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Street outreach encounters were used to collect data of reported alcohol and other drug use among gay and bisexual males (N=11,375) in Hollywood and West Hollywood, California over a 9-year period from January 1999 to December 2007. Analyses were conducted to assess demographic data, self-reported HIV status, and frequency of alcohol and other drug use. Participants averaged 32.3 (SD=7.7) years, slightly over half were Caucasian/white (53%), and most were identified as gay (85.8%). Self-reported HIV seroprevalence was 20.7%. Observations began January to June 1999, with 46.0% reporting recent methamphetamine use, and ended July to December 2007, with 24.8% reporting recent use of methamphetamine. Percent reporting methamphetamine use peaked in the first half of 2002 at 53% and dipped to a low of 11.1% in the second half of 2006. Findings demonstrate the common use of methamphetamine over the observation period in this high-risk group even in the face of a recent decline in reported use. These data also indicate the need for ongoing methamphetamine abuse and HIV-prevention interventions in this particular high-risk population.
Methamphetamine use has gained high levels of attention among substance users who are gay and bisexual men and other men who have sex with men (MSM) in urban areas of the United States.1,2 In a probability-based survey, approximately 11% of gay and bisexual men in Los Angeles and 13% in San Francisco reported using the drug in the previous 6 months.3 MSM continue to experience increases in prevalence of HIV,4 likely linked to methamphetamine-associated sexual transmission behaviors.5–8 Several indicators point to the popularity of methamphetamine in gay male communities.6,9–11 This popularity of methamphetamine stems from, in part, its availability, reasonably low cost, and disinhibiting effects in relation to sexual behaviors. In addition, methamphetamine functions to facilitate many social and sexual activities for a sub-group of urban, gay, and bisexual men.6,9–11
This study reports on the use of methamphetamine among gay and bisexual males over a 9-year period in Los Angeles. Analyses charted the percent of men reporting types of substances used and, specifically, the trends of these reports over 6-month periods. Tracking substance use trends in outreach samples often serves as a bellwether of emerging trends, particularly among high-risk populations.
Participants were self-identified gay and bisexual males contacted via street-based HIV-prevention outreach sessions. Included are participants who mentioned any recent substance use (previous 30 days). All participants were men contacted in the Hollywood and West Hollywood areas of Los Angeles County, a 7-mile region that accounts for the highest concentration of annual AIDS cases in Los Angeles County12 and has a high density of gay and bisexual male residents.
The street outreach HIV-prevention program provided low-intensity health education and risk-reduction interventions using teams of ethnically diverse, bilingual (English and Spanish), and indigenous street outreach workers. Over the entire 9-year period, prior to entering the field, outreach workers received 6 to 8 weeks of intensive training (from first author) and demonstrated proficiency in how to identify high-risk venues, establish trust and rapport, approach gay and bisexual men in sexually charged and/or drug intense settings, administer a brief assessment, and provide culturally appropriate referrals, when needed. Additionally, recruitment and intervention procedures used during street outreach were consistent throughout the 9-year period.
Teams of outreach workers canvassed areas known to be frequented by substance-using gay and bisexual males, including sex clubs, bars, bathhouses, cruising areas, parks, coffee houses, and specific street corners and alleys. Outreach activities were conducted by rotating teams between 11:00 a.m. and 5:00 a.m. Individuals who appeared to match the target population of gay and bisexual male substance users were approached by outreach workers who then conducted “encounters,” i.e., low-intensity HIV-risk-reduction interventions, that lasted from 16 to 60 min.
Using a unique identifier to ensure anonymity, outreach workers recorded participant responses on a brief instrument that assessed demographics (gender identity, sexual identity, age, race/ethnicity), self-reported HIV status, alcohol and other drug use in the previous 30 days (including injection and non-injection drug use), HIV drug-risk behaviors (injection practices), sexual behaviors in the previous 30 days (oral sex, insertive and receptive anal sex, vaginal sex), HIV sexual risk behaviors (frequency of condom use), and sexual partner type (male, female, pre-operative transgender, post-operative transgender, exchange partner). All data were self-reported. Outreach workers also recorded descriptive information on the encounter (e.g., duration, location, time of day, supplies given). Data included in this study are confined to demographics, HIV status, and substance use. Participants were not compensated for their participation.
This study reports only on responses from the first recorded encounter with a unique participant. The goal of the outreach encounter was to assess the participant’s level of drug use and sexual risk behaviors, provide low-intensity risk-reduction strategies, provide the participants with risk-reduction supplies (e.g., condoms and bleach) and survival kits (e.g., sunscreen, combs, razors, toothbrushes, and toothpaste), and provide referrals to needed services, if appropriate.
Reports from encounters were entered into electronic databases using scanners. Once captured into files, data were sequestered into 6-month periods. Duplicates for participants using the same anonymous code as well as those reporting no substance use were eliminated from these analyses. Cases with missing responses were deleted, yielding a database with only complete unduplicated cases.
