In the shadows of a prevention campaign: sexual risk behavior in the absence of crystal methamphetamine

Motivational Enhancement Interventions to Increase Pre-Exposure Prophylaxis Use in Sexual Minority Men Who Use Stimulants: Protocol for a Pilot Sequential Multiple Assignment Randomized Trial

BACKGROUND

Although pre-exposure prophylaxis (PrEP) could substantially mitigate HIV risk, sexual minority men who use stimulants commonly experience difficulties with engaging in PrEP clinical services. Motivational interviewing (MI) and contingency management (CM) reduce substance use and condomless anal sex (CAS) in this population, but these motivational enhancement interventions require modifications to promote engagement along the PrEP care continuum.

OBJECTIVE

PrEP Readiness Interventions for Supporting Motivation (PRISM) is a pilot sequential multiple assignment randomized trial testing the feasibility, acceptability, and preliminary effectiveness of distinct combinations of telehealth MI and CM in 70 cisgender sexual minority men who use stimulants that are not currently taking PrEP.

METHODS

A national sample was recruited via social networking applications to complete a baseline assessment and mail-in HIV testing. Those with nonreactive HIV results were randomized to receive either (1) a 2-session MI intervention focusing on PrEP use (session 1) and concomitant stimulant use or CAS (session 2) or (2) a CM intervention with financial incentives for documented evidence of PrEP clinical evaluation by a medical provider (US $50) and filling a PrEP prescription (US $50). At the 3-month follow-up assessment, participants who reported they had not filled a prescription for PrEP were randomized a second time to either (1) switch to a second-stage intervention (ie, MI+CM or CM+MI) or (2) continue with assessments only. Outcomes for both responders and nonresponders were reassessed at a 6-month follow-up. The primary outcome is documented evidence of filling a PrEP prescription over 6 months. Self-reported secondary outcomes include PrEP clinical evaluation by a medical provider, stimulant use, and CAS. Qualitative exit interviews were conducted with a subgroup of responders and nonresponders to characterize their experiences with the MI and CM interventions.

RESULTS

Implementation of PRISM underscores challenges in reaching sexual minority men who use stimulants to optimize HIV prevention efforts. Approximately 1 in 10 (104/1060) eligible participants have enrolled. Of the 104 who enrolled, 87 (84%) completed mail-in HIV testing. We delivered 5 preliminary HIV-positive results, including posttest counseling with referrals to confirmatory testing.

CONCLUSIONS

Lessons learned from PRISM underscore the central importance of a flexible, participant-centered approach to support the engagement of sexual minority men who use stimulants. Leveraging telehealth platforms to deliver motivational enhancement interventions also expanded their reach and potential public health impact with this high-priority population. Further research is needed to determine the effectiveness of telehealth MI and CM for supporting PrEP use in sexual minority men who use stimulants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04205487; https://clinicaltrials.gov/study/NCT04205487.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48459.

Randomized Controlled Trial of Motivational Enhancement Interventions to Increase Pre-Exposure Prophylaxis Use in Sexual Minority Men Who Use Stimulants

Background

Although pre-exposure prophylaxis (PrEP) could substantially mitigate HIV risk, sexual minority men (SMM) who use stimulants commonly experience difficulties with engaging in PrEP clinical services. Motivational interviewing (MI) and contingency management (CM) reduce substance use and condomless anal sex in this population, but these motivational enhancement interventions require adaptation to promote engagement along the PrEP care continuum.

Methods

PRISM is a pilot sequential multiple assignment randomized trial (SMART) testing the feasibility, acceptability, and preliminary effectiveness of distinct combinations of telehealth MI and CM in 70 cisgender SMM who use stimulants that are not currently taking PrEP. A national sample was recruited via social networking applications to complete a baseline assessment and mail-in HIV testing. Those with non-reactive HIV results are randomized to receive either: 1) a 2-session MI intervention focusing on PrEP use (session 1) and concomitant stimulant use or condomless anal sex (session 2); or 2) a CM intervention with financial incentives for documented evidence of PrEP clinical evaluation by a medical provider ($50) and filling a PrEP prescription ($50). At the 3-month follow-up assessment, participants who report they have not filled a prescription for PrEP are randomized a second time to either: 1) Switch to a second-stage intervention (i.e., MI + CM or CM + MI); or 2) Continue with assessments only. Outcomes for both responders and non-responders are reassessed at a 6-month follow-up. The primary outcome is documented evidence of filling a PrEP prescription. Self-reported, secondary outcomes include PrEP clinical evaluation by a medical provider, stimulant use, and condomless anal sex. Qualitative exit interviews are conducted with a sub-group of responders and non-responders to characterize their experiences with the MI and CM interventions.

