To our knowledge, this is the first study to present both mood and sexual behavior profiles of individuals with and without METH dependence and/or HIV infection as well as, explore how the contexts of METH and HIV interact with mood to affect sexual behavior. Although our results suggest many differences in mood and sexual behavior across the four groups examined, we will focus our discussion on statistically significant findings in which we found the independent and combined contexts of METH and HIV play an influential role in negative mood states as well as sexual behavior patterns among non-monogamous MSM. We also found a significant negative association between negative mood states and condom use. However, neither the METH nor the HIV context was found to have a moderating effect on the association between negative mood and condom use.
In terms of sexual behavior, participants in the METH+/HIV+ group reported that 6–25% of their sexual encounters included receptive anal and/or insertive anal sex and 51–75% of encounters included oral sex. Compared to recent reports of METH+/HIV+ MSM sexual practices (Halkitis et al., 2005c
; Semple et al., 2006c
), these rates of sexual behavior are not uncharacteristically high. However, upon examination of condom use frequencies among METH+/HIV+ participants, it is clear that these rates of sexual behavior could be of substantial concern in relation to the spread of HIV and other sexual transmitted infections.
Approximately 75% or more of sex among METH+/HIV+ participants was unprotected. Interestingly, the METH−/HIV+ group reported significantly greater use of condoms. Thus, it appears that among those in HIV+ groups, METH use is a critical factor in the frequency of condom use: among METH+ individuals, frequency of condom use is 6–25% and among METH− individuals it is at 51–75%. However, recent work (Semple et al., 2006c
) found that although unprotected sex among METH+/HIV+ individuals was widespread, fewer unprotected sex acts were performed with HIV− and unknown partners compared to HIV+ partners. This said, the current study examined non-monogamous MSM only, and thus, although we did not capture this information specifically, the potential for sex with HIV− and unknown partners may be greater. However, even if all of the HIV+ participants in this study had sex with seroconcordant partners, this still may contribute to an increased risk of reinfection or superinfection with HIV variants as well as transmission of other sexually transmitted infections (STIs). Thus, interventions to address condom use and potentially other protective behaviors among HIV-infected MSM METH users are warranted.
The METH+/HIV+ group not only had a greater likelihood of unprotected sex but also reported more than twice the number of partners in the previous year than the other groups. Previous studies (Halkitis et al., 2005c
; Semple et al., 2006c
) have attributed greater number of partners to METH use, which is known to increase sexual arousal and thus sexual partner seeking. However, in this study, although participants in both METH+ groups reported much higher rates of sex while intoxicated than did the METH- groups, only the METH+/HIV+ group reported a significantly greater number of partners than the METH− groups. In fact, the METH−/HIV+ group reported a higher, albeit not significant, number of partners than the METH+/HIV− group.
In addition to unprotected sex and number of partners, injection drug use and sexual encounters with IDUs can increase risk for reinfection and transmission of HIV and other STIs. In this study, the METH+/HIV+ group, and to a lesser extent the METH+/HIV− group, reported greater number of IDU partners in the past year than the METH− groups. Although this finding is not surprising given the likely close proximity of IDU behavior to METH use behavior, it supports a further need for prevention efforts among IDUs and their partners.
In terms of mood, specifically depressed mood, many studies have reported higher rates among METH+ (Peck et al., 2005
; Semple et al., 2005b
) and HIV+ (Dew et al., 1997
; Evans et al., 1999
) individuals. In this study, levels of depression based on established criteria for the BDI (American Psychiatric Association. Task Force for the Handbook of Psychiatric Measures & Rush, 2000
), across all groups fell within the range of mild symptomatology, except among the METH−/HIV− group, which was classified as minimal. Yet, we observed that participants in the METH+/HIV+ group reported depression scores that were greater than those in either of the single-risk groups. The METH+ only and HIV+ only groups had similarly elevated depression scores, suggesting an additive effect of the combined risk factors on mood disturbance.
In addition to depression, we also found that the METH+/HIV+ group reported significantly more confusion-bewilderment than the control group. Confusion-bewilderment may be indicative of cognitive difficulties as a result of METH dependence and/or the known central nervous system consequences of HIV-infection. This is supported by recent work (Rippeth et al., 2004
) with a similar sample of MSM concordant and discordant for METH and HIV that identified a monotonic relationship between number of risk factors and cognitive impairment as determined by detailed neuropsychological assessment.
A relationship between mood and sexual risk behavior, although inconsistent in the literature, was found in this study between all measured mood scales and condom use. After adjusting for METH or HIV-status, significant main effects of tension-activity, vigor-activity, fatigue-inertia and TMD were found for condom use within the context of both METH and HIV, whereas main effects of depression and confusion-bewilderment were only significant within the context of HIV. This supports the notion that a relationship does exist between mood and sexual risk behavior and that this relationship is potentially context dependent. However, results from the moderator analysis do not suggest a moderating effect of either METH or HIV on the relationship between mood and condom use. This finding is perhaps related to our relatively small sample and homogeneity on the mood scales in which detection of a moderating effect is weakened as a result of not having a full range of values for the independent variables (i.e. mood scales) (Bennett, 2000
; Aguinis, 2004
). Thus, larger and more heterogeneous samples are required to address the moderating effects of these contexts further.
There are several limitations that must be considered. First, the study is cross-sectional and thus temporal order of the relationships examined cannot be established. For example, it is possible that a subset of the METH using population who has a propensity for risk behaviors through some mechanism not measured in this study is the subset that ends up contracting HIV, and therefore their risky sex profiles obtained in this study reflect longstanding characteristics. Certainly, METH and HIV status were determined prior to the current mood assessment; thus, the temporal order of the variables is not completely unknown. Nevertheless, mood that was assessed, although prefaced in the “past 7 days”, may actually represent a longstanding mood state pre-dating the participants’ current METH and/or HIV status. Second, sample size for each of the four groups was relatively small and therefore the study may lack sufficient power to detect effects that otherwise are present, thus having a greater probability of Type II errors. In addition, the measure utilized to capture sexual behavior asked respondents to select an answer within a range of frequencies and thus the estimates of the frequencies of sexual behavior are imprecise and introduce statistical “noise.” Finally, we were unable to link condom use to specific sexual practices and/or to specific partner types. Thus, it is unknown to what extent unprotected sex within this study occurred within a specific sexual practice and with whom this sexual practice was performed. Therefore, these results are preliminary and require replication in prospective investigations.
In summary, the present findings suggest that mood and sexual behavior of non-monogamous MSM differ depending on the context in which they are examined. As hypothesized, participants in the METH+/HIV+ group reported significantly greater negative mood and sexual risk behavior when compared to controls. Further, this study suggests a complex relationship between negative mood and condom use in the context of HIV and METH. Although a consistent relationship between negative mood and condom use was found, of potentially greater importance is that METH and to a lesser extent HIV-status, potentially modifies these negative mood effects on condom use. Thus, our data support the development of new and refinement of existing sexual risk reduction interventions among non-monogamous MSM that incorporate multi-faceted approaches, including both substance abuse and mental health treatment.