Men who have sex with men and also inject drugs-profiles of risk related to the synergy of sex and drug injection behaviors

The Dimensions of Desire Among Gay, Bisexual, and Other Men Who Have Sex With Men (gbMSM): An Evolutionary Concept Analysis

Background and Purpose: Within nursing discourses, the concept of desire among gay, bisexual, and other men who have sex with men (gbMSM) is not well understood. Among nurses, this concept is often constructed as being synonymous with sexual and other risk-taking behaviors, which can influence the type of care nurses provide to gbMSM and affect how this group engages with nurses - and their health. This misinterpretation of what desire represents has resulted in gbMSM becoming the target of public health campaigns and nursing interventions aimed at curbing their deviant behaviors. Such an approach by nurses, however, overlooks the meaning of desire among gbMSM. Methods: To enhance nursing knowledge about, and improve nursing practice for, gbMSM, a concept analysis of desire specific to this group was undertaken using Rodger's evolutionary model. For this analysis, 90 articles reviewed from the disciplines of nursing and allied health, medicine, and psychology. Results: Findings from this analysis revealed a complexity to desire among gbMSM that extended well beyond engagement in radical sexual practices and into dimensions of desire for connection, freedom, and acceptance. These revelations were applied to demonstrate how nurses' beliefs about desire and subsequent regulations for "good health" can inhibit the ways in which desire is produced among gbMSM. Implications for Practice: Such findings demonstrate a need to develop future approaches for nursing practice that recognize the innate value and individual perspectives about desire held by this group, which can be uniquely tailored to meet their health needs.

Sexually Transmitted Infections Among Men and Transgender Women Using HIV Pre-exposure Prophylaxis in a Large Integrated Health System-A Cohort Study

BACKGROUND

Sexually transmitted infections (STIs) are common in people using pre-exposure prophylaxis (PrEP). We examined risk and factors associated with STIs in a cohort of PrEP users in an integrated health system in the United States.

SETTING

The Kaiser Permanente Southern California is a large integrated health system that provides comprehensive medical services to approximately 4.7 million demographically diverse members.

METHODS

We identified men and transgender women initiating PrEP between January 1, 2014, and June 1, 2018, and followed through December 31, 2018. Demographic and clinical factors potentially associated with the risk of bacterial STIs during PrEP use were evaluated using Poisson regression models.

RESULTS

Among 5042 individuals tested for STIs with 7198 person-years of follow-up, 1709 (33.9%) had at least one new STI. The estimated incidence of STIs was 48.3 per 100 person-years, and the most common STI was rectal chlamydia. Most repeat STIs (61.4%) occurred <180 days apart. In a multivariable analysis, an history of STIs in the prior 6 months through 7 days after the PrEP initiation was the most prominent risk factor of STIs during PrEP use (adjusted risk ratio: 1.78, 95% confidence intervals: 1.65 to 1.93). Other risk factors included younger age (<35 years), being Hispanic, and having a history of alcohol use disorder or drug use disorder.

CONCLUSIONS

Quarterly STI testing and targeted intervention to mitigate STI risk are warranted for young and racial minority PrEP users, particularly for those with prior history of STIs and substance use disorders.

"It's not just the hit itself": the social practice of injecting drug use among gay and bisexual men in Australia

BACKGROUND

Injecting drug use is purportedly more common among gay and bisexual men (GBM) than the general Australian population. Approaches designed to support the wellbeing of people who inject drugs may not be effective for GBM who inject, due to divergent settings, substances, and/or symbolism. We sought to identify the critical elements shaping injecting among GBM as a social practice and the implications for health and psychosocial wellbeing.

METHODS

We conducted 19 in-depth interviews with GBM in Australia with lifetime experience of injecting drug use, adopting the Frameworks Method for data analysis. Framed by social practice theory, transcripts were coded to delineate the constituent material, competency, and meaning elements of GBM's injecting practices. We developed themes encompassing the dynamic interrelationship between practice elements and wellbeing aspects.

RESULTS

Of 19 participants interviewed (aged 24-60 years), 17 identified as gay, two as bisexual. Injecting histories ranged from 2-32 years; most injected methamphetamine (n = 18). Injecting involved the integration of sexual function with substances and injecting skills in dyadic/communal settings. Beyond traditional harm reduction aspects, 'safe injecting' concerned trustworthiness of fellow practitioners, preventing addiction, and maintaining a solid self-concept. Injecting occurred as a dyadic/communal practice, in which an uneven distribution of materials (substances, sexual capital) and competencies (self-injecting) influenced risk and power dynamics. Pleasurable meanings of belonging, desirability and self-actualisation - gained from communities of practice - conflicted with injecting-related stigma, social dependencies, and fear of harms to body, mind, and sense of self.

CONCLUSION

Injecting is a heterogenous practice, including among GBM. Shifting configurations of its composite elements influence GBM's perceptions and experiences of pleasure, risk, and harms. Efforts to support their wellbeing should take a dyadic/communal approach and seek to rectify the uneven distribution of material and competency elements in these settings.

Using mobile health technologies to test the association of cocaine use with sexual desire and risky sexual behaviors among people with and without HIV who use illicit stimulants

BACKGROUND

Cocaine use is broadly associated with risky sexual behavior potentially through elevated sexual desire. Understanding the within-person effects of cocaine on sexual desire and risky sexual behavior and the modification of HIV infection may inform primary and secondary HIV interventions.

METHODS

We conducted a mobile health (mHealth) study in a community sample of males and females with (n = 28) and without (n = 32) HIV who use illicit stimulant drugs. Participants completed ecological momentary assessments (EMAs) and daily diaries over 28 days. Mixed effects models were employed to examine the within-person association of cocaine use with sexual desire and risky sexual behavior.

RESULTS

Participants completed 3505 EMA responses, with 36 % involving recent cocaine use, including powder and/or crack cocaine. They completed 1427 daily diary responses, with cocaine use reported on 49 % of these days and sexual behavior on 21 % of these days. Sexual desire was highest in the first hour since cocaine use and gradually decreased with time. Sexual desire was lowest when participants had not used any cocaine in the past 6 h, and it correlated positively with the amount of use. Participants were more likely to have risky sexual behavior on days they used cocaine. These associations were similar for participants with and without HIV.