Discussion

Implementation of this pilot SMART underscores the challenges in reaching SMM who use stimulants to optimize HIV prevention efforts such that approximately one in ten (104/1,060) eligible participants enrolled. However, 85% (70/82) of enrolled participants with non-reactive HIV results were randomized. Further research is needed to determine the effectiveness of telehealth MI and CM for supporting PrEP use in SMM who use stimulants.

Trial Registration

This protocol was registered on clinicaltrials.gov (NCT04205487) on December 19, 2019.

Illicit drug use among lesbian, gay, bisexual, pansexual, trans and gender diverse, queer and asexual young people in Australia: Intersections and associated outcomes

INTRODUCTION

High rates of illicit drug use have been reported among gay and bisexual young men, however limited research has examined patterns of drug use among the broader population of lesbian, pansexual, trans and gender diverse, asexual and queer (LGBTQA) young people. We examined factors associated with illicit drug use in the past 6 months and lifetime experiences of self-reported concern with drug use among LGBTQA youth in Australia.

METHODS

A cross-sectional survey was conducted involving 6418 LGBTQA participants aged 14-21 years, 5914 of whom provided information relating to their use of illicit drugs. Multivariable logistic regressions examined demographic factors and life experiences associated with drug use in the past 6 months and lifetime experiences of self-reported concern with drug use.

RESULTS

Overall, 26.4% of participants aged 14-17 and 41.9% aged 18-21 reported any drug use in the past 6 months, of whom 23.5% had ever been concerned about their drug use. Cannabis use was most commonly reported (28.3%), followed by ecstasy/MDMA (7.1%), antidepressants (5.6%) and LSD (3.5%). Higher odds of drug use were reported among cisgender men and those who had experienced homelessness or sexual harassment in the past 12 months. Higher odds of self-identified concern about drug use were observed among participants reporting challenging life experiences.

DISCUSSION AND CONCLUSIONS

Rates of illicit drug use among LGBTQA young people in this study were considerably higher than those observed in general population youth studies in Australia and were further elevated among those who had experienced LGBTQA-related prejudice or harassment, or homelessness.

Running with Scissors: a Systematic Review of Substance Use and the Pre-exposure Prophylaxis Care Continuum Among Sexual Minority Men

Purpose of Review

Patterns of sexualized drug use, including stimulants (e.g., methamphetamine) and chemsex drugs, are key drivers of HIV incidence among sexual minority men (SMM). Although pre-exposure prophylaxis (PrEP) mitigates HIV risk, there is no consensus regarding the associations of substance use with the PrEP care continuum.

Recent Findings

SMM who use substances are as likely or more likely to use PrEP. Although SMM who use stimulants experience greater difficulties with daily oral PrEP adherence, some evidence shows that SMM who use stimulants or chemsex drugs may achieve better adherence in the context of recent condomless anal sex. Finally, SMM who use substances may experience greater difficulties with PrEP persistence (including retention in PrEP care).

Summary

SMM who use stimulants and other substances would benefit from more comprehensive efforts to support PrEP re-uptake, adherence, and persistence, including delivering behavioral interventions, considering event-based dosing, and providing injectable PrEP.

Sex, drugs and techno - a qualitative study on finding the balance between risk, safety and pleasure among men who have sex with men engaging in recreational and sexualised drug use

BACKGROUND

Recreational and sexual drug use among men who have sex with men may result in increased risk of poor health. The aim of this study was to better understand drug use and harm reduction techniques among Swedish men who have sex with men traveling to Berlin in order to improve the health of this population and inform public health strategies.

METHODS

A qualitative study based on semi-structured interviews with 15 Swedish men aged 23-44 with experience of drug use were recruited through network sampling. Interviews were conducted in Stockholm and Berlin and analysed using content analysis. The interview guide included questions on drug use, context, health and safety.

RESULTS

The participants engaged in drug use in both settings and in various contexts. Participants saw themselves as capable of finding a balance between pleasure, safety and risk with the aim to maximize positive effects while minimizing negative ones. The different risks of drug use were known, and participants relied on knowledge, harm reduction strategies and self-defined rules of intake to stay safe and healthy in a broad sense, both short term (i.e. during each session) and long term. Choice of drug and, frequency of intake, multi-use, risk of overdose, risk of HIV, purpose and context of use, how often, etc. were all part of the overall strategy. Knowledge of these methods was spread within the community and on-line rather than from counsellors or other health care providers. However, it did not always translate perfectly into practice and some had experienced overdoses and problematic use.

