Interventions for non-injection substance use among US men who have sex with men: what is needed

Targeted Oral Naltrexone for Mild to Moderate Alcohol Use Disorder Among Sexual and Gender Minority Men: A Randomized Trial

OBJECTIVE

The authors sought to determine the efficacy of targeted naltrexone in sexual and gender minority men (SGM) who binge drink and have mild to moderate alcohol use disorder.

METHODS

In a double-blind placebo-controlled trial, a total of 120 SGM who binge drink and have mild to moderate alcohol use disorder were randomized in a 1:1 ratio to receive targeted oral naltrexone (50 mg) or placebo with weekly counseling for 12 weeks. The study's primary endpoints were binge-drinking intensity, defined as 1) number of drinks in the past 30 days; 2) any binge drinking in the past week; 3) number of binge-drinking days in the past week; and 4) number of drinking days in the past week. The study also measured changes in alcohol use with two alcohol biomarker measures: ethyl glucuronide in urine samples and phosphatidylethanol (PEth) in dried blood spot samples.

RESULTS

Ninety-three percent completed the trial, with 85% of weekly follow-up visits completed. In intention-to-treat analyses, naltrexone was associated with a significantly reduced reported number of binge-drinking days (incidence rate ratio [IRR]=0.74, 95% CI=0.56, 0.98; number needed to treat [NNT]=2), weeks with any binge drinking (IRR=0.83, 95% CI=0.72, 0.96; NNT=7.4), number of drinks per month (IRR=0.69, 95% CI=0.52, 0.91; NNT=5.7 for 10 drinks), and alcohol craving scores (coefficient=-9.25, 95% CI=-17.20, -1.31). In as-treated analyses among those who took their medication on average at least 2.5 days per week (the median frequency in the study), naltrexone reduced any binge drinking (IRR=0.84, 95% CI=0.71, 0.99), number of binge-drinking days (IRR=0.67, 95% CI=0.47, 0.96), and PEth concentrations (coefficient=-55.47, 95% CI=-110.75, -0.20). At 6 months posttreatment, naltrexone had sustained effects in number of drinks per month (IRR=0.69, 95% CI=0.50, 0.97), number of binge-drinking days (IRR=0.67, 95% CI=0.47, 0.95), and any binge drinking in the past week (IRR=0.79, 95% CI=0.63, 0.99).

CONCLUSIONS

Targeted naltrexone significantly reduced drinking outcomes among SGM with mild to moderate alcohol use disorder during treatment, with sustained effects at 6 months posttreatment. Naltrexone may be an important pharmacotherapy to address binge drinking in populations with mild to moderate alcohol use disorder.

Tina's ParTy line: Polysubstance use patterns in sexual minority men living with HIV who use methamphetamine

INTRODUCTION

This cross-sectional study examined the associations of demographic, structural and psychological factors with distinct typologies of polysubstance use in sexual minority men (SMM) living with HIV who use methamphetamine.

METHODS

In total, 161 SMM living with HIV who reported methamphetamine use in the past 3 months were recruited in San Francisco from 2013 to 2017 for a randomised controlled trial. A latent class analysis was conducted by leveraging baseline measures of self-reported use of 15 substances in the past 3 months as well as validated screening measures of hazardous alcohol and cannabis use. Correlates of latent class membership were examined using a three-step categorical latent variable logistic regression.

RESULTS

Four typologies of substance use were identified: (i) methamphetamine use only (43%); (ii) methamphetamine and crack-cocaine use (22%); (iii) party and play use-methamphetamine, gamma-hydroxybutyrate and amyl nitrites (i.e. poppers) with erectile dysfunction drugs (31%); and (iv) high polysubstance use (4%). SMM of colour and those with a history of incarceration were more commonly classified as engaging in methamphetamine and crack-cocaine use compared to party and play use. Men with higher sexual compulsivity scores were more commonly classified as engaging in party and play use and polysubstance use.

DISCUSSION AND CONCLUSIONS

There is substantial heterogeneity in polysubstance use patterns among SMM living with HIV who use methamphetamine. This will inform the development of tailored substance use interventions addressing the unique needs of SMM of colour and targeting sexual compulsivity as a prominent comorbidity for some men.

Psychometric properties of measures of substance use: a systematic review and meta-analysis of reliability, validity and diagnostic test accuracy

Background

Synthesis of psychometric properties of substance use measures to identify patterns of use and substance use disorders remains limited. To address this gap, we sought to systematically evaluate the psychometric properties of measures to detect substance use and misuse.