CONCLUSION

This study demonstrates the dynamic and proximal effects of cocaine use on sexual desire and risky sexual behavior. Our findings support the development of HIV prevention interventions that utilize mHealth technology to reduce sexual risk behavior among persons who use stimulant drugs.

Correlates of Transactional Sex and Violent Victimization among Men Who Inject Drugs in Los Angeles and San Francisco, California

Men who inject drugs (MWID) and engage in transactional sex (i.e., receive money or drugs in exchange for sex) are vulnerable to HIV and violence. However, MWID who engage in transactional sex have been less studied than women. We examine factors associated with transactional sex among MWID in Los Angeles and San Francisco and whether transactional sex is associated with violent victimization. MWID were recruited using targeted sampling methods in 2011-2013 and completed surveys that covered demographics, drug use, HIV risk, violence, transactional sex, and other items. Multivariable logistic regression was used to (1) determine factors independently associated with transactional sex and (2) determine if transactional sex was independently associated with violence victimization in the last 6 months among MWID. An interaction term between income source and sexual identity was included in the transactional sex model. Of the 572 male PWID in the sample, 47 (8%) reported transactional sex in the past 6 months. Self-reported HIV infection was 7% for MWID who did not report transactional sex, 17% for MWID who reported transactional sex, and 24% for MWID who reported transactional sex and reported gay or bisexual identity. In multivariable analysis, transactional sex was positively associated with gay or bisexual identity (GB without illegal income adjusted odds ratio [AOR] = 5.16; 95% confidence interval [CI] = 1.86-14.27; GB with illegal income AOR = 13.55, CI = 4.57-40.13), coerced sex in the last 12 months (AOR = 11.66, CI = 1.94-70.12), and violent victimization in the last 12 months (AOR = 2.31, CI = 1.13-4.75). Transactional sex was negatively associated with heroin injection (last 30 days) (AOR = 0.37; 95% CI = 0.18-0.78). Transactional sex was independently associated with violent victimization in the last 12 months (AOR = 2.04; 95% CI = 1.00-4.14) while controlling for confounders. MWID who engaged in transactional sex are at elevated risk for HIV and multiple forms of violent victimization. Interventions focused on this at-risk subpopulation are urgently needed and should include access to substance use disorder treatment, victimization services, and harm reduction services across the HIV care continuum.

A Syndemic Model of Exchange Sex Among HIV-Positive Men Who Have Sex With Men

Exchange sex is a behavior associated with HIV transmission risk among men who have sex with men (MSM). Few studies have examined exchange sex among HIV-positive MSM. We utilize a syndemic framework to account for co-occurring psychosocial problems that suggest the presence of intertwining epidemics (i.e., syndemics), which have not been examined within the context of exchange sex among HIV-positive MSM. In 2015, MSM were recruited via online sexual networking Web site and app advertisements for Sex Positive!^[+], a video-based online intervention that aimed to improve health outcomes for men living with HIV. Participants completed surveys every three months for a year. Surveys covered demographics, drug use, exchange sex, intimate partner violence (IPV), and past 2-week depressive symptoms. We conducted three logistic regression models to assess syndemic factors associated with exchange sex in the past 3 months. Of the 722 HIV-positive MSM included in the sample, 59 (8%) reported exchange sex in the past 3 months at 12-month follow-up. HIV-positive MSM who had more syndemic factors had greater odds of exchange sex. Exchange sex was associated with being African-American/Black, age 18-29 years, past and present experiences with IPV, stimulant use, polysubstance use, and depressive symptoms. Exchange sex was associated with multiple psychosocial factors, indicating exchange sex may be part of a syndemic involving substance use, depression, HIV, and IPV. Interventions should address the social and behavioral circumstances that perpetuate environments that can foster multiple negative health outcomes.

The role of syringe exchange programs and sexual identity in awareness of pre-exposure prophylaxis (PrEP) for male persons who inject drugs

BACKGROUND

Male persons who inject drugs (male PWID) are at heightened risk for HIV, particularly if they also have sex with men. Pre-exposure prophylaxis (PrEP) could aid in HIV prevention for this population, but PrEP awareness within different sexual identities among male PWID is not well-understood. We report factors associated with greater awareness among male PWID to identify efficient means of awareness dissemination.

METHODS

Data from the 2015 National HIV Behavioral Surveillance (NHBS) system cycle on injection drug use collected in New York City (NYC) were used. Bivariable analyses, using chi-squared statistics, were conducted to examine correlates of awareness of PrEP with socio-demographic, behavioral, and health care variables. Log-linked Poisson regression with robust standard errors was used to estimate adjusted prevalence ratios and determine differences in awareness of PrEP.

RESULTS

Among a sample of 332 male PWID (i.e., PWID who identified as male, not transgender) we find awareness of PrEP to be low (23%) among male PWID despite 68% reporting condomless vaginal/anal sex and 32% reporting injection equipment sharing in the last twelve months. Multivariable analysis found greater PrEP awareness associated with gay or bisexual identity (aPR: 2.77, 95% CI: 1.81-4.24) and having a conversation about HIV prevention at a syringe exchange program (SEP) (aPR: 2.71, 95% CI: 1.87-3.94) to be associated with increased PrEP awareness.

CONCLUSION

We found low rates of PrEP awareness among male PWID. However, our findings provide insight into information diffusion that can be utilized to increase PrEP awareness among male PWID and among all PWID. We suggest that gay and bisexual social networks and syringe exchange programs are diffusing PrEP awareness among male PWID and can be harnessed to increase PrEP awareness among male PWID.

Characterizing Men Who Have Sex with Men and Use Injection Drugs in Vancouver, Canada

We examined factors associated with reporting sex with men among men who inject drugs in Vancouver, Canada. Data were drawn from three open prospective cohorts of people who use drugs between 2005 and 2014. Generalized estimating equations were used to identify factors associated with reporting non-transactional sex with men (MSM) in the previous 6 months. Of 1663 men who used injection drugs, 225 (13.5%) were MSM over the study period. Sex with men was independently associated with younger age [Adjusted Odds Ratio (AOR) = 0.96], childhood sexual abuse (AOR = 2.65), sex work (AOR = 3.33), crystal methamphetamine use (AOR = 1.30), borrowing used syringes (AOR = 1.39), inconsistent condom use (AOR = 1.76), and HIV seropositivity (AOR = 3.82). MSM were less likely to be Hepatitis C-positive (AOR = 0.43) and to have accessed addiction treatment in the previous 6 months (AOR = 0.83) (all p < 0.05). Findings highlight vulnerabilities and resiliencies among MSM-PWID and indicate a need for trauma-informed and affirming harm reduction and substance use treatment services for MSM-PWID.