CONCLUSIONS

The findings of this study point to the need for increased adoption of harm reduction techniques in this population focusing on mitigating harm and prevention of risk of problematic use or starting injection drugs. Existing traditional services require adaptations to become more accessible and acceptable to sub-groups of drug users, including low-threshold services providing non-judgemental, evidence-based information. This will require funding of alternative providers such as STI/HIV clinics, among others, and health care providers to increase adoption of prevention strategies, specifically pre-exposure prophylaxis for HIV.

Prior HIV testing behaviour is associated with HIV testing results among men, trans women and trans men who have sex with men in the United States

BACKGROUND

Among those at high risk for HIV, it is important to examine the ways in which someone who has recently tested for HIV might differ from someone who has not.

METHODS

In 2017-2018, a total of 5001 men, trans women and trans men who have sex with men from across the United States completed an online survey about their recent testing behaviour as well as self-collected oral samples for HIV testing.

RESULTS

In total, 3.8% tested HIV-positive and-among those with positive results-35% were recent HIV infections (ie, self-reported an HIV-negative test result within the 12 months prior to enrollment). Those with HIV-positive results-regardless of how recent their HIV test was prior to enrollment-differed from those with negative results in ways that are known to be associated with HIV risk: racial and income disparities, housing instability, recent transactional sex and recent methamphetamine use. Among those with HIV-positive results at enrollment, only having a primary care physician distinguished those who recently tested negative prior to enrollment versus not. Among those with HIV-negative results, there were numerous differences between those who had recently tested for HIV prior to enrollment, versus not, such that those who had not recently tested were significantly more likely to report being at higher risk for HIV.

CONCLUSION

Strategies aimed at improving more frequent HIV testing among HIV-negative persons at high risk for HIV should address other needs including stable housing, transactional sex, access to a primary care provider and methamphetamine use.

Stimulant expectancy questionnaire for men who have sex with men: A measure of substance-related beliefs

ISSUE ADDRESSED

Stimulant use has been identified as a key risk factor for sexual behaviours leading to HIV transmission. Substance-related expectancies are associated with substance use and postsubstance use thoughts, feelings and behaviours. Expectancies held by specific cultural subgroups have rarely been investigated, particularly regarding a range of commonly used stimulants.

METHOD

The Stimulant Expectancy Questionnaire for Men who have Sex with Men (SEQ-MSM) was initially generated through consumer panel and interviews regarding the most commonly used stimulants among MSM in Australia (methamphetamine, amphetamines and ecstasy), with initial administration among 98 MSM to facilitate item reduction. A community sample of 427 MSM was used to validate the SEQ-MSM, with exploratory factor analysis (EFA; n = 202) and confirmatory factor analysis (CFA; n = 225).

RESULTS

EFA revealed three distinct substance reinforcement domains ('Enhanced sexual experience', 'Sexual communication and negotiation' and 'Cognitive impairment'). The scale was associated with stimulant consumption patterns (including greater expectancies regarding sexual enhancement among methamphetamine users), and the factor structure, comprising a final form of the MSM-SEQ, was confirmed through CFA.

CONCLUSIONS

The SEQ-MSM represents a reliable measure of outcome expectancies related to the range of commonly used stimulants among Australian MSM. Development of applied validation studies with the SEQ-MSM is a key next step in advancing health promotion, clinical interventions and research efforts to reduce harm (eg, HIV transmission) associated with stimulant use (particularly methamphetamine) among MSM. SO WHAT?: Objectives: This research maps expectancies specific among gay and men who have sex with men (MSM), and relationships between expectancies and stimulant use patterns and behaviours postuse - including sexual activity (eg, condomless anal sex).

