |
|  |  |  |  |  |
| Marijuana | 5.7% | 2.1% | 15.0% | 6.6% |
| Cocaine | 1.4% | 0.7% | 4.3% | 2.1% |
| Inhalants | 0.0% | 0.0% | 0.6% | 1.0% |

**Cochran, Ackerman, Mays, & Ross (2004). **_**Addiction, 99**_**, 989-998**

**Notes:**
This slide shows Prevalence of Drug dependence and dysfunctional use of various drugs

DD (in the first 2 columns) was defined as answering yes to at least 3 of six Sx of drug dependence in the past year.  
Dysfunc use (2nd 2 columns) was defined as answering yes to any of 6 Sxs in past year.

Again, the red highlighted figures indicate significant differences between groups.

Weakness – didn’t ask about methamphetamines

There was more dysfunctional drug use among MSM than MSW, but most of that difference was accounted for by difference in use of marijuana.

## 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

**Notes:**
Stall et al., 1999 = 56% lifetime
Shoptaw et al, 2002 = 41% of meth users in Tx

## 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)_

**Notes:**
Party drugs, circuit parties
Poly-drug use in sexualized settings including GHB, ketamine, ecstasy, poppers, 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)
Much easier for men to hook up to use drugs and have sex – expanded social networks

## Current Trends: Viagra Use

- 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%

**Kim et al (2002). **_**AIDS, 16**_**, 1425-8**

**Chu et al (2003). **_**JAIDS, 33**_**, 191-3**

**Notes:**
Rapid increase in prevalence of use among MSM in urban centers after its introduction – some valid use due to HIV, aging, etc.
But, Viagra is often used by substance using men to decrease negative sexual effects of substances

Of MSM using Viagra, less than half report that it was prescribed by a physician

Viagra use is related to illicit substance use and risky sexual behavior in some studies

## 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

**Notes:**
MSM appear to use a broader variety of drugs and are more likely to be poly-drug users than heterosexual men

Higher rates of use do not appear to translate into more substance abuse, with the exception of marijuana

Certain drugs are much more popular among MSM, particularly “party” drugs or sexually-related drugs

Cultural shifts in the popularity of different drugs and settings for drug use present intervention challenges

## 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

## Substance Use, Sexual Risk, and other Public Health Problems

## Slide 23

**Notes:**
Marketers to MSM make implicit and explicit links between sexual behavior and alcohol

## Slide 24

## 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

## 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**** **

**Notes:**
There are 3 study designs that have been used to try to establish a link between substance use and risk

Global Associations:
users of substance X report greater risk behavior
Situational Associations:
users of substance X before/during sex report greater risk behavior
Event-Level Analysis:
users of substance X during particular sexual episodes report greater risk behavior

## 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

## 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

**Notes:**
Gillmore and colleagues found that substance use not related to risk; condoms used more with casual partners and by HIV-negative men, regardless of substance use

Using the EXPORE data set, Colfax and colleagues found that use of poppers, amphetamines, and cocaine and heavy alcohol consumption was related to serodiscordant UA among 4000+ HIV-negative MSM

## 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

**Notes:**
(Chesney, et al., 1998; Ostrow et al., 1995; Penkower et al., 1991; Seage et al., 1992; Penkower et al., 1991; Colfax, 2004)

## 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**** **

## 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

## Number of Health Problems and Vulnerability to HIV in MSM

| Number of prbms
 | 
0
(n = 1392) | 
1
(n = 812) | 
2
n = 341) | 
3-4
(n = 129) | 
Z Test
(p) |
| --- | --- | --- | --- | --- | --- |
| Percent HIV+ | 
13.0% | 
20.9% | 
27.2% | 
22.4% | 
0.001 |
| Percent w/ Sex Risk | 
7.1% | 
11.2% | 
15.8% | 
22.5% | 
0.001 |

**Stall, Mills, Williamson et al. (2003). AJPH, 93, 939-42**

**Notes:**
In the UMHS, Ron Stall did some analyses looking at what the predictors of various prevalent health problems were among MSM – and they found that the problems were all highly related and intercorrelated.

## 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).

**Notes:**
This is consistent with mental health literature showing 25-58% of substance users also having another DSM-IV diagnosis (Brems et al., 1997).

## 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

## HIV Prevention Approaches for Substance Using MSM

## 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

**Notes:**
First, it is important to acknowledge that when we are trying to address the HIV prevention needs of substance using MSM, there are 2 cultures that collide here – 

And with people with multiple co-morbidities, issues arise about what to treat first and how.
Substance use disorder, anxiety disorder, high-risk sexual behavior.  Have to start somewhere, and treating one of DSM disorders may help with other disorders and risk reduction

## 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

## 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

**Notes:**
#3 is it possible to elaborate a bit on potential ways/opportunities to integrate HIV prevention and drug abuse treatment among those populations?  Part of the audience are from addiction treatment programs and eager to know what they can bring back or implement at their program.

## 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**

## 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

## 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**

## 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

## 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

## 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?

## 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

## 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**

**Notes:**
Of 585 clients, 456 were recruited (78%) – 
	391 completed 2 or more waves
	147 were randomized to one of two conditions
	176 treatment dropouts
1\	68 had early treatment groups only (<30 days)

## 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-

## 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

## 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

## 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

## SEX: A Crucial Component to Preventionand Treatment for SU-MSM

- Why MSM Use Substances During Sex:
- Enhancing the sexual experience
- Increasing sexual arousal
- Facilitating sexual encounters
- Increasing the capacity for sexual behaviors
- Prolonging sexual experiences
- Increasing the capacity to “turn a trick”

**Myers et al. (2004). **_**Addiction Research and Theory, 12**_**, 213-29**

## Elements of Prevention Conclusions: Programs for MSM 

- Individual-level factors
- Understanding of SU-sex link for that person
- Assess and treat/refer for comorbidities
- Address contextual factors in Tx
- Drug type, partner type, serostatus, setting, peers
- Community factors
- Integrated, available services fully open to MSM
- Community norms and support for SU-MSM