HIV Pre-exposure Prophylaxis for People Who Inject Drugs: The Context of Co-occurring Injection- and Sexual-Related HIV Risk in the U.S. Northeast

Background: People who inject drugs (PWID) are at increased risk for HIV infection through sharing contaminated needles and injection equipment, and engaging in condomless sex. Objectives: To qualitatively examine the overlapping nature of these behaviors among PWID in the US Northeast. Methods: We recruited HIV-uninfected PWID and key informants through community-based organizations. Qualitative interviews explored sexual partnerships as they related to sharing contaminated needles and injection equipment, engaging in condomless sex, and associated indications for PrEP among PWID. Results: Among 33 PWID, 66% engaged in condomless vaginal or anal sex in the past 3 months, and 27% had three or more sexual partners in this same time period. Over half engaged in any past month distributive or receptive syringe sharing (64%). We identified three contexts through which overlapping sexual and injection-related HIV risks emerged, including (1) multiple concurrent sexual partnerships; (2) using and injecting drugs with sexual partners (including increase injecting of crystal methamphetamine); and (3) exchanging sex for money or drugs (including among male PWID). Condom use was inconsistent across these contexts. Limited interactions with healthcare providers often resulted in sexual risks being overlooked in light of competing health concerns. Conclusions: Sexual risk for HIV acquisition is complex and multi-faceted among PWID yet may be overlooked by prevention and healthcare providers. Comprehensive HIV prevention efforts must acknowledge the distinct contexts in which overlapping injection and sexual risk behaviors occur. Increased sexual health screening and risk reduction services including PrEP for PWID may help curtail transmission in this population.

HIV infection among MSM who inject methamphetamine in 8 US cities

BACKGROUND AND AIMS

Men who have sex with men (MSM) and inject drugs are at risk for HIV infection. Although research exists on non-injection methamphetamine (meth) use and sexual risk among MSM, less is known about meth injection and its association with HIV infection among MSM who inject drugs.

METHODS

We analyzed data from men aged ≥18 years who reported injecting drugs and male-to-male sexual contact. Men were recruited using respondent-driven sampling, interviewed, and tested for HIV during the 2012 and 2015 cycles of National HIV Behavioral Surveillance among persons who inject drugs. We included data from 8 cities where ≥10 MSM reported meth as the primary drug injected. We assessed differences in demographic characteristics, past 12 months risk behaviors, and HIV infection between MSM who primarily injected meth and those who primarily injected another drug.

RESULTS

Among 961 MSM, 33.7% reported meth as the drug they injected most often. Compared to MSM who primarily injected other drugs, MSM who primarily injected meth were more likely to have had ≥5 condomless anal sex partners, have been diagnosed with syphilis, and were less likely to report sharing syringes. In multivariable analysis, injecting meth was associated with being HIV-positive (adjusted prevalence ratio 1.48; 95% confidence interval 1.08-2.03). Including number of condomless anal sex partners in mediation analysis rendered this association no longer significant.

CONCLUSIONS

HIV prevalence among MSM who primarily injected meth was almost 50% higher than among MSM who primarily injected other drugs, and this association was mediated by sexual risk.

Crystal Methamphetamine use among Gay Men in Sydney

Crystal methamphetamine is used by gay men in Sydney in a variety of social and sexual contexts and by various means including injection. This paper presents detailed ethnographic data that explore some of the social and cultural characteristics of Sydney gay men's crystal use and other associated practices. The meaning of these practices is explored through a discussion of cultural boundaries and social exchange that traverses them. These boundaries help to limit drug-related harms in some ways but also generate certain risks. A nuanced understanding of the cultural meaning of various drug use practices may assist in producing culturally relevant harm-reduction education.

Evidence for risk reduction among amphetamine-injecting men who have sex with men; results from national HIV behavioral surveillance surveys in the Seattle area 2008-2012

In the Seattle area men who have sex with men and also inject amphetamines (amphetamine-injecting MSM/IDU) are disproportionately likely to be infected with HIV. To characterize their distinctive characteristics, we combined data from two Seattle-area surveys of men who have sex with men (MSM) and two surveys of injection drug users (IDU). Amphetamine-injecting MSM/IDU were compared with: male IDU, MSM and other MSM/IDU. Amphetamine-injecting MSM/IDU were older than MSM but younger than IDU, more likely to be white than either group, and had an educational level higher than IDU but below MSM. They had the highest HIV prevalence (56 vs. 4-19 %). However, reported HIV cases among them fell from 92 in 1990 to 25 in 2012. They were most likely to report ten or more sex partners (49 vs. 4-26 %), an STD diagnosis (22 vs. 1-7 %) and be tested for HIV (odds ratio 1.00 vs. 0.34-0.52), and least likely to share needles (odds ratio 1.00 vs. 6.80-10.50). While sexual risk remains high, these data suggest measurable and effective risk reduction with respect to sharing injection equipment and HIV testing among Seattle-area amphetamine-injecting MSM/IDU.

HIV prevalence trends, risky behaviours, and governmental and community responses to the epidemic among men who have sex with men in China

Purpose of Review. Numerous studies reported the rapid spread of HIV/AIDS epidemic among men who have sex with men (MSM) in China. This paper aims to investigate the overall epidemic trend and associated high-risk behaviours among Chinese MSM and to explore the governmental and community responses to the epidemic. Recent Findings. HIV prevalence among Chinese MSM increased rapidly in all Chinese regions in the past decade and disproportionally affected the Southwest China. In addition to the high-risk homosexual behaviours, overlapping bisexual, commercial, and drug use behaviours are commonly observed among Chinese MSM. The Chinese government has significantly expanded the surveillance efforts among MSM over the past decade. Community responses against HIV have been substantially strengthened with the support of international aid. However, lack of enabling legal and financial environment undermines the role of community-based organisations (CBOs) in HIV surveillance and prevention. Conclusion. HIV continues to spread rapidly among MSM in China. The hidden nature of MSM and the overlapping homosexual, bisexual, and commercial behaviours remain a challenge for HIV prevention among MSM. Strong collaboration between the government and CBOs and innovative intervention approaches are essential for effective HIV surveillance and prevention among MSM in China.