Determining the Roles that Club Drugs, Marijuana, and Heavy Drinking Play in PrEP Medication Adherence Among Gay and Bisexual Men: Implications for Treatment and Research

Researchers have established that substance use interferes with anti-retroviral medication adherence among gay and bisexual men (GBM) living with HIV. There is limited parallel examination of pre-exposure prophylaxis (PrEP) adherence among HIV-negative GBM. We conducted retrospective 30-day timeline follow-back interviews and prospective semi-weekly diary data for 10 weeks with 104 PrEP-using GBM, half of whom engaged in club drug use (ketamine, ecstasy, GHB, cocaine, or methamphetamine)-generating 9532 days of data. Participants reported their day-by-day PrEP, club drug, marijuana, and heavy alcohol use (5 + drinks in one sitting). On average, club drug users were no more likely to miss a dose of PrEP than non-club drug users (M = 1.6 doses, SD = 3.0, past 30 days). However, we found that club drug use (at the event level) increased the odds of missing a dose on the same day by 55% and the next day (e.g., a "carryover effect") by 60%. Further, missing a dose on one day increased the odds of missing a dose the following day by eightfold. We did not identify an event-level effect of marijuana use or heavy drinking on PrEP adherence. Our data suggest club drug users could have greater protective effects from daily oral or long-acting injectable PrEP compared to a time-driven PrEP regimen because of the concurrence of club drug use and PrEP non-adherence.

Should I Convince My Partner to Go on Pre-Exposure Prophylaxis (PrEP)? The Role of Personal and Relationship Factors on PrEP-Related Social Control among Gay and Bisexual Men

An estimated 35-68% of new HIV infections among gay, bisexual, and other men who have sex with men (GBM) are transmitted through main partnerships. Pre-exposure prophylaxis (PrEP) is highly effective in reducing HIV seroconversion, yet PrEP uptake has been modest. PrEP-naïve GBM with HIV-negative, PrEP-naïve main partners enrolled in One Thousand Strong (n = 409), a U.S. national cohort of GBM, were asked about (1) the importance of partner PrEP use and (2) their willingness to convince their partner to initiate PrEP. On average, participants thought partner PrEP was only modestly important and were only moderately willing to try to convince their partner to initiate PrEP. Personal PrEP uptake willingness and intentions were the strongest indicators of partner PrEP outcomes. Being in a monogamish relationship arrangement (as compared to a monogamous arrangement) and the experience of intimate partner violence victimization were associated with increased willingness to persuade a partner to initiate PrEP.

Preintervention Profiles of Information, Motivational, and Behavioral Self-Efficacy for Methamphetamine Use and HIV Medication Adherence Among Gay and Bisexual Men

Although rates of crystal methamphetamine use in the United States have fallen from their peak in the mid-2000s, use remains a major public health concern, which disproportionately affects gay and bisexual men (GBM). It poses a particular challenge for HIV-positive men, for whom it has been linked to medication adherence problems as well as compromised immune function. Although the information, motivation, and behavioral skills (IMB) model has been widely used to conceptualize health behavior, little is known about GBM's initial levels of information, motivation, and behavioral self-efficacy to improve HIV medication adherence and to reduce crystal methamphetamine use at the outset of treatment. The present study identified profiles of IMB factors related to HIV medication adherence and crystal methamphetamine use in a sample of 210 HIV-positive GBM who consented to participate in an intervention study. Results indicated three distinct patterns of IMB factors. The largest group was ready to change both adherence and methamphetamine use (n = 104). This group also had depression scores that were significantly lower than other groups. A second group appeared ready to change medication adherence, but was ambivalent about changing methamphetamine use (n = 60). This group reported significantly more symptoms of methamphetamine dependence than the other groups. A third group was characterized by global IMB barriers to change (n = 46). Results are discussed in the context of tailoring psychoeducation, motivational interviewing, and cognitive behavioral interventions to match these preintervention patterns of IMB factors.

Recreational drug use in men who have sex with men (MSM) attending UK sexual health services is significantly higher than in non-MSM

INTRODUCTION

The aim of this study was to investigate the pattern of recreational drug use in patients attending a genitourinary medicine clinic, and to determine whether drug use was greater among men who have sex with men (MSM) patients, when compared to non-MSM male patients.

METHODS

A questionnaire was given to all patients attending the genitourinary medicine clinics at two inner city teaching hospitals over 3 months (July to September 2011). The questionnaire was self-completed by patients while waiting to be seen by a clinician. Data were collected on age, gender, gender of sexual partner(s), and previous/current recreational drug use (type/frequency of drugs used). Only data from male respondents have been analysed in this paper.

RESULTS

1328 questionnaires were completed. Of the male respondents (n=729), 475 (65.2%) were identified as non-MSM and 254 (34.8%) were identified as MSM. The mean ± SD age of male respondents was 31 ± 9 years years. Lifetime and last month use of mephedrone, ketamine, volatile nitrites ('poppers'), sildenafil (Viagra), GHB, and GBL were all significantly higher in the MSM group compared to the non-MSM group. Lifetime use of cocaine powder, MDMA, amphetamine, and methamphetamine were also significantly higher in the MSM group; however, there was no significant difference in last month use of these drugs between MSM and non-MSM groups.