Methods

We conducted a systematic review and meta-analysis of literature on measures of substance classes associated with HIV risk (heroin, methamphetamine, cocaine, ecstasy, alcohol) that were published in English before June 2016 that reported at least one of the following psychometric outcomes of interest: internal consistency (alpha), test-retest/inter-rater reliability (kappa), sensitivity, specificity, positive predictive value, and negative predictive value. We used meta-analytic techniques to generate pooled summary estimates for these outcomes using random effects and hierarchical logistic regression models.

Results

Findings across 387 paper revealed that overall, 65% of pooled estimates for alpha were in the range of fair-to-excellent; 44% of estimates for kappa were in the range of fair-to-excellent. In addition, 69, 97, 37 and 96% of pooled estimates for sensitivity, specificity, positive predictive value, and negative predictive value, respectively, were in the range of moderate-to-excellent.

Conclusion

We conclude that many substance use measures had pooled summary estimates that were at the fair/moderate-to-excellent range across different psychometric outcomes. Most scales were conducted in English, within the United States, highlighting the need to test and validate these measures in more diverse settings. Additionally, the majority of studies had high risk of bias, indicating a need for more studies with higher methodological quality.

Critical Review: When the Party is Over: A Systematic Review of Behavioral Interventions for Substance-Using Men Who Have Sex with Men

Because problematic patterns of alcohol and other substance use are prevalent drivers of the HIV/AIDS epidemic, comprehensive interventions are needed for substance-using men who have sex with men (SUMSM). We conducted a systematic review of 12 randomized controlled trials (RCTs) of behavioral interventions for reducing condomless anal intercourse (CAI) in SUMSM. Three RCTs observed that cognitive behavioral or motivational interviewing interventions achieved a 24% to 40% decrease in CAI. Interventions also tended to demonstrate greater efficacy for reducing CAI and substance use among those who had lower severity of substance use disorder symptoms. Although behavioral interventions for SUMSM are one potentially important component of biobehavioral HIV/AIDS prevention, further research is needed to examine whether integrative approaches that cultivate resilience and target co-occurring syndemic conditions demonstrate greater efficacy. Multilevel intervention approaches are also needed to optimize the effectiveness of pre-exposure prophylaxis and HIV treatment as prevention with SUMSM.

Availability and Use of Substance Abuse Treatment Programs Among Substance-Using Men Who Have Sex With Men Worldwide

BACKGROUND

Substance use is common among men who have sex with men (MSM) worldwide, and epidemiologic data suggest that alcohol/substance-using MSM are at greater risk for HIV. However, there are scarce data on substance abuse treatment programs (SATPs) for substance-using MSM.

OBJECTIVES

We examined proportions of substance use as well as SATP availability and use. We used multivariable regression models, controlling for potential confounders, to examine behavioral and demographic correlates of SATP availability and use.

METHODS

This is a cross-sectional study of a multi-region, online sample of substance-using MSM.

RESULTS

In this sample, 75% were substance-using MSM of whom 36% reported at-least-weekly use. Substance use was most prevalent among respondents from Eastern Europe/Central Asia (86%) and Latin America (79%). Among substance-using MSM, 96% and 33% reported alcohol intoxication and other substance use, respectively; 11% reported having high SATP availability; and 5% reported using SATPs. Controlling for global region of origin and age, high SATP availability was associated with high access to HIV risk-reduction education (aOR = 3.19; CI = 1.48-6.89), mental health services (aOR = 2.53; CI = 1.32-4.83), and medical care (aOR = 2.32; CI = 1.12-4.80); less than college-level education (aOR = 0.32; CI = 0.18-0.54); and higher comfort levels with providers (aOR = 1.75; CI = 1.30-2.37). Controlling for substance use frequency and personal income additionally, using SATPs was associated with higher levels of connection to the gay community (aOR = 2.76; CI = 1.22-6.22).

CONCLUSION

In this global sample of MSM, we found high alcohol intoxication and other substance use proportions. Few substance-using MSM report SATP availability, highlighting the need to develop novel substance use programs outside traditional treatment settings.

Race/ethnicity, education, and age are associated with engagement in ecological momentary assessment text messaging among substance-using MSM in San Francisco

BACKGROUND

Ecological momentary assessments (EMA) are data collection approaches that characterize behaviors in real-time. However, EMA is underutilized in alcohol and substance use research among men who have sex with men (MSM). The aim of this analysis is to explore the correlates of engagement in EMA text messages among substance-using MSM in San Francisco.

METHODS

The present analysis uses data collected from the Project iN pilot study (n=30). Over a two-month period, participants received and responded to EMA daily text messages inquiring about their study medication, alcohol, and methamphetamine use. Baseline characteristics including demographics, alcohol use, and substance use were examined as potential correlates of engagement in EMA text messages in logistic regression and proportional hazards models.