Unmet healthcare need among women who use methamphetamine in San Francisco

Methamphetamine use has increased substantially in the United States since the 1990s. Few studies have examined the healthcare service needs of women who use methamphetamine. This study describes unmet medical needs in a community-based sample of women who use methamphetamine in San Francisco, CA. Women who use methamphetamine were recruited in San Francisco and participated in a computer-assisted survey (N = 298 HIV-negative women). Multivariate analysis was performed to explore associations among sociodemographic variables, drug use, use of health and social services, and unmet healthcare need across three domains: chronic health problems, dermatologic problems, and women's preventive healthcare. Sixty-nine percent of participants reported a need for care for a chronic health condition, and 31% of them had an unmet need for care, in the last six months. Thirty-five percent of participants reported a need for dermatologic healthcare, and 66% had an unmet need for care in the last 6 months. Ninety-two percent of participants reported a need for women's preventive healthcare and 46% had an unmet need for care in the last year. Women who reported having a healthcare provider had lower odds of reporting an unmet need for a chronic health condition or women's preventive healthcare. Women who used a case manager had lower odds of having an unmet need for dermatologic care. A significant proportion of women who use methamphetamine in this sample had an unmet need for women's preventive healthcare, and overall these women had a significant unmet need for healthcare. These findings suggest that contact with a healthcare provider or a caseworker could help to expand access to healthcare for this vulnerable population.

Determinants of risky sexual behavior among injecting drug users (IDUs) in Georgia

Injection risk practices and risky sexual behaviors place injection drug users (IDUs) and their sexual partners particularly vulnerable to HIV. The purpose of the study was to describe and understand determinants of high-risk sexual behavior among IDUs in Georgia. A cross-sectional, anonymous survey assessed knowledge, behavior and HIV status in IDUs in five Georgian cities (Tbilisi, Gori, Telavi, Zugdidi, Batumi) in 2009. The study enrolled in total 1,127 (1,112 males, 15 females) IDUs. Results indicate that occasional sexual relationships are common among male IDUs, including married ones. A subsample of 661 male IDUs who reported having occasional and paid sex partners during the last 12 months was analyzed. Multivariate analysis shows that not having a regular partner in the last 12 month (adjusted odds ratio (aOR) 1.57, 95 % CI 1.04 2.37), and using previously used needles/syringes at last injecting (aOR 2.37, 95 % I 1.10-5.11) are independent correlates of inconsistent condom use with occasional and paid sexual partners among IDUs. Buprenorphine injectors have lower odds of inconsistent condom use with occasional and paid sexual partners compared to heroin injectors (aOR 0.47, 95 % CI 0.27-0.80), and IDUs who live in Telavi are twice more likely to engage in such risky sexual behavior than capital city residents (aOR 2.55, 95 % CI 1.46-4.48). More effective programs focused on sexual risk behavior reduction strategies should be designed and implemented.

Injecting drug use among gay and bisexual men in Sydney: prevalence and associations with sexual risk practices and HIV and hepatitis C infection

Injecting drug use is commonly reported among gay and bisexual men in Australia. We examined the prevalence and covariates of injecting drug use among men participating in the Sydney Gay Community Periodic Survey between 2004-06 and 2011. In 2004-06, data was collected about which drugs were injected, while in 2011, data was collected about hepatitis C (HCV) and esoteric sexual practices. In 2004-06, 5.6 % of men reported injecting drugs in the previous 6 months; 3.4 % reported methamphetamine injection and 0.4 % heroin injection. In 2011, men who injected drugs were less likely to be employed full-time, and more likely to be HCV-positive, HIV-positive, to have used party drugs for sex, and to have engaged in esoteric sexual practices. The strong associations between injecting drug use, sexual risk practices and blood-borne virus infection suggests the need for combined sexual health and harm reduction services for gay and bisexual men who inject drugs.

High-risk behaviors associated with injection drug use among recently HIV-infected men who have sex with men in San Diego, CA

The contribution of injection drug use to HIV risk among men who have sex with men (MSM) is understudied. MSM infected with HIV within the prior 12 months completed a questionnaire assessing sociodemographic, sexual, drug use, and social factors. Analyses were performed to identify factors associated with lifetime history of injection drug use. Among 212 participants, the mean age was 33.8 years, 72% were White, 89% had attended college, and 9.4% reported ever injecting drugs. In multivariable logistic regression analysis, ever trading sex and using methamphetamine during sex with at least one of their last three partners were associated with injection drug use. Adjusting for these variables, in separate models, ever perpetrating violence against others (Adjusted Odds Ratio [AOR] = 3.16), having physically abusive sexual partners (AOR = 3.08), or physically abusing sexual partners (AOR = 10.17) were significantly (P < 0.05) associated with injection drug use. These findings suggest that violence is more common among MSM who inject drugs, which should be considered in HIV prevention efforts.

Two-Year Outcomes of Treatment for Methamphetamine Use

While evaluation research supports the general effectiveness of substance abuse treatment, there is not a comprehensive literature on treatment effectiveness for methamphetamine (MA) use. The authors consider three outcome measures--MA use, criminal activity, and employment--compared across three periods: 24-months pretreatment, during treatment, and 24-months post-treatment. Data are from an intensive natural history interview conducted two to three years after treatment for 349 randomly selected admissions to treatment for MA abuse in a large publicly-funded county treatment system. Through this naturalistic design, data provide a system-wide perspective on effectiveness of treatment as usual. Results showed reduction in MA use and crime during and following treatment and increased employment following treatment over pretreatment levels. Regression analyses showed higher levels of education and more time in treatment related to more positive post-treatment outcomes for all three measures. Lower percentage of post-treatment months with MA use also was related to more pretreatment MA-related problems, lower pretreatment MA use, and residential (compared to outpatient) treatment modality. Lower post-treatment criminal activity was also related to gender (being female), lower pretreatment criminal activity, and residential modality. Higher percentage of post-treatment months with employment also was related to gender (being male), ethnicity (not African-American), and higher pretreatment employment.