CONCLUSIONS

Both lifetime and last month use of most recreational drugs was more common in MSM, when compared to non-MSM males. Sexual health clinics may provide an opportunistic encounter to identify patterns of recreational drug use, explore motivations for use, and implement strategies to reduce harms related to drug use. This will require a multidisciplinary approach to address the psychosocial aspects of drug taking behaviours, in combination with healthcare professionals experienced in the management of recreational drug use.

Aggregate versus day level association between methamphetamine use and HIV medication non-adherence among gay and bisexual men

Methamphetamine use is associated with HIV infection, especially among gay and bisexual men. Methamphetamine use contributes to disease progression both directly, by increasing viral load and damaging the immune system, and indirectly, by decreasing medication adherence. Research examining the association of methamphetamine use and non-adherence has traditionally compared groups of users and nonusers on adherence, compared methamphetamine use between participants above or below some threshold level of adherence (e.g. >90 % dose adherence), or examined aggregate relationships. Using Timeline Follow-back procedures, the present study examined aggregate, threshold, and day-level associations of methamphetamine use with non-adherence in 210 HIV-positive gay and bisexual methamphetamine-using men. Methamphetamine use was not associated with adherence behavior at the aggregate-level, but methamphetamine use on a given day was associated with 2.3 times the odds of non-adherence on that day. Threshold results were equivocal. These data suggest that the methamphetamine and non-adherence relationship is complicated: non-adherence is more likely to occur on days in which methamphetamine is used, but participants reported more non-adherence days in which methamphetamine was not used. This seeming paradox generates questions about the selection of analytical techniques and has important implications for behavioral interventions targeting substance use and adherence among HIV-positive individuals.

Predictors of day-level sexual risk for young gay and bisexual men

As HIV infection rates remain high among young gay and bisexual men, investigations into determinants of sexual risk are paramount. This study examined independent and interactive effects of substance use, mental health, perceived benefits of unprotected sex, and type of sex partner on odds of not using condoms. Analyses included 188 high-risk substance using HIV-negative and unknown status young gay and bisexual men (ages 18-29). Substance use and endorsing favorable attitudes towards unprotected sex strongly predicted sexual risk. Mental health moderated the relationship between partner type (main vs. casual) and condom use such that increased anxiety and depression were associated with increased odds of using condoms with main partners and not using condoms with casual partners. Understanding how these determinants of HIV risk converge to predict unprotected anal sex can identify essential risk relationships for prevention, obtain effects sizes of greater magnitude and prolonged sustainability, and build robust couples-based interventions.

Conflict and expectancies interact to predict sexual behavior under the influence among gay and bisexual men

As the mechanisms of the associations between substance use and risky sex remain unclear, this study investigates the interactive roles of conflicts about casual sex and condom use and expectancies of the sexual effects of substances in those associations among gay men. Conflict interacted with expectancies to predict sexual behavior under the influence; low casual sex conflict coupled with high expectancies predicted the highest number of casual partners, and high condom use conflict and high expectancies predicted the highest number of unprotected sex acts. Results have implications for intervention efforts that aim to improve sexual decision-making and reduce sexual expectancies.

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.

Age cohort differences in the effects of gay-related stigma, anxiety and identification with the gay community on sexual risk and substance use

Different cohorts of gay/bisexual men experience unique developmental factors given their distinct socio-historical contexts. This study examined the moderating effects of age on three psychosocial predictors of HIV risk behavior and substance use. Analyses drew on data from a study of substance using HIV-negative and unknown status gay/bisexual men (N= 302) at risk for HIV infection. Anxiety was a strong independent predictor of sexual risk and substance use, and its effects on the sex risk outcomes were moderated by age, such that older and more anxious participants had more frequent instances of sexual risk. Identification with the gay community protected against HIV risk, and its effects on sex risk outcomes were moderated by age, such that younger participants who identified with the gay community reported less sexual risk. Understanding HIV risk within socio-historical contexts is essential in tailoring prevention by taking into account recipients' ages.