RESULTS

Participants had a 74% response rate to EMA text messages over the study period. MSM of color had significantly lower adjusted odds of responding to EMA texts 80% of the time or more, compared to white MSM (adjusted odds ratio=0.05, 95%CI=0.01-0.38). College-educated MSM had a lower adjusted hazard of week-long discontinuation in EMA texts (adjusted hazard ratio=0.12, 95%CI=0.02-0.63). Older MSM had a higher adjusted hazard of week-long discontinuation in EMA texts (adjusted hazard ratio=1.15, 95%CI=1.01-1.31).

CONCLUSION

Differences in engagement in EMA text prompts were discovered for MSM with different racial/ethnic backgrounds, ages, and education levels. Substance use variables were not correlated with engagement in text messages, suggesting that EMA may be a useful research tool among actively substance-using MSM in San Francisco.

Feasibility, Acceptability, and Tolerability of Targeted Naltrexone for Nondependent Methamphetamine-Using and Binge-Drinking Men Who Have Sex with Men

BACKGROUND

There are no effective pharmacologic strategies for nondependent methamphetamine (meth)-using and binge-drinking men who have sex with men (MSM) at high-risk for HIV. We sought to determine the feasibility of enrolling and retaining this population in a pharmacologic trial; the acceptability of pharmacotherapy study procedures; and the tolerability of targeted naltrexone versus placebo.

METHODS

Thirty meth-using and binge-drinking MSM were randomly assigned 1:1 to 50 mg naltrexone or placebo for 8 weeks for targeted administration (ie, during craving or in anticipation of meth or alcohol use). Substance use counseling and behavioral assessments were conducted every 2 weeks. Medication use was measured using WisePill dispensers.

RESULTS

Trial completion was 93%; visit completion rate was 95%. Mean weekly number of medication pills taken was 2.1 and was similar between arms. Participant satisfaction rate was 96%. There were neither serious adverse events nor differences in adverse event rates between arms. In exploratory intention-to-treat analyses, there were no differences in meth use and drinking. Naltrexone participants had greater reductions in serodiscordant receptive anal intercourse [incident rate ratio (IRR) = 0.15; 95% CI = 0.05 to 0.42] and serodiscordant condomless receptive anal intercourse (IRR = 0.11; 95% CI = 0.03 to 0.37), compared with placebo. In subgroup analyses among frequent meth users, naltrexone participants had greater reductions in meth-using days (IRR = 0.78; 95% CI = 0.62 to 0.99). In as-treated analyses, frequent study medication users in the naltrexone arm had greater reductions in binge drinking days (IRR = 0.72; 95% CI = 0.54 to 0.97).

CONCLUSIONS

Targeted naltrexone is a feasible, acceptable, and tolerable intervention strategy for nondependent meth-using and binge-drinking MSM. Naltrexone was associated with significant sexual risk reductions; and for some individuals, naltrexone was associated with meth and binge-drinking reductions.

Binge drinking concurrent with anal intercourse and condom use among men who have sex with men

Men who have sex with men (MSM) are the demographic group most severely affected by HIV in the USA. Global association studies have shown that MSM who binge drink are more likely to engage in risky sexual behaviors and day- and event-level analyses have linked binge drinking to sexual risk behavior on specific days and during specific sexual encounters. Despite this strong foundation of research, no studies have examined the association between the frequency of situational binge drinking (i.e., binge drinking concurrent with sexual activity) and aggregated sexual risk over periods of longer duration. We used multivariable logistic regression to assess the relationship between situational binge drinking (i.e., binge drinking concurrent with anal intercourse) and condomless anal intercourse (CAI) and among a cross-sectional sample of 124 MSM in San Francisco, CA. There was a positive relationship between frequency of situational binge drinking and CAI (1-5 times vs. never: adjusted odds ratio = 2.78, 95% CI = 1.01-7.63; 6-10 times vs. never: 6.19, 1.27-30.22; more than 10 times vs. never: 11.88, 1.31-107.60). By filling a methodological gap and complementing existing global and event-level analyses, this positive situational relationship strengthens the evidence linking binge drinking and sexual risk, enhances the comparability of the existing literature, and further suggests that the integration of dual strategies that aim to prevent HIV and reduce binge drinking may be warranted.

Occupational and demographic factors associated with drug use among female sex workers at the China-Myanmar border

BACKGROUND

Within the last decade, the use of amphetamine type stimulants (ATS) has swelled in Myanmar. Regionally, female sex workers have reported turning to ATS for occupational reasons. In doing so, drug-using female sex workers (FSW) face compounded risks for HIV and other sexually transmitted infections (STI). Here, we examine the factors that impact FSW drug use in Muse, a town along the China-Myanmar border.