Potential for sexual transmission of HIV infection from male injecting-drug users who have sex with men in Tehran, Iran

BACKGROUND

Iran faced an HIV epidemic among injecting-drug users (IDUs) and has responded to this threat. Meanwhile, there is growing concern over the possibility of bridging HIV infection from IDUs to other populations, including men who have sex with men (MSM).

METHODS

Cross-sectional biobehavioral surveys were conducted among 370 injecting-drug users recruited from drug treatment centers, a drop-in center, as well as streets in drug-populated areas in Tehran, Iran, between 2003 and 2004.

RESULTS

Data from these surveys showed that about 12% of male, sexually experienced IDUs have had same-gender sex, and HIV prevalence is high (19%), but condom use during the last sexual encounter was low (20%). A multivariate analysis showed that IDUs who had sex with men (MSM IDUs), compared to other sexually experienced IDUs, are younger (AOR, 0.89; 95% CI, 0.81-0.98), more likely to have used a shared needle/syringe for drug injection (AOR, 4.29; 95% CI, 1.82-10.12), and have had more than 5 sexual partners in their lifetime (AOR, 2.71; 95% CI, 1.14-6.44).

CONCLUSIONS

These results show that MSM IDUs exhibit more drug-related and sexual risk behaviors that may serve as a bridge for sexual transmission of HIV to other populations, including the broader MSM community, in Tehran. This report intends to encourage health authorities in Iran to take serious action to prevent sexual transmission of HIV from MSM IDUs to their sexual networks.

Male injecting drug users in the Deep South: bisexual behaviour is a marker for elevated HIV risk

This study determined whether bisexual male injecting drug users (IDUs) as compared with heterosexual IDUs were more likely to engage in HIV-associated risk behaviours. Respondent-driven sampling was employed to recruit a sample of 382 male IDUs residing in the southeastern USA. Data were collected in face-to-face interviews. Weighted analyses showed that bisexual IDUs in the past 12 months were 4.6 times as likely to share needles and 3.5 times as likely to share a cooker; having multiple female sexual partners and trading money or drugs for sex with women were marginally significant. Bisexual IDUs were 10 times as likely to self-report HIV. Male IDUs, who engage in bisexual behaviour, are also engaging in HIV-associated drug and to some degree sexual-risk behaviours with women more so than heterosexual IDUs. Their higher prevalence of HIV infection coupled with their risk behaviours place themselves and other IDUs at heightened risk of both acquiring and transmitting HIV.

An examination of social network characteristics of men who have sex with men who use drugs

OBJECTIVES

The purpose of this study was to compare the social network characteristics of men who have sex with men (MSM) to men who did not have sex with men (NMSM) in a sample of predominately African-American drug users. Specifically, we were interested in examining the differences in structure of the networks and drug and sexual risk partners within the network.

METHODS

Data came from 481 male participants who reported having > or =1 sex partner in the past 90 days. MSM were defined as having sex with a male. Data on social network composition were collected using a Social Network Inventory.

RESULTS

Of 481 men, 7% (n = 32) were categorised as MSM. Nearly two-thirds of MSM did not identify as gay. MSM were more likely to be HIV positive compared with NMSM. Social networks of MSM were younger and a greater proportion was HIV positive. After adjusting for HIV status, networks of MSM were less dense indicating fewer connections among network members. Among injection drug using men in the sample, MSM reported a greater number of needle sharing networks than NMSM.

CONCLUSIONS

These findings underscore the importance of including social network factors in investigations of HIV risk among MSM. Further studies should focus on dynamics within a network and how they may operate to affect behaviour and health.

High-risk sexual and drug using behaviors among male injection drug users who have sex with men in 2 Mexico-US border cities

OBJECTIVES

The population of Latino men who have sex with men (MSM) and who are also injection drug users (IDUs) is understudied. We explored risk behaviors of MSM/IDUs compared with other male IDUs in 2 Mexican border cities.

STUDY DESIGN

In 2005, IDUs who had injected within the previous 30 days were recruited using respondent-driven sampling (RDS) in Tijuana and Ciudad Juárez. They underwent antibody testing for HIV, HCV, and syphilis and interviewer-administered surveys. Men were categorized as MSM if they reported > or =1 lifetime male partners. Logistic regression was used to compare MSM/IDUs with non-MSM/IDUs.

RESULTS

A third (31%) of 377 male IDUs were categorized as MSM (47% in Tijuana and 13% in Ciudad Juárez, P <0.01). Combined RDS-adjusted prevalence of HIV and Hepatitis C was 3% (95% CI: 1, 5) and 96%, (95% CI: 94, 99) respectively, while 17% (95% CI: 2, 36) of MSM and 8% (95% CI: 3, 12) of non-MSM tested positive for syphilis antibody. In multivariate logistic regression adjusted for site, MSM/IDUs were more likely than non-MSM/IDUs to have ever used inhalants (OR: 3.4; 95% CI: 1.8, 6.2) or oral tranquilizers (OR: 2.4; 95% CI: 1.3, 4.6), received treatment for a drug problem (OR:1.9; 95% CI: 1.1, 3.2) shared needles in the last six months (OR: 2.1; 95% CI: 1.0, 4.2) and also had higher numbers of lifetime female partners (log-transformed continuous variable, OR: 1.6; 95% CI: 1.2, 2.1).

CONCLUSIONS

In these Mexican cities, the proportion of MSM among male IDUs was high. Compared with other male IDUs, MSM/IDUs were more likely to engage in behaviors placing them at risk of acquiring HIV/STIs. Culturally appropriate interventions targeting Latino MSM/IDUs are warranted.

Characteristics of a sample of men who have sex with men, recruited from gay bars and Internet chat rooms, who report methamphetamine use

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.

