Homeless gay and bisexual (G/B) young men have multiple risk factors which increase their risk of contracting hepatitis B virus (HBV) and Human Immunodeficiency Virus (HIV). This study used baseline information from structured instruments to assess correlates of knowledge to HIV and HBV infection from a 267 young (18–39 year old) gay/bisexual (G/B) active methamphetamine, cocaine and crack-using homeless men enrolled in a longitudinal trial. The study is designed to reduce drug use and improve knowledge of hepatitis and HIV/AIDS in a community center in Hollywood California. Regression modeling revealed that previous hepatitis education delivered to G/B men was associated with higher levels of HIV/AIDS and hepatitis knowledge. Moreover, higher HIV/AIDS knowledge was associated with combining sex and drinking alcohol. Associations with hepatitis B knowledge was found among G/B men who were engaging in sex while under the influence of marijuana, who were receiving support from non-drug users, and who had been homeless in the last four months. While being informed about HIV/AIDS and hepatitis did not preclude risky sexual and drug use behavior, knowledge about the dangers of concurrent sex with substance use is important. As higher levels of knowledge of hepatitis was associated with more moderate drug use, early access to testing and teaching harm reduction strategies remains critical to reduce exposure and infection of HBV and HIV in this population.
Hepatitis B virus; HIV; Gay/bisexual homeless young men
Homeless gay and bisexual (G/B) men are at risk for reporting suicide attempts and have high risk of depressed mood, defined as elevated level of depressive symptoms. This study describes baseline socio-demographic, cognitive, psychosocial and health- and drug-related correlates of depressed mood in 267 stimulant-using homeless G/B young men who entered a study designed to reduce drug use. G/B men without social support were 11 times more likely to be experience depressed mood than their counterparts who had support while persons who reported severe body pain were almost 6 times more likely to report depressed mood than those without pain. Other factors that increased risk of depressed mood included being homeless in the last four months, injecting drugs, reporting poor or fair health status and high levels of internalized homophobia. This study is one of the first to draw a link between pain experienced and depressed mood in homeless young G/B men. Understanding the correlates of depressed mood among homeless G/B young men can help service providers design more targeted treatment plans and more appropriate referrals to ancillary care services.
Homeless; gay and bisexual; young men; depressed mood; stimulant-using
This study compared outcomes in methamphetamine use and sexual risk behaviors from a modified gay-specific, cognitive behavioral therapy (GCBT) combined with a low-cost contingency management (CM; [GCBT+CM]) intervention to prior findings from clinical trials of the original GCBT. Effect sizes for primary outcomes were compared using meta analysis. Comparisons of effect sizes at end of treatment showed the modified GCBT+CM produced significantly fewer consecutive weeks of methamphetamine abstinence (−0.44, CI: −0.79, −0.09) and fewer male sexual partners (−0.36, CI: −0.71, −0.02) than the first trial of GCBT, and more days of methamphetamine use (0.35, CI: 0.02, 0.68) than the second trial of GCBT. At 26-week follow-up, the modified GCBT+CM produced greater effects in reducing the number of male sexual partners (−0.54, CI: −0.89, −0.19; −0.51, CI: −0.84, −0.18). The original GCBT produced more and mostly short-term beneficial drug use outcomes, though sexual behavior changes consistently favored the modified GCBT+CM. On balance, most benefits are retained with the modified GCBT+CM intervention.
methamphetamine abuse treatment; gay and bisexual men; sexual risk behavior; cognitive behavioral therapy; contingency management
Homeless men who have sex with men (MSM) are a particularly vulnerable population with high rates of substance dependence, psychiatric disorders, and HIV prevalence. Most need strong incentives to engage with community-based prevention and treatment programs. Contingency Management (CM) was implemented in a community HIV prevention setting and targeted reduced substance use and increased health-promoting behaviors over a 24-week intervention period. Participants in the CM condition achieved greater reductions in stimulant and alcohol use (χ2 = 27.36, p<.01) and, in particular, methamphetamine use (χ2 = 21.78, p<.01), and greater increases in health-promoting behaviors (χ2 = 37.83, p<.01) during the intervention period than those in the control group. Reductions in substance use were maintained to 9- and 12-month follow-up evaluations. Findings indicate the utility of CM for this high-risk population and the feasibility of implementing the intervention in a community-based HIV prevention program.
contingency management; out-of-treatment; methamphetamine; homeless; men who have sex with men (MSM)
Men who have sex with men (MSM) who use methamphetamine experience high risks for HIV infection due to sexual transmission behaviors often engaged in when under the influence of methamphetamine. Methamphetamine-using MSM use various forms of information technology (IT) communication such as instant messaging, social networking sites, and websites to facilitate a sexual and/or drug “hook up.” Given the acceptability of IT communication in their daily lives, an IT intervention represents an appropriate strategy to reach and intervene with out-of-treatment, methamphetamine-using MSM. The aim of this study was to conduct formative work to develop a text messaging intervention to reduce methamphetamine use and high-risk sexual behaviors among out-of-treatment MSM, which involved conducting focus groups, community partners’ meetings, and a pre-test intervention. These activities culminated in the development of a two-week, text-messaging intervention that delivered real-time electronic correspondence based on the behavioral change theories of Social Support Theory, Health Belief Model, and Social Cognitive Theory. The focus groups, community meetings, and pre-test were used to identify the IT communication device, the text messages that best support risk reduction and healthier behavioral choices, and logo, flyer and website development. The input and feedback from the target population and community partners were critical to the successful development of a culturally appropriate intervention. The knowledge gleaned from the formative work of this study will be vitally helpful in designing future IT studies.