METHODS

In 2012, 101 FSW were recruited from entertainment venues and brothels along the Myanmar-Chinese border. Participants participated in a self-administered behavioral survey covering demographics, drug use, sex work, and risk behaviors. Bivariate and regression analyses were conducted in SPSS.

RESULTS

Thirty four percent of respondents indicated current drug use. ATS derivatives were the most commonly used drugs (87.5%) with injection drug use being nearly non-existent in the sample. Drug using FSWs were older, had engaged in sex work longer, had more Chinese clients, and were more likely to have a previous boyfriend who had used drugs. They were also 3.5 times more likely to report a STI. Client condom use, HIV testing rates, and familiarity with public health resources did not statistically differ by drug use status.

CONCLUSION

More research is needed to examine how romantic and professional sexual relationships push-and-pull FSW into using drugs. Our results suggest that diverse safer sex strategies, beyond client condom use, should be promoted with drug using FSWs, including strategies that acknowledge the impact of ATS use.

Differences in Relationship Characteristics Between HIV-Negative Male Couples Who Used and Did Not Use Substances with Sex

Although substance use is linked to HIV seroconversion, little is known about male couples substance use with sex. The present study sought to: describe whether neither, one, or both partners in the couple used a particular substance with sex within or outside their relationship; assess, by substance type used with sex, whether relationship factors differed between these groups of couples. Dyadic data from 83 behaviorally non-monogamous HIV-negative male couples were used with multinomial regression models. Those who used with sex within the relationship varied by substance type; outside the relationship, most only had one partner who used with sex. Couples with one or both partners who used substances with sex within or outside the relationship were more likely to have higher commitment to their relationship yet less likely to trust their main partner; mixed results were found regarding communication. Further research is warranted toward the need for preventive intervention development.

Latent class analysis of substance use among men who have sex with men in Malaysia: Findings from the Asian Internet MSM Sex Survey

BACKGROUND

High prevalence of substance use among men who have sex with men (MSM) may drive the HIV epidemic in Malaysia but patterns of substance use among Malaysian MSM have not been examined. Our study investigated specific Malaysian MSM risk groups to determine the association between their substance use and sexual risk behaviors.

METHODS

Data from Malaysian respondents (n=1235) in a large, multinational online survey of Asian MSM in 2010 were used to identify latent classes of substance use. Subsequent covariates were included in a joint model to predict class membership.

RESULTS

The 3-class model was identified as the best fitting model, which included: (1) 'negligible substance use' for those reporting none or using any substance sparingly; (2) 'soft substance use' for those using poppers, ecstasy and drinking before sex; and (3) 'amphetamine-type stimulant (ATS) use' for those using stimulants (methamphetamine, ecstasy), erectile dysfunction drugs and recreational drug use before sex. Men in the 'ATS use' category were significantly less likely to not know their HIV status (AOR: 0.30, 95%CI: 0.14,0.66), more likely to have had more than 6 male sex partners (AOR: 4.83, 95% CI: 1.92-12.2), to have group sex (AOR:4.07, 95% CI: 2.31-7.15), to report inconsistent condom use (AOR:2.01, 95% CI: 1.12-3.60), to be HIV-infected (AOR:3.92, 95% CI: 1.63-8.42) and to have had any sexually transmitted infections (AOR:3.92, 95% CI:1.70, 9.08), compared to men in the 'negligible substance use' category.

CONCLUSIONS

Our study identified subgroups of Malaysian MSM with distinct substance use patterns and HIV-related risk profiles, which provides implication for targeting HIV prevention in this subpopulation.

Systematic review of interventions to reduce problematic alcohol use in men who have sex with men

ISSUES

Rates of heavy drinking, alcohol problems and alcohol-related disorders are high among men who have sex with men (MSM) and are an important public health issue. Associations between heavy drinking and human immunodeficiency virus (HIV) acquisition among MSM also suggest that drinking may have more severe and chronic consequences for this population relative to others. Consequently, effective interventions to reduce heavy drinking and alcohol-related risk factors among MSM are needed.

APPROACH

We conducted a systematic review of randomised controlled trials of interventions to reduce heavy drinking and/or alcohol-related problems among MSM. We searched five electronic databases, screened 3722 records and identified 5 studies involving 1022 participants that satisfied inclusion criteria, which included having: (i) incorporated a comparison condition; (ii) randomised participants to groups; and (iii) reported quantitative outcomes.

KEY FINDINGS

The methodological quality of studies varied, and meta-analysis was not conducted because of heterogeneity in intervention approaches and outcomes. Studies provided preliminary support for the use of motivational interviewing/motivational enhancement-based interventions (MI) and hybrid MI and cognitive behavioural therapy treatments for heavy drinking among MSM over no treatment. Perhaps the most important conclusion of this review, however, is that well-designed, theoretically informed research focused on establishing the efficacy of interventions for hazardous drinking and alcohol use disorders among MSM is alarmingly scarce.