Maintenance of endemicity in urban environments: a hypothesis linking risk, network structure and geography

In industrialised countries, a rapid epidemic phase of HIV transmission has largely given way to more moderated endemic transmission. The dynamics of endemic transmission may differ substantially from those generating epidemic spread. We hypothesise that three elements play an important role in maintaining endemicity in high prevalence urban environments. First, persons are likely to be subject to multiple risks from multiple sources rather than engaging in a single, hierarchically classified, risk behaviour. Second, the network structure in these environments may include a substrate of "fixed" factors (a large connected component, a characteristic degree distribution and small world phenomenon) upon which is superimposed a number of variable factors (transitivity, assortativity) that determine the level of prevalence. Third, the geographic range of persons in these milieux is constricted, making it likely that new partners will already be connected. The confluence of these three factors assures the ongoing risk bombardment needed for maintenance of endemicity. Further empirical and theoretical analysis will be required in order to validate this hypothesis.

Assessing the feasibility of harm reduction services for MSM: the late night breakfast buffet study

BACKGROUND

Despite the leveling off in new HIV infections among men who have sex with men (MSM) in San Francisco, new evidence suggests that many recent HIV infections are linked with the use of Methamphetamine (MA). Among anonymous HIV testers in San Francisco, HIV incidence among MA users was 6.3% compared to 2.1% among non-MA users. Of particular concern for prevention programs are frequent users and HIV positive men who use MA. These MSM pose a particular challenge to HIV prevention efforts due to the need to reach them during very late night hours.

METHODS

The purpose of the Late Night Breakfast Buffet (LNBB) was to determine the feasibility and uptake of harm reduction services by a late night population of MSM. The "buffet" of services included: needle exchange, harm reduction information, oral HIV testing, and urine based sexually transmitted infection (STI) testing accompanied by counseling and consent procedures. The study had two components: harm reduction outreach and a behavioral survey. For 4 months during 2004, we provided van-based harm reduction services in three neighborhoods in San Francisco from 1-5 a.m. for anyone out late at night. We also administered a behavioral risk and service utilization survey among MSM.

RESULTS

We exchanged 2000 needles in 233 needle exchange visits, distributed 4500 condoms/lubricants and provided 21 HIV tests and 12 STI tests. Fifty-five MSM enrolled in the study component. The study population of MSM was characterized by low levels of income and education whose ages ranged from 18-55. Seventy-eight percent used MA in the last 3 months; almost 25% used MA every day in the same time frame. Of the 65% who ever injected, 97% injected MA and 13% injected it several times a day. MA and alcohol were strong influences in the majority of unprotected sexual encounters among both HIV negative and HIV positive MSM.

CONCLUSION

We reached a disenfranchised population of MA-using MSM who are at risk for acquiring or transmitting HIV infection through multiple high risk behaviors, and we established the feasibility and acceptability of late night harm reduction for MSM and MSM who inject drugs.

Hepatitis C virus infection among methamphetamine-dependent individuals in outpatient treatment

Research on the relationship between illicit drug use and infectious diseases have primarily focused on the major problem of heroin injection and HIV transmission. Over the past decade, however, research have shown that rates of hepatitis C infection among injection drug users have surpassed those of HIV infection. There has been little systematic study on the relationship between hepatitis C virus (HCV) and the role of methamphetamine (MA) use in the transmission of the virus. This study examined the prevalence of hepatitis C infection among a sample of 723 MA-dependent individuals who sought outpatient treatment from 1999 through 2005. Roughly 15% of the total sample and 44% of the injectors were found to be infected with HCV. Controlling for participant characteristics, we found through multiple logistic regression analyses that HCV infection was more associated with injection use, older age, and female sex. Findings suggest a need for targeted education and prevention efforts about hepatitis C among high-risk MA users, including HCV testing coupled with referrals to HCV treatments.

High prevalence of HIV infection associated with incarceration among community-based injecting drug users in Tehran, Iran

OBJECTIVES

To determine the prevalence and correlates of HIV-1 infection among community-based injecting drug users (IDUs) in Tehran, Iran.

METHODS

In October 2004, 213 IDUs were recruited from a drop-in center and its neighboring parks and streets in Tehran. Participants were interviewed using a structured questionnaire regarding their sociodemographics and HIV risk characteristics, and specimens of oral mucosal transudate were collected and tested for HIV-1 antibodies. Data were analyzed using chi and multiple logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The prevalence of HIV-1 infection was 23.2% (48 of 207) among male injecting drug users. In the multivariable analysis, a history of shared drug injection inside prison (OR, 2.45; 95% CI, 1.01-5.97) and that of multiple incarcerations (OR, 3.13; 95% CI, 1.08-9.09) were associated with significantly higher prevalence of HIV-1 infection.

CONCLUSIONS

The prevalence of HIV-1 infection has reached an alarming level among IDUs in Tehran, with incarceration-related exposures revealed to be the main correlates of HIV-1 infection. Urgent and comprehensive harm reduction programs for drug users in prison and those in the community in Tehran are of prime importance to prevent further transmission of HIV infection.

Commercial Sex Work and Risk of HIV Infection Among Young Drug-Injecting Men Who Have Sex With Men in San Francisco

OBJECTIVE

The objective of this study was to investigate the relationship between sex work and HIV infection among young injection drug-using men who have sex with men (MSM-IDU).

STUDY DESIGN

This study was a cross-sectional analysis of behavioral and serologic data collected from 227 street-recruited MSM-IDU in San Francisco, California, between January 2000 and November 2001.

RESULTS

Sixty-eight percent of participants reported being paid by another man for sex. HIV prevalence was 12% (95% confidence interval, 8-16%); 42% of seropositive participants were unaware of their infection. HIV was independently associated with higher number of paying male partners and history of gonorrhea and inversely associated with number of female partners, education, and syringe-sharing. Consistent condom use overall was 41%, but varied significantly by type of partner.

CONCLUSIONS

Among MSM-IDU in San Francisco, sex work with men is strongly associated with HIV infection and the prevalence of condom use is low. HIV prevention among MSM-IDU must be tailored to address the excess risk associated with sex work.