Basic frequencies for each of the variables of interest were calculated. Frequencies for heroin, GHB, and ketaine, as well as for any injection drug use, were omitted due to their low rates. Demographic factors assessed included race/ethnicity (Caucasian/white, African American/black, Latino/Hispanic, multi-cultural/other), age (in years), and sexual identification (gay, bisexual, heterosexual). HIV status was measured as positive, negative, unknown, refused, or did not ask. All analyses were conducted using SPSS (Version 13.0).
From January 1, 1999 to December 31, 2007, 11,375 unique participants were encountered. Participants ranged in age from 13 to 79 years, with the mean age 32.3 years (SD=7.7). Slightly over half (53%) were Caucasian/white, 21.8% were Hispanic/Latino, 17.1% were African American/Black, and 8.1% were multi/other. The majority of participants reported their sexual identity as gay (85.8%); 20.7% reported to be HIV-infected, 67.4% reported to be HIV-uninfected; and 11.9% missing (either refused/do not know, or no data collected).
Figure 1 shows the trends for reports of recent alcohol use and other drugs over the 9-year period. With the exception of a 1.5-year period (from the second half of 2005 through the second half of 2006), methamphetamine was the most frequently reported drug, after alcohol and marijuana. From the first half of 1999 through the first half of 2005, the percentage of participants reporting alcohol use decreased by 15%; however, prevalence returned to near initial reports by the second half of 2005. The vast majority of participants reported alcohol use at least once in the previous 30 days. Marijuana use dropped from 75.5% in 1999 to 26.3% in the first half of 2006.
The percentage of participants reporting methamphetamine use peaked in the first half of 2002 at 53.2% and was at the lowest point in the second half of 2006 at 11.1%. The zenith for ecstasy use preceded that for methamphetamine and occurred in the first half of 2001 at 24.2%. By mid-2003, less than 10% of participants reported ecstasy use. Use of amyl nitrite appeared to increase slowly through the second half of 2003, with reported use lower for several years followed by increases again in 2007; low rates of use of crack and powder cocaine were observed through all periods.
The percentage of gay and bisexual male substance users reporting recent methamphetamine use and contacted via street outreach in Hollywood and West Hollywood, California was consistently high from January 1999 to June 2005, ranging between 33% and 53%. Percentages reporting methamphetamine use decreased for a brief period of time, from July 2005 to December 2006, and then began to increase again to 25% for the second half of 2007. Marijuana, ecstasy, and crack cocaine use peaked and dipped through the 9-year period.
Rates of reported alcohol and marijuana use were also high, although there was a steady decline in the percent of participants reporting marijuana use over the period. The high rates of alcohol and marijuana use would be expected, since outreach venues were selected to reflect the program’s objective to provide HIV-prevention outreach services to current substance-using, out-of-treatment MSM. Yet these rates are substantially higher than carefully constructed population-based samples of MSM.1,3
Although these data do not directly explain the changes in substance use over time (e.g., drop in marijuana use, rise and fall and rise again in methamphetamine use), it is expected that accessibility and cost of these substances, as well as exposure to prevention efforts and availability of treatment slots, all influence reported rates of use. Additionally, over time, there have been minor changes in outreach venues due to environmental changes in the targeted area (e.g., police raids and gentrification that have displaced the target population). More controlled longitudinal studies are required to tease out these influences on substance use among this high-risk population.
Reported trends in recent drug use documented through street outreach encounters can be seen as a harbinger of the drugs used by more conventional gay and bisexual populations. Methamphetamine remains the most frequently reported substance used by gay and bisexual males in Los Angeles, following alcohol and marijuana, an observation that is consistent with these data collected via street outreach in this high-risk group. These data also demonstrate that, with the exception of a brief decline in reported use, methamphetamine remains a popular drug of choice among this population. Given the previously demonstrated links between methamphetamine use, high-risk sexual behaviors, and HIV infection,7 as well as the continued use of methamphetamine, there is a compelling need for ongoing methamphetamine abuse and HIV-prevention interventions to this particular high-risk population.
This study is limited in that it is a convenience sample of urban gay and bisexual male substance users contacted via outreach in specifically gay neighborhoods in Los Angeles. It is possible that some individuals may have been inadvertently sampled more than once if they were assigned different unique identifiers. These data are self-reported, and therefore, some participants may have misrepresented their substance use, although we note that outreach workers were trained to assure participants of their confidentiality and no personal identifiers were obtained. Similarly, it is possible that the self-reported measure of one’s HIV-negative serostatus might have been overestimated. Finally, these findings may not generalize to other gay and bisexual males who do not frequent areas targeted for street outreach. Despite these limitations, the data represent a series of snapshots of the drug use of a high-risk population in Los Angeles County.
This study was supported by the Los Angeles County, Department of Public Health, Office of AIDS Programs and Policy, contracts #H204213, #H211853, #H700861, and the City of West Hollywood, Department of Human Services, Social Services Division. The authors thank Karina Kortbein, Ann Reiner, M.P.H., Jane Rohde, M.P.H., and Mely D. Silverio, Ph.D. for their statistical support.