CONCLUSIONS

Effective interventions to reduce hazardous drinking among MSM and prevent key alcohol-related outcomes, including risk for HIV transmission and health problems among HIV-positive MSM, are needed to mitigate health disparities in this population.

Relationship characteristics differ based on use of substances with sex among an urban internet sample of HIV-discordant and HIV-positive male couples

Previous research with men who have sex with men (MSM) has found that substance use with sex is strongly associated with HIV acquisition and poor adherence to HIV treatments. Although some studies have assessed male couples' use of substances with unprotected anal sex, little is known on whether differences in their relationship dynamics are associated with their usage. Current HIV prevention initiatives underscore the importance of studying male couples' relationship dynamics. Using dyadic data from 28 HIV-positive and 58 HIV-discordant male couples, this analysis sought to: (1) describe, by substance type, whether neither, one, or both partners in the couple used a particular substance with sex within their relationship or outside of the relationship, respectively, and (2) assess, by substance type, whether relationship characteristic differences existed between these three groups of couples with respect to substance use with sex within and outside the relationship. Data from 86 dyads came from a cross-sectional, Internet study. Multivariate multinomial regression models were employed to achieve the aims. Except for alcohol, most did not use substances with sex. Within the relationship, those who used with sex varied by substance type; outside the relationship, most couples had only one partner who used with sex regardless of substance type. Several relationship characteristic differences were noted between the groups of couples. Within the relationship, marijuana and erectile dysfunction medication (EDM) use with sex was associated with having less tangible resources; for outside the relationship, these were associated with perceiving to have greater quality of alternatives. In general, amyl nitrates and party drug use with sex were associated with viewing the main partner as being less dependable for trustworthiness. Marijuana and party drug use with sex within the relationship and EDM use with sex outside the relationship were negatively associated with being able to communicate constructively. Mixed results were noted for relationship satisfaction. Additional research is urgently needed for prevention and promotion of healthy relationships for male couples who use substances with sex.

Prevalence of consistent condom use with various types of sex partners and associated factors among money boys in Changsha, China

INTRODUCTION

Money boys with inconsistent condom use (less than 100% of the time) are at high risk of infection by human immunodeficiency virus (HIV) or sexually transmitted infection (STI), but relatively little research has examined their risk behaviors.

AIM

We investigated the prevalence of consistent condom use (100% of the time) and associated factors among money boys.

METHODS

A cross-sectional study using a structured questionnaire was conducted among money boys in Changsha, China, between July 2012 and January 2013.

MAIN OUTCOME MEASURE

Independent variables included socio-demographic data, substance abuse history, work characteristics, and self-reported HIV and STI history. Dependent variables included the consistent condom use with different types of sex partners.

RESULTS

Among the participants, 82.4% used condoms consistently with male clients, 80.2% with male sex partners, and 77.1% with female sex partners in the past 3 months. A multiple stepwise logistic regression model identified four statistically significant factors associated with lower likelihoods of consistent condom use with male clients: age group, substance abuse, lack of an "employment" arrangement, and having no HIV test within the prior 6 months. In a similar model, only one factor associated significantly with lower likelihoods of consistent condom use with male sex partners was identified in multiple stepwise logistic regression analyses: having no HIV test within the prior six months. As for female sex partners, two significant variables were statistically significant in the multiple stepwise logistic regression analysis: having no HIV test within the prior 6 months and having STI history.

CONCLUSIONS

Interventions which are linked with more realistic and acceptable HIV prevention methods are greatly warranted and should increase risk awareness and the behavior of consistent condom use in both commercial and personal relationship.

A roadmap for adapting an evidence-based HIV prevention intervention: personal cognitive counseling (PCC) for episodic substance-using men who have sex with men

Episodic (less than weekly) drug use and binge drinking increase HIV-related sexual risk behaviors among men who have sex with men (MSM), yet no evidence-based interventions exist for these men. We describe an adaptation process of the Personalized Cognitive Counseling (PCC) intervention for utilization with high-risk, HIV-negative episodic, substance-using MSM. Participants (N = 59) were racially diverse, and reported unprotected anal intercourse and concurrent binge drinking (85%), use of poppers (36%), methamphetamine (20%) and cocaine (12%). Semi-structured interviews with 20 episodic, substance-using MSM elicited sexual narratives for engaging in unprotected anal intercourse while using alcohol or drugs. Emergent qualitative themes were translated into self-justifications and included in a revised PCC self-justification elicitation instrument (SJEI). The adapted SJEI was pretested with 19 episodic, substance-using MSM, and the final adapted PCC was pilot-tested for acceptability and feasibility with 20 episodic, substance-using MSM. This process can be used as a roadmap for adapting PCC for other high-risk populations of MSM.