MSM; Methamphetamine; HIV; IT communication; Text messaging.
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; Gay and bisexual men; Street outreach; HIV
Among men who have sex with men (MSM) in Los Angeles County, methamphetamine use is associated with high rates of HIV prevalence and sexual risk behaviors. In four separate samples of MSM who differed in the range of their intensity of methamphetamine use, from levels of recreational use to chronic use to those for MSM seeking drug abuse treatment, the association between methamphetamine use and HIV infection increased as the intensity of use increased. The lowest HIV prevalence rate (23%) was observed among MSM contacted through street outreach who mentioned recent methamphetamine use, followed by MSM who used at least once a month for six months (42%), followed by MSM seeking intensive outpatient treatment (61%). The highest rate (86%) was observed among MSM seeking residential treatment for methamphetamine dependence. The interleaving nature of these epidemics calls for comprehensive strategies that address methamphetamine use and concomitant sexual behaviors that increase risk of HIV transmission in this group already at high risk. These and other data suggest that MSM who infrequently use methamphetamine may respond to lower intensity/lower cost prevention and early intervention programs while those who use the drug at dependence levels may benefit from high intensity treatment to achieve goals of reduced drug use and HIV-risk sexual behaviors.
Methamphetamine; HIV; MSM.
In response to increases in methamphatemine-associated sexually transmitted diseases, the San Francisco Department of Public Health implemented a contingency management (CM) field program called the Positive Reinforcement Opportunity Project (PROP).
Methamphetamine-using men who have sex with men (MSM) in San Francisco qualified for PROP following expressed interest in the program, provision of an observed urine sample that tested positive for methamphetamine metabolites and self-report of recent methamphetamine use. For 12 weeks, PROP participants provided observed urine samples on Mondays, Wednesdays and Fridays and received vouchers of increasing value for each consecutive sample that tested negative to metabolites of methamphetamine. Vouchers were exchanged for goods and services that promoted a healthy lifestyle. No cash was provided. Primary outcomes included acceptability (number of enrollments/time), impact (clinical response to treatment and cost-effectiveness as cost per patient treated).
Enrollment in PROP was brisk indicating its acceptability. During the first 10 months of operation, 143 men sought treatment and of these 77.6% were HIV-infected. Of those screened, 111 began CM treatment and averaged 15 (42%) methamphetamine-free urine samples out of a possible 36 samples during the 12-week treatment period; 60% completed 4 weeks of treatment; 48% 8 weeks and 30% 12 weeks. Across all participants, an average of $159 (SD = $165) in vouchers or 35.1% of the maximum possible ($453) was provided for these participants. The average cost per participant of the 143 treated was $800.
Clinical responses to CM in PROP were similar to CM delivered in drug treatment programs, supporting the adaptability and effectiveness of CM to non-traditional drug treatment settings. Costs were reasonable and less than or comparable to other methamphetamine outpatient treatment programs. Further expansion of programs like PROP could address the increasing need for acceptable, feasible and cost-effective methamphetamine treatment in this group with exceptionally high rates of HIV-infection.
Methamphetamine abusers often complain of feelings of depression that can complicate accurately diagnosing these individuals during treatments for methamphetamine abuse. This article presents an examination of temporal associations between documented methamphetamine use and reported ratings of depression among 162 gay and bisexual male methamphetamine abusers who participated in a 16-week randomized clinical trial of four behavioral therapies for methamphetamine abuse. Methamphetamine use was measured using thrice-weekly urine samples analyzed for drug metabolite. Self-reported depressive symptoms were collected weekly using the Beck Depression Inventory (BDI). At treatment entry, 73.2% of participants rated their depressive symptoms as mild or higher in severity (BDI≥10), with 28.5% reporting BDI scores in the moderate to severe range (BDI≥19). All participants reported significant decreases in depressive symptoms from baseline through the end of treatment, regardless of treatment condition, HIV status, or mood disorder diagnosis. A mixed regression model showed methamphetamine use for up to 5 days prior to the BDI score strongly predicted depressive symptoms (F1,968=18.6, P<.0001), while BDI scores had no significant association with subsequent methamphetamine use. Findings show that behavioral methamphetamine abuse treatment yields reductions in methamphetamine use and concomitant depressive symptom ratings that are sustained to 1 year after treatment entry.
Depression; methamphetamine; drug abuse treatment; gay men
Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamine-using MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fifty-three participants enrolled in the study; 35 participants (66%) initiated PEP after a high-risk exposure. The median time from exposure to medication administration was 37.8 h (range 12.5–68.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57–100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI +1–+3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.04–1.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.