Findings from this study indicate that a higher proportion of MSM in this very-low-income sample report using crack during their last sexual episode (33%) than men who reported using methamphetamine during sex (22%). Yet, to the extent that event-specific behaviors represent typical sexual behavior, it seems the methamphetamine users may face greater risks for encountering HIV than MSM who incorporate crack use with their sexual behavior. Not only was HIV prevalence higher among MSM who used methamphetamine during sex (49%) compared to those who used crack (24%), but having an HIV positive partner, having a high number of partners, and having unprotected sex all were associated with increased odds of using methamphetamine during sex. Unprotected sex was associated with increased odds of crack use during sex only when a partner was thought to be HIV negative. Compounding these risks is the association between use of methamphetamine during sex and exchanging sex for money or drugs and having sex in a public sex venue. These findings are compelling in describing the functional differences for these two stimulants in transacting sexual risks for HIV transmission in active drug users. Together with cohort data showing higher seroincidence for methamphetamine using MSM (Plankey et al., 2007
), our findings describe potential behavioral linkages between methamphetamine use and extreme sexual behaviors facilitated by the drug in increasing risks for HIV transmission.
Although observed rates of reported crack and methamphetamine use during sex are concentrated in small subgroups in this sample, the prevalence of HIV for MSM is high, particularly among men who use methamphetamine during sex. The event-level findings emphasize behavioral disinhibition during sex that occurs under the influence of stimulants, methamphetamine in particular, and corresponding high potential for HIV transmission between MSM. Whether crack or methamphetamine facilitate unprotected sexual behavior between MSM and women, thus creating a “behavioral bridge” (Laumann and Youm, 1999
) by which HIV is transmitted from MSM to heterosexual networks, requires further study.
Methamphetamine using MSM in this sample reported on sexual episodes with a relatively small number of female partners (n=26) and, of these, unprotected sex was reported during only 12 events. Ten out of these 12 unprotected sexual events were between women believed to be HIV negative or of unknown HIV status and men negative for HIV. However, of MSM who reported using methamphetamine during sex, 38% (n=122) reported that they had sex with a female partner in the last six months despite providing information primarily on events with male partners. Although most (53%) of the men who used methamphetamine identified with being “gay or homosexual,” 33% identified with the term “bisexual” and a small proportion identified as “heterosexual” (5%), “on the down low or messing around with the other team” (4%), or another term (5%) (data not shown). It is not clear whether MSM who used methamphetamine during sex misrepresented the number of women with whom they had sex in the past six months. Nevertheless, the risk for transmission for women via sex with methamphetamine using men in this sample was quite low. In all of the unprotected methamphetamine events reported, only one was between an HIV positive MSM and a woman, Although data from this study suggest that methamphetamine-using MSM may not pose a significant risk to women, further study is needed to assess behaviors of behaviorally bisexual methamphetamine users.
MSM who used crack reported on a higher number (n=90) of sexual events with women and tended to identify as bisexual (42%) or heterosexual (18%) rather than as gay (21%). Although unprotected sex was associated with increased odds of crack use during sex when the MSM perceived a partner (male or female) was HIV negative, only 35 crack events with women were reported as unprotected. As well, none of the unprotected crack events with women was between an HIV positive MSM and a woman believed to be HIV negative or positive and only one was between an HIV positive MSM and a woman of unknown HIV status. Although data from this study suggest that the risks of HIV transmission to women when MSM use either stimulant during sex are weak within this group of older, low-income MSM, further study is needed, perhaps within younger, higher income MSM to assess the potential role for these drugs in the sexual transmission of HIV to female partners.
Associations between sexual risk-taking and stimulant use during sex observed in the episodes of the men’s last sexual episode with recent partners provide evidence for HIV prevention programs to focus on drug-associated sexual transmission risks for HIV in similar groups in Los Angeles. While findings are most relevant to the local group of MSM in Los Angeles, they may also apply to urban communities with similarly established HIV epidemics and primary transmission behaviors involving male-to-male sexual behaviors in the presence of high rates of illicit stimulant use.
Although several studies describe associations between stimulant use and high-risk sexual behaviors in resourced communities of MSM, findings from the present study shed light on event-level HIV risk factors in an understudied group of very poor, urban, older MSM with a remarkably high prevalence of HIV. Due to the high prevalence of HIV and risk behaviors associated with methamphetamine use during sex, epidemiologists and interventionists alike must take care not to overlook study, intervention, and treatment within this group.
These findings are important as they measure drug use at the time of the sexual behavior, rather than correlating measures of recall for overall drug use in the past 6 months with measures of recall for overall sexual behaviors. While we did not ask about sequencing of drug use and sexual behavior, we did query sexual behaviors that occurred under the influence of illicit stimulants. The strategy of not requiring individuals to report on whether stimulant use preceded high risk sex (or the reverse) is based on recognition that drug-associated sexual episodes are experienced as unitary phenomena that cannot be parsed reliably in terms of timing of events. Thus, the focus on event-level data when reporting on associations between drug use during sex and other episode-level risks such as condom use is a strength of the study. Findings based on over 1,500 reported unique sexual episodes provide greater opportunities for correlating factors with event level behaviors than studies of global estimates of these behaviors.
Limitations to this study’s findings include self-report bias, selection bias due to our application of RDS, and small cell sizes that resulted from disproportionate use of crack by older, Black MSM. Bias due to self-reporting is a potential problem in all survey studies, but bias was minimized by our use of audio computer self-administered interviews (ACASI). In addition, our implementation of RDS yielded a sample that was overwhelmingly very poor, which may reflect unique challenges to the sampling method that arise when using a dual core (MSM and/or drug users) to define the referral approach. This study described drug and risk behaviors of a unique group of very low-income urban men who have sex with both men and women, a largely neglected group in the prevention literature. It is not known whether the associations observed in this group would also be seen in younger MSM or MSM of other income strata. Finally, because of the some small cell sizes and corresponding wide confidence intervals, care must be taken in interpreting findings about age and race. Limitations notwithstanding, findings provide an uncommon event-level observation into a largely hidden group of men who face significant risks for both drug dependence and for HIV transmission.