Differences in Gay Male Couples' Use of Drugs and Alcohol With Sex by Relationship HIV Status

Prior studies with men who have sex with men have documented a strong association between substance use with sex and risk for acquisition of HIV. However, few studies have been conducted about gay male couples' use of substances with sex, despite the fact that between one third and two thirds of men who have sex with men acquire HIV from their relationship partners. The present study sought to (1) describe whether one or both partners in the male couple uses substances with sex-by substance type-within and/or outside of their relationship, and (2) assess whether differences exist in those who use substances with sex within and outside the relationship by the couples' HIV status. Dyadic data for this analysis were collected in the United States from a nation-wide cross-sectional Internet study about male couples' relationships and behaviors. Couple-level descriptive and comparative analyses were employed with 361 male couples. Except for alcohol, most couples did not use substances with sex. Of those who did, rates of who used it with sex and substance type within the relationship varied; most couples only had one partner who used substances with sex outside the relationship. Significantly higher proportions of concordantly HIV-negative and HIV-positive couples had both partners who used substances (all types) with sex within their relationship over discordant couples. Most couples had one partner who used outside the relationship; only marijuana and erectile dysfunction medication use with sex significantly differed by couples' HIV status. Findings indicate the need to conduct additional research for prevention development.

A cause for concern: male couples' sexual agreements and their use of substances with sex

Substance use is strongly associated with HIV risk among gay men. Many gay couples establish sexual agreements. However, little is known about gay couples' use of substances with sex, and whether substance use is associated with couples' agreements. The present study assessed whether gay couples' use of substances with sex was associated with their establishment of, type of, and adherence to, a sexual agreement. Dyadic data from 275 HIV-negative US gay couples were collected online in a nation-wide, cross-sectional study, and analyzed at the couple-level. Findings revealed that couples with an established agreement, and a recently broken agreement, were more likely to have used amyl nitrates and marijuana with sex within their relationship. This same trend was also noted, but for alcohol use with sex outside of couples' relationships. Further research is urgently needed to examine the fluidity of HIV-negative gay male couples' sexual agreements and substance use with sex.

Substance use and drinking outcomes in Personalized Cognitive Counseling randomized trial for episodic substance-using men who have sex with men

BACKGROUND

Non-dependent alcohol and substance use patterns are prevalent among men who have sex with men (MSM), yet few effective interventions to reduce their substance use are available for these men. We evaluated whether an adapted brief counseling intervention aimed at reducing HIV risk behavior was associated with secondary benefits of reducing substance use among episodic substance-using MSM (SUMSM).

METHODS

326 episodic SUMSM were randomized to brief Personalized Cognitive Counseling (PCC) intervention with rapid HIV testing or to rapid HIV testing only control. Both arms followed over 6 months. Trends in substance use were examined using GEE Poisson models with robust standard errors by arm. Reductions in frequency of use were examined using ordered logistic regression.

RESULTS

In intent-to-treat analyses, compared to men who received rapid HIV testing only, we found men randomized to PCC with rapid HIV testing were more likely to report abstaining from alcohol consumption (RR=0.93; 95% CI=0.89-0.97), marijuana use (RR=0.84; 95% CI=0.73-0.98), and erectile dysfunction drug use (EDD; RR=0.51; 95% CI=0.33-0.79) over the 6-month follow-up. PCC was also significantly associated with reductions in frequency of alcohol intoxication (OR=0.58; 95% CI=0.36-0.90) over follow-up. Furthermore, we found PCC was associated with significant reductions in number of unprotected anal intercourse events while under the influence of methamphetamine (RR=0.26; 95% CI=0.08-0.84).

CONCLUSION

The addition of adapted PCC to rapid HIV testing may have benefits in increasing abstinence from certain classes of substances previously associated with HIV risk, including alcohol and EDD; and reducing alcohol intoxication frequency and high-risk sexual behaviors concurrent with methamphetamine use.

Alcohol and substance use among transgender women in San Francisco: prevalence and association with human immunodeficiency virus infection

INTRODUCTION AND AIMS

Alcohol and substance use can have negative health consequences among both human immunodeficiency virus (HIV)-positive and -negative individuals, and are associated with behaviors that facilitate HIV transmission and acquisition. The relationship of substance use and HIV is well documented among key populations at risk for HIV. However, although transwomen (male-to-female transgender) are disproportionately impacted by HIV, this overlap remains understudied in this population. We sought to evaluate the association between HIV, alcohol and substance use among transwomen.

DESIGN AND METHODS

We conducted a secondary data analysis of Respondent Driven Sampling study which collected information on self-reported alcohol and substance use among 314 transwomen. We used multivariable logistic regression to assess relationship between HIV infection and classes and patterns of alcohol and substance use.