Behavioral interventions for HIV-positive and HCV-positive drug users

The nature, context and frequency of use of various licit and illicit non-injection drugs associated with an elevated risk of HIV infection. Beyond HIV, a high proportion of HIV-infected IDUs are co-infected with HCV (hepatitis C virus). In this review, we provide a brief review of the epidemiology of these problems, discuss behavioral interventions that can reduce ongoing high risk behaviors among HIV-seropositive IDUs and MSM-DUs, and review the literature which has evaluated their effectiveness. The majority of these interventions have focused on HIV-seronegative heterosexuals and therefore need to be considered in this larger context; however, where possible we discuss the potential impact of these interventions among HIV-seropositive persons. In addition, we briefly discuss interventions which have the potential to simultaneously reduce ongoing transmission of both HIV and HCV. Finally, given the dearth of information on the effectiveness of behavioral interventions in reducing the burden of the HIV and HCV epidemics among persons already infected with either or both viruses, we describe some newer, promising interventions and offer suggestions for future studies.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

High HIV, hepatitis C and sexual risks among drug-using men who have sex with men in northern Thailand

BACKGROUND

Men who have sex with men (MSM) and who use drugs have shown high HIV risks in Europe, and the Americas. We investigated MSM-drug user demographics, HIV sexual and drug use risks and behaviors in Chiang Mai, northern Thailand to identify prevention targets.

METHODS

A total of 2005 males aged 13 years and older were enrolled during inpatient drug treatment from 1999-2000 and assessed for HIV, hepatitis C virus (HCV), syphilis, and for demographics and risks by questionnaire. Data were analyzed using chi and multiple logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of 2005 males in treatment, 1752 (87.4%) had ever had sex, and 66 of 1752 (3.8%) reported ever having sex with another man; mostly Katoey (transgendered male) partners. MSM had higher HIV rates (OR, 2.32; 95% CI, 1.36-3.96) and were younger (P = 0.002); more likely to be Thai (P < 0.0001); better educated (P < 0.0001); had more lifetime sex partners (P < 0.0001), more female partners (P = 0.002), more female paid partners (P < 0.0001), and been paid for sex (P < 0.0001). MSM were more likely to have ever injected (P < 0.0001), sold drugs, been in prison, injected in prison, used heroin, and to have HCV (OR, 2.59; 95% CI, 1.55-4.34).

CONCLUSIONS

Northern Thai MSM-drug users are at high HIV and HCV risk. In addition to sex risks with men, they have more sex with women and sex workers than other men, which fits Thai MSM patterns but not Western ones. Prevention must take into account their high rates of substance use and multiple partner types.

Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who also inject drugs

OBJECTIVES

Gay and bisexual men and injection drug users (IDU) are the two main groups at risk of HIV exposure in the United States, but few studies have focused on the intersection of these two groups. Little is known about HIV-positive gay and bisexual IDU. The aim of this study is to identify and compare differences in HIV transmission risk behaviors and psychological distress in HIV-positive gay and bisexual men by injection versus non-injection drug use.

METHODS

Data were from the baseline assessment of a randomized controlled trial of an HIV prevention intervention for HIV-positive gay and bisexual men.

RESULTS

Of the 1168 men, 236 (20%) reported injection drug use, 500 (43%) reported only non-injection drug use, and 422 (36%) reported no drug use. More of the IDU reported having sex with women, and identified themselves as "barebackers" (i.e. men who intentionally have unprotected anal intercourse). IDU reported more unprotected sexual behaviors than men who did not use drugs, but their sexual risk behaviors were similar to those of men who used non-injection drugs. IDU, compared with other drug users, reported more use of non-injected methamphetamine, amphetamine, barbiturates, and gamma hydroxybutyrate. More IDU, compared with the other two groups, reported sexual abuse, anxiety, and hostility.

CONCLUSION

HIV-positive gay and bisexual IDU are a distinct group from other HIV-positive gay and bisexual men. Prevention case management and interventions that help men cope with multiple health concerns and prevent HIV transmission are needed for this population.

HIV prevalence and risk behaviors among men who have sex with men and inject drugs in San Francisco

The dual risks of male-to-male sex and drug injection have put men who have sex with men and inject drugs (MSM-IDU) at the forefront of the HIV epidemic, with the highest rates of infection among any risk group in the United.States. This study analyzes data collected from 357 MSM-IDU in San Francisco between 1998 and 2002 to examine how risk behaviors differ by HIV serostatus and self-identified sexual orientation and to assess medical and social service utilization among HIV-positive MSM-IDU. Twenty-eight percent of the sample tested HIV antibody positive. There was little difference in risk behaviors between HIV-negative and HIV-positive MSM-IDU. Thirty percent of HIV-positive MSM-IDU reported distributive syringe sharing, compared to 40% of HIV negatives. Among MSM-IDU who reported anal intercourse in past 6 months, 70% of positives and 66% of HIV negatives reported unprotected anal intercourse. HIV status varied greatly by self-identified sexual orientation: 46% among gay, 24% among bisexual, and 14% among heterosexual MSM-IDU. Heterosexual MSM-IDU were more likely than other MSM-IDU to be homeless and to trade sex for money or drugs. Gay MSM-IDU were more likely to have anal intercourse. Bisexual MSM-IDU were as likely as heterosexual MSM-IDU to have sex with women and as likely as gay-identified MSM-IDU to have anal intercourse. Among MSM-IDU who were HIV positive, 15% were currently on antiretroviral therapy and 18% were currently in drug treatment, and 87% reported using a syringe exchange program in the past 6 months. These findings have implications for the development of HIV interventions that target the diverse MSM-IDU population.

Sexual Risk Among Injection Drug Users Recruited From Syringe Exchange Programs in California

OBJECTIVE

The objective of this study was to examine correlates of sexual risk among injection drug users (IDUs).

STUDY

A total of 1445 IDUs were recruited from California syringe exchange programs.

RESULTS

Consistent condom use was independently related to being HIV-positive, having multiple sex partners, not having a steady partner, not sharing syringes, and not injecting amphetamines for men; and engaging in sex work, not sharing syringes, and not having a steady partner for women. Having multiple recent sexual partnerships that included a steady partner was related to engaging in sex work, speedball injection, and amphetamine use among men; and younger age, having had a sexually transmitted disease (STD), engaging in sex work, and using alcohol among women. Having heterosexual anal sex was related to having had an STD, having multiple sexual partners, using amphetamines, and syringe-sharing for men; and younger age and amphetamine use for women.

CONCLUSIONS

Comprehensive prevention interventions addressing multiple sexual and injection risk behaviors are needed for IDUs.