Attitudes about and HIV risk related to the "most common place" MSM meet their sex partners: comparing men from bathhouses, bars/clubs, and Craigslist.org

This study examined attitudes toward the most common place where men who have sex with men (MSM) met their recent male sex partners. In 2009-2010, MSM were surveyed in bars/clubs, bathhouses, and on Craigslist.org . We found strong but differential overlap between venue of recruitment and participants' most common place: 81% of men from Craigslist indicated their most common place was the Internet, 65% of men from bathhouses indicated their most common place was bathhouses, and 47% of men from bars/clubs indicated their most common place was bars/clubs. In general, interest in seeing more information on drugs/alcohol and HIV and interacting with a health outreach worker in participants' most common place ranged from "agree" to "strongly agree." However, men whose most common place was bars/clubs rated these items lowest on average. Rates of unprotected anal intercourse (UAI) were high (43%), thus targeted efforts in bars/clubs, bathhouses, and on the Internet may be ideal venues for reaching high-risk MSM. Although most common place was unrelated to UAI, it was related to factors that contextualize men's encounters (e.g., attitudes toward HIV status disclosure, and perceptions about barebacking, anonymous sex, and alcohol use). Outreach providers should consider these contextualizing aspects as they continue to retool their efforts.

Changes in stimulant drug use over time in the MACS: evidence for resilience against stimulant drug use among men who have sex with men

Stimulant drug use is associated with numerous health problems among men who have sex with men (MSM). This paper describes how stimulant drug use changes over a four and one-half year period from 2003 until 2008. Participants were 2,389 men (17,222 person-visits) from The Multicenter AIDS Cohort Study (MACS)-an ongoing, prospective study of HIV infection among MSM. Group-based trajectory analyses of data from these men over the study period yielded a four groups solution: consistent users (9.8%), men whose use increased (5.4%), men whose use declined (6.9%), and abstinent or rarely-using men (77.9%). There were significant differences between groups in terms of demographic, behavioral risk and HIV serostatus. Men who increased or decreased stimulant drug use over time reported congruent changes in sexual risk taking. The fact that sexual risk levels parallel stimulant drug use over time suggests that finding ways to lower rates of stimulant drug use among MSM could be a tool in HIV prevention.

"It's one of the better drugs to use": perceptions of cocaine use among gay and bisexual Asian American men

Research on drug use among gay and bisexual men has primarily focused on examining the link between drug use- most notably, methamphetamine-sexual practices, and risk of HIV transmission. Drawing on in-depth qualitative data from 40 interviews with gay and bisexual Asian American men, we examine perceptions and meanings associated with cocaine use in the San Francisco Bay Area gay community. We found that the participants, in contrast to their negative perceptions of methamphetamine use, believed that cocaine enhanced sociability and was acceptable for use in most social situations. Furthermore, participants perceived little connection between cocaine use and risky sexual practices, emphasizing the drug's safety relative to other illicit substances. Based on these findings, we suggest that an increase in the favorability of cocaine use might be an unintended consequence of methamphetamine prevention campaigns targeting the gay community, with their emphasis on the harmful effects of drug use, unsafe sex, and HIV risk.

An integrated theoretical approach to substance use and risky sexual behavior among men who have sex with men

Research demonstrates a consistent association between substance use and sexual risk, particularly among men who have sex with men (MSM). The present study builds upon two existing theories (Cognitive Escape Theory and Expectancy Theory) to examine the synergistic role of sexual conflict (surrounding unsafe sex) and expectancies in sexual behavior among 135 MSM. Two conflicts were examined: (1) The conflict between motivation to practice safer sex and temptation for unprotected sex; and (2) The conflict between motivation to practice safer sex and perceived benefits of unprotected sex. Factorial ANOVAs (2 × 2; high versus low expectancies and conflict versus no conflict) revealed a significant interaction between conflict and expectancies-individuals who reported high levels of conflict were more sensitive to the effect of expectancies than were those experiencing low levels of sexual conflict. Results demonstrate the synergistic effects of conflict and expectancies and highlight the importance of integrating existing theories to more fully consider the intrapsychic operation and experience of sexual conflicts.

Methamphetamine use, attitudes about condoms, and sexual risk behavior among HIV-positive men who have sex with men

This study examined attitudes about condoms as a moderator of the relationship between methamphetamine use and sexual risk behavior in a sample of 297 HIV-positive, methamphetamine-using men who have sex with men (MSM). To test for a moderating effect of attitudes towards condoms, an interaction term was included in multiple regression analysis along with age, income, negative condom attitudes, frequency of methamphetamine use, and Beck depression score. A post hoc analysis was conducted to determine the relations between methamphetamine use and unprotected sex for persons with more vs. less negative attitudes toward condoms. These analyses indicated that when individuals had more negative attitudes toward condoms, the relation between methamphetamine frequency and unprotected sex was significant, while among participants with less negative attitudes toward condoms, no significant association was found. Addressing methamphetamine-using MSM's attitudes about condoms can serve as a form of harm reduction for those who are not yet ready or willing to discontinue methamphetamine use.