RESULTS

We found that 58% of transwomen used alcohol, and 43.3% used substances. The most common substances used were: marijuana (29%), methamphetamine (20.1%), crack cocaine (13.4%), and 'club drugs' (13.1%). Transwomen who reported any methamphetamine use [adjusted odds ratio (AOR) 3.02 (95% confidence interval (CI) = 1.51-6.02)], methamphetamine use before or during anal intercourse [AOR 3.27 (95% CI = 1.58-6.77)], and at least weekly methamphetamine use [AOR 3.89 (95% CI = 1.64-9.23)] had significantly greater odds of testing positive for HIV.

DISCUSSION AND CONCLUSIONS

Transfemales have high prevalence of alcohol and substance use; those tested positive for HIV used significantly more methamphetamine in general, and in conjunction with sex. Given the disproportionate prevalence of HIV and substance use in this population, interventions aimed at addressing both substance use and HIV risk among transwomen are urgently needed.

Systematic review of cognitive behavioural interventions for HIV risk reduction in substance-using men who have sex with men

Men who have sex with men (MSM) experience disproportionately high rates of HIV and substance use. Though interventions based on cognitive behavioural therapy (CBT) are effective for many psychiatric disorders, systematic reviews of CBT for substance use present mixed results and CBT has not been systematically reviewed for HIV risk reduction in MSM. Randomised controlled trials (RCTs) of non-pharmacological CBT for substance-using MSM were systematically reviewed to assess the evidence for these interventions' impact on unprotected anal intercourse (UAI). We searched 20 databases on 22 September 2012. Of the 2801 records identified, both authors separately assessed 70 full-text articles for inclusion. In three included RCTs, one RCT compared CBT against non-treatment control and two RCTs compared CBT against CBT variants. Across studies, CBT led to UAI reductions, though at one-year follow-up, these reductions were generally not greater than in other trial arms. This evidence of moderate quality indicates that while CBT may reduce UAI in substance-using MSM, it is unclear if CBT is more effective than mere assessment. All RCTs tested intensive, clinic-based interventions requiring sustained participant commitment, indicating a need for research into briefer interventions, with particular focus on episodic substance use and effectiveness trials.

Alcohol and drug use during unprotected anal intercourse among gay and bisexual men in Scotland: what are the implications for HIV prevention?

Objectives

To examine alcohol and drug use during unprotected anal intercourse (UAI), and whether use is associated with HIV-related risk behaviours among gay and bisexual men in Scotland.

Methods

Cross-sectional survey of 17 gay commercial venues in Glasgow and Edinburgh in May 2011 (n=1515, 65.2% response rate); 639 men reporting UAI are included.

Results

14.4% were always and 63.4% were sometimes drunk during UAI in the previous 12 months; 36.3% always/sometimes used poppers; 22.2% always/sometimes used stimulant or other recreational/illicit drugs; and 14.1% always/sometimes used Viagra. All were significantly correlated and, in multivariate analysis, the adjusted odds of having UAI with 2+ partners in the previous 12 months were significantly higher for men who reported stimulant or recreational/illicit drug use during UAI (AOR=2.75, 95% CI 1.74 to 4.34) and the adjusted odds of UAI with casual partners were higher for men who reported poppers use (AOR=1.50, 95% CI 1.03 to 2.17). Men who reported always being drunk during UAI were more likely to report UAI with 2+ partners (AOR=1.68, 95% CI 1.01 to 2.81), casual partners (AOR=2.18, 95% CI 1.27 to 3.73), and partners of unknown/discordant HIV status (AOR=2.14, 95% CI 1.29 to 3.53), than men who were not.

Conclusions

Our study suggests alcohol and drug use may be relatively common during UAI among gay and bisexual men in Scotland. Brief alcohol or drug interventions, particularly in clinical settings, are justified, but should be properly evaluated and take into account the potential influence of broader, situational and social factors on sexual risk.

Dose-response associations between number and frequency of substance use and high-risk sexual behaviors among HIV-negative substance-using men who have sex with men (SUMSM) in San Francisco

We evaluated the relationship between frequency and number of substances used and HIV risk [ie, serodiscordant unprotected anal intercourse (SDUAI)] among 3173 HIV-negative substance-using MSM. Compared with nonusers, the adjusted odds ratio (AOR) for SDUAI among episodic and at least weekly users, respectively, was 3.31 [95% confidence interval (CI), 2.55 to 4.28] and 5.46 (95% CI, 3.80 to 7.84) for methamphetamine, 1.86 (95% CI, 1.51 to 2.29) and 3.13 (95% CI, 2.12 to 4.63) for cocaine, and 2.08 (95% CI, 1.68 to 2.56) and 2.54 (95% CI, 1.85 to 3.48) for poppers. Heavy alcohol drinkers reported more SDUAI than moderate drinkers [AOR, 1.90 (95% CI, 1.43 to 2.51)]. Compared with nonusers, AORs for using 1, 2, and ≥3 substances were 16.81 (95% CI, 12.25 to 23.08), 27.31 (95% CI, 18.93 to 39.39), and 46.38 (95% CI, 30.65 to 70.19), respectively. High-risk sexual behaviors were strongly associated with frequency and number of substances used.