Prevalence, health outcomes, and patterns of psychotropic substance use in a Chinese population in Hong Kong: a population-based study

Two anonymous population-based surveys were conducted between August 2001 and April 2002 using computer-assisted telephone interviews of 3793 male and 3244 female randomly selected residents of Hong Kong in order to estimate the prevalence of psychotropic substance use and identify risk factors and associations with health outcomes among users in Hong Kong. The study cohort was comprised of ethnically Chinese adults between the ages of 18 and 60 years of age. In the last 12 months, 5% of males and 1.8% of females had used psychotropic substances such as cannaboids, methylamphetamines, ketamines, cocaine, opiates, barbiturates, and benzodiazepines. Of the male drug users, almost one-third had done so outside of Hong Kong. "Risk factors" for substance use included: younger age, unemployment, being an early school leaver, being unmarried, "heavy alcohol consumption," and smoking. Psychotropic substance use in the past year was strongly associated with increased prevalence of long-lasting (> or =3 months) sexual health problems during the past year and with a higher prevalence of HIV/STD risk behaviors. The prevalence of substance use in Hong Kong has been under-reported. Although significant correlations were noted between substance use and various respondent attributes, the directionality of the associations needs to be determined with longitudinal studies. It may be prudent to integrate substance use and HIV/STD prevention efforts.

Factors associated with sex trade involvement among male participants in a prospective study of injection drug users

OBJECTIVES

While much research to date has examined female sex trade work, little has been done to evaluate factors associated with male sex trade involvement or to assess their health service needs. This is particularly true for male sex trade workers who are also injection drug users (IDUs). Therefore, the present analyses were undertaken to evaluate factors associated with sex trade work in a prospective cohort study of male IDUs.

METHODS

We identified factors associated with sex trade involvement among male participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available at semiannual intervals, variables potentially associated with sex trade involvement were evaluated with adjusted odds ratios (AOR) and 95% confidence intervals (CI) computed using generalised estimating equations (GEE).

RESULTS

Between 1996 and 2003, 995 male IDUs were enrolled into the VIDUS cohort among whom 108 (11%) reported being involved in the sex trade at enrolment and 102 (10%) individuals initiated sex trade involvement during the follow up period. In multivariate analyses, factors independently associated with sex trade involvement included HIV positive serostatus (AOR: 1.77 (95% CI: 1.44 to 2.17)), daily cocaine injection (AOR: 1.37 (95% CI: 1.11 to 1.70)), daily crack smoking (AOR: 1.36 (95% CI: 1.07 to 1.72)), borrowing syringes (AOR: 1.73 (95% CI: 1.32 to 2.25)), and inconsistent use of condoms with casual sexual partners (AOR 0.66, CI 0.53 to 0.82). We also found that male sex trade workers were more likely to report having sought but been unable to access substance abuse treatment (AOR: 1.28 (95% CI: 0.98 to 1.67); p=0.076).

CONCLUSIONS

Males involved in the sex trade in this setting have higher levels of HIV infection and engage in risky injection behaviours at an elevated rate. Since these behaviours have major implications for HIV acquisition and public health, prevention efforts and targeted provision of addiction treatment to this population should be expanded.

A comparison of injection and non-injection methamphetamine-using HIV positive men who have sex with men

There is a paucity of research on the psychosocial and behavioral characteristics of individuals who inject methamphetamine (meth). The present study compared injection and non-injection users of meth in terms of background characteristics, drug use patterns, health and social problems, sexual risk behavior, and psychosocial factors. The sample consisted of 194 HIV+Men who have Sex with Men (MSM) who were enrolled in a sexual risk reduction intervention for meth users. Men who injected meth were significantly more likely to be Caucasian, bisexual, homeless, divorced/separated, with lower educational attainment as compared to non-injectors. Injectors also reported more years of meth use, greater frequency and amount of meth use, more social and health problems, including higher prevalence of STDs and Hepatitis C, and more sexual risk behaviors. In terms of psychosocial factors, injection users of meth scored significantly higher on measures of impulsivity and experiences of rejection, and lower on a measure of emotional support. A multivariate logistic regression revealed that educational attainment and experiences of rejection were the factors that best discriminated between injection and non-injection users of meth. The unique characteristics of injection meth users are discussed in relation to the development of effective HIV prevention programs for the target population.

The chemical bases of the various AIDS epidemics: recreational drugs, anti-viral chemotherapy and malnutrition

In 1981 a new epidemic of about two-dozen heterogeneous diseases began to strike non-randomly growing numbers of male homosexuals and mostly male intravenous drug users in the US and Europe. Assuming immunodeficiency as the common denominator the US Centers for Disease Control (CDC) termed the epidemic, AIDS, for acquired immunodeficiency syndrome. From 1981-1984 leading researchers including those from the CDC proposed that recreational drug use was the cause of AIDS, because of exact correlations and of drug-specific diseases. However, in 1984 US government researchers proposed that a virus, now termed human immunodeficiency virus (HIV), is the cause of the non-random epidemics of the US and Europe but also of a new, sexually random epidemic in Africa. The virus-AIDS hypothesis was instantly accepted, but it is burdened with numerous paradoxes, none of which could be resolved by 2003: Why is there no HIV in most AIDS patients, only antibodies against it? Why would HIV take 10 years from infection to AIDS? Why is AIDS not self-limiting via antiviral immunity? Why is there no vaccine against AIDS? Why is AIDS in the US and Europe not random like other viral epidemics? Why did AIDS not rise and then decline exponentially owing to antiviral immunity like all other viral epidemics? Why is AIDS not contagious? Why would only HIV carriers get AIDS who use either recreational or anti-HIV drugs or are subject to malnutrition? Why is the mortality of HIV-antibody-positives treated with anti-HIV drugs 7-9%, but that of all (mostly untreated) HIV-positives globally is only 1.4%? Here we propose that AIDS is a collection of chemical epidemics, caused by recreational drugs, anti-HIV drugs, and malnutrition. According to this hypothesis AIDS is not contagious, not immunogenic, not treatable by vaccines or antiviral drugs, and HIV is just a passenger virus. The hypothesis explains why AIDS epidemics strike non-randomly if caused by drugs and randomly if caused by malnutrition, why they manifest in drug- and malnutrition-specific diseases, and why they are not self-limiting via anti-viral immunity. The hypothesis predicts AIDS prevention by adequate nutrition and abstaining from drugs, and even cures by treating AIDS diseases with proven medications.