HIV in young men who have sex with men: a review of epidemiology, risk and protective factors, and interventions

Epidemiological studies have found that young men who have sex with men (YMSM) represent the majority of young people infected with HIV annually in the United States. Further, they are one of the few risk groups to show an increase in the rate of infections in recent years. In addition to these disparities in prevalence and infection rates, there is an inequity in prevention and intervention research on this population. The purpose of this article is to review the existing YMSM literature on HIV epidemiology, correlates of risk, and intervention research. The article concludes that promising future directions for basic research include a focus on multiple clustering health issues, processes that promote resiliency, the role of family influences, and the development of parsimonious models of risk. In terms of intervention research, the article suggests that promising future directions include Internet-based intervention delivery, integration of biomedical and behavioral approaches, and interventions that go beyond the individual level to address partnership, structural, community, and network factors.

“It's a quick way to get what you want”: a formative exploration of HIV risk among urban Massachusetts men who have sex with men who attend sex parties

Community-based studies with men who have sex with men (MSM) suggest that between 8% and 25% of MSM have met recent male sexual partners at private sex parties. Little is known about HIV sexual risk behaviors of MSM who attend sex parties and whether risk reduction interventions can be delivered in this setting. In 2008, 40 MSM who reported attending and/or hosting sex parties in Massachusetts in the past 12 months completed a qualitative interview and quantitative assessment. Participants reported attending a mean number of 10 sex parties in Massachusetts in the past 12 months. A significant percentage (43%) reported also hosting sex parties. Participants had made sexual partner connections across multiple venues, including public cruising areas, bars/clubs, and the Internet. At the most recent sex party attended, the majority had used alcohol (58%) and/or drugs (50%), and one quarter (25%) put themselves at risk of acquiring or transmitting HIV or other sexually transmitted infections (STIs) by having unprotected anal sex with a mean number of three serodiscordant male sex partners. Although many participants perceived that communicating about sexual health in the sex party context would “ruin the mood,” the majority (80%) considered some form of HIV prevention at sex parties to be appropriate and necessary, as well as acceptable. Nonintrusive prevention and education activities were especially endorsed (i.e., condoms, lubricants, and coupons for free HIV/STI testing). The majority of participants (75%) expressed some interest in “safer sex” parties. MSM attending sex parties appear to be a subpopulation at high risk for HIV and STI acquisition and transmission. Risk reduction interventions responsive to the needs of MSM who attend sex parties are warranted.

The involvement of gamma-hydroxybutyrate in reported sexual assaults: a systematic review

Over the past few years gamma-hydroxybutyrate (GHB) has generated widespread media interest as a possible 'date rape drug'. Our goal was to examine the extent to which GHB is associated with drug-facilitated sexual assaults. Literature was searched systematically and 11 studies, published between 1961 and June 30, 2009, were identified dealing specifically with the role of GHB in sexual assaults. GHB was detected in 0.2-4.4% of reported sexual assaults. The results demonstrate that a wide range of drugs may be present in cases of sexual assault, and many of them are much more frequent than GHB. Our results do not support the widespread labelling of GHB as a date rape drug as the prevalence of GHB is much lower than of other substances used in sexual assaults. On the other hand, however, the possible risk of GHB in this regard should not be neglected. Nevertheless, over-sensitive and sensation seeking media reports focusing on the association of sex crime and GHB might be counterproductive and misleading as they turn the attention away from other substances that are often used in sexual assaults.

Life events and sexual risk among HIV-negative, heterosexual, methamphetamine users

Identifying psychosocial factors associated with sexual risk behavior among methamphetamine users is essential to enhancing HIV and sexually transmitted infection prevention. This study examined the relationship between positive and negative life events and sexual risk behavior in a sample of 100 HIV-negative, heterosexually identified, methamphetamine-using men and women. Negative life event categories included death of a significant other, negative health event involving self or significant other, and child custody or visitation issues. Categories of positive life events included birth or pregnancy involving self or significant other, a positive relationship event, and a positive life change. Multivariate analyses demonstrated that negative life events were positively associated with total number of unprotected sex acts, whereas positive life events were not associated with sexual risk taking. Also, amount of methamphetamine used did not moderate the relationship between life events and sexual risk behavior. These data support future research to identify underlying mechanisms that link negative life events to sexual risk taking in this high-risk population.