Recruiting drug using men who have sex with men in behavioral intervention trials: a comparison of internet and field-based strategies

Although online and field-based samples of men who have sex with men (MSM) have been compared on a variety of markers, differences in drug use have not been well examined. In addition, generalization from studies comparing recruitment methods is often limited by a focus on either HIV seropositive or seronegative MSM. We compared two New York City-based samples of MSM recruited simultaneously between July 2009 and January 2010-one sample recruited in the field (n = 2,402) and one sample recruited via the Internet (n = 694). All recruitment efforts targeted men without restriction on age or self-reported HIV status. Our results show marked differences in drug and alcohol use between online and field-based samples of MSM. Specifically, men surveyed online were significantly more likely to have tried a variety of drugs, including methamphetamine, cocaine, and ecstasy. Men recruited online were also more likely to report older age, HIV positive serostatus, and "never" using condoms. Internet-based recruitment was found to be more cost-effective in terms of recruitment yield than was field-based recruitment.

The influence of drug consumption on condom use and other aspects related to HIV infection among male sex workers in Spain

Higher rates of substance use have been associated with unsafe sex behavior. Male sex workers (MSW) present high rates of drug use during or after the professional sexual exchange with clients and also in their leisure. This research describes patterns of drug consumption among MSW in Spain and explores both the effect of substance use on professional and risk sexual behaviors. Participants were 100 agency MSW offering their services in Valencia and Castellón (Spain). Most of them were drug users and the most common substances were "soft drugs" and cocaine. An absence of injection drugs was found. Drug consumers indicated a higher HIV risk perceived and lower perceived influence of substance use on condom use negotiation. Drug influence on condom use is not clear. More investigation about drug influence on sexual risk behaviors among MSW is needed. The role of steady partners and clients must be taken into account too.

Racial and ethnic disparities and implications for the prevention of HIV among persons who inject drugs

PURPOSE OF REVIEW

There are now an estimated 16 million people who inject drugs (PWID) throughout the world, 3 million of whom are estimated to be infected with HIV. In many countries, substantial proportions of PWID belong to racial/ethnic/nationality minority groups, and are at increased likelihood of being infected with HIV. This article reviews current evidence on ethnic disparities in HIV infection among PWID and assesses the issues that would need to be addressed to reduce these disparities.

RECENT FINDINGS

An ongoing systematic review of ethnic disparities has found that, in a pooled weighted odds ratio, ethnic minority PWID are twice as likely to be HIV seropositive than ethnic majority, PWID from the same geographic area. If implemented with sufficient quality and coverage, current HIV prevention programs probably have the capability of ending HIV transmission among both ethnic majority and minority PWID. Large-scale, evidence-based prevention programs need to be implemented in the contexts of patterns of injecting drug use that continue to evolve-with injecting practices spreading to new areas, changes in drugs injected, and some transitions from injecting to noninjecting drug use. Lack of financial resources and policies against evidence-based programming are increasingly important problems that are likely to have particularly adverse effects on ethnic minority PWID.

SUMMARY

Racial/ethnic/nationality disparities in HIV infection are quite common among PWID. Addressing these disparities will be a fundamental challenge within a human rights approach to public health.

The urgency of providing comprehensive and integrated treatment for substance abusers with HIV

Substance abuse is linked to many new cases of HIV infection. Barriers such as the myth that drug users cannot adhere to HIV/AIDS treatment block progress in curbing the spread of HIV in that population. In this article we explain the need to aggressively seek out high-risk, hard-to-reach substance abusers and to offer them HIV testing, access to treatment, and the necessary support to remain in treatment--both for HIV and for substance abuse. We summarize evidence showing that injection drug users can successfully undergo HIV treatment; that many substance abusers adhere to antiretroviral therapy as well as do people who don't inject drugs; and that injection drug users who undergo substance abuse treatment are more likely to obtain and stay in treatment for their HIV infection. This evidence makes a strong case for integrating substance abuse treatment with HIV treatment programs and providing substance abusers with universal access to HIV treatment. But an integrated strategy will require changes in the health care system to overcome lingering obstacles that inhibit the merging of substance abuse treatment with HIV programs.