Randomized trial to reduce club drug use and HIV risk behaviors among men who have sex with men

The authors examined the effectiveness of motivational interviewing (MI) on club drug use and risky sex in non-treatment-seeking men who have sex with men (MSM). MSM (N = 150) were assessed and randomly assigned to 4 sessions of MI or an educational control intervention. Follow-up occurred at quarterly intervals for 1 year. Primary outcomes were days of any club drug use and number of unsafe sex acts. On average, club drug use declined during follow-up. A significant interaction effect showed that MI was associated with less club drug use during follow-up compared with education but only among participants with lower severity of drug dependence (p < .02; small to medium effect size). MI did not result in a significant reduction in risky sex relative to education. The results support the use of MI targeting club drug use in at-risk or mildly dependent users not seeking treatment but not in more severely dependent users. MI does not appear effective in reducing risky sexual behavior in this population.

Sexual compulsivity and sexual behaviors among gay and bisexual men and lesbian and bisexual women

Within the existing body of research, the information pertaining to sexual compulsivity (SC) among women, both homo- and heterosexual, remains rather limited in comparison to men. The aim of this study was to assess the prevalence of SC in a community sample of gay and bisexual men and lesbian and bisexual women and to identify differences in sexual practices based on classification as sexually compulsive within gender. Supporting previous research, the findings indicated that gay and bisexual men were significantly higher in SC when compared to lesbian and bisexual women. Similarly, sexually compulsive gay and bisexual men were more likely to report drug use with sex than their non-sexually compulsive peers, suggesting that "party n' play" may play a larger role for men with SC. In addition, the findings demonstrated empirical support for the proposition that lesbian and bisexual women with symptoms of SC were more likely to engage in specialized sexual behaviors in comparison to their non-sexually compulsive peers. These data suggest that SC manifests differently in gay, lesbian, and bisexual men and women.

Club drug use and dependence among young adults recruited through time-space sampling

OBJECTIVES

Ketamine, methylenedioxymethamphetamine (MDMA/ecstasy), cocaine, gamma-hydroxybutyrate (GHB), methamphetamine, and d-lysergic acid diethylamide (LSD/acid) have been identified as "club drugs" because of their link to club culture among young adults. Yet little is known about users' demographic differences in the prevalence of club drugs. This study sought to provide a comprehensive profile of users' demographic differences in prevalence of club drug use and dependence.

METHODS

Using time-space sampling, a stratified sample of 400 18- to 29-year-old club-going young adults was recruited into the Club Drugs and Health Project.

RESULTS

Though participants reported using an array of club drugs, almost all participants (90.0%) were cocaine users. Although there were several sexual orientation and gender differences in recent drug exposure, patterns of use (measured in days) were fairly similar across gender, sexual orientation, and age. Finally, a majority of individuals (58.5%) met or exceeded criteria for club drug dependence, with most (61.7%) indicating cocaine was the one drug causing them significant problems.

CONCLUSIONS

Cocaine is a major drug in club culture. It is essential to develop culturally appropriate drug education and prevention initiatives for young adults using club drugs.

Recruiting hard-to-reach drug-using men who have sex with men into an intervention study: lessons learned and implications for applied research

Drug (ab)use researchers and service providers across the globe have been challenged with locating target populations and subsequently enrolling participants into their programs. This study presents data from nearly 3 years (2004-2006) of recruiting "high-risk" drug-using gay and bisexual men into a clinical research trial based in New York City. During the enrollment period, two recruitment/marketing strategies were utilized: (1) marketing of the intervention research study itself to men who were in the early stages of identifying problems with their drug use and risky sexual behavior and (2) two-stage recruitment via a lower-threshold/commitment (i.e., brief survey) and subsequent offering/enrollment into the full trial upon completion of the initial visit (i.e., a foot-in-the-door). The second approach was substantially more effective in enrolling participants into the full trial (6.3 participants/month vs. 2.5 participants/month). Furthermore, recruitment costs for the foot-in-the-door approach were substantially reduced ($356.57 per participant vs. $497.03 per participant). Compared to the marketing of interventions themselves to target populations, a two-stage recruitment strategy incorporating lower-threshold interactions may be a more effective approach to recruit for interventions.