While many studies have examined correlates of trading sex for money, few have examined factors associated with exclusive trading of sex for drugs. We identified sociodemographic, behavioral, and psychological correlates of trading sex for methamphetamine in a sample of HIV-negative heterosexual men and women who were enrolled in a sexual risk reduction intervention in San Diego, California. Of 342 participants, 26% overall (21% of males and 31% of females) reported trading sex for methamphetamine in the past two months. Multiple logistic regression analysis revealed that recently trading sex for methamphetamine was independently associated with being female, homeless, binging on methamphetamine, sexual victimization in the past two months, engaging in anal sex 24 or more times in the past two months, and higher sexual compulsivity scores. Effective interventions for this high-risk population should consider gender-focused counseling for sexual abuse, motivational enhancement therapy, social-cognitive skills training, as well as enhanced access and utilization of social services, including drug treatment.

Although rates of methamphetamine use continue to increase throughout the United States, little is known about the individuals who sell methamphetamine at the street level. This exploratory study examined the prevalence and correlates of drug-dealing behavior in a sample of 404 heterosexually-identified methamphetamine users who were participants in a sexual risk reduction intervention in San Diego, CA. Twenty-nine percent of participants (N = 116) reported “dealing” methamphetamine in the past two months. In a multivariate logistic regression, methamphetamine dealing was associated with being male (OR = 1.99; 95% CI 1.16 – 3.39), younger age (OR = 1.87 per year; 95% CI 1.10 – 3.17), more frequent use of methamphetamine (OR = 2.69; 95% CI 1.59 – 4.57), injecting methamphetamine (OR = 3.10; 95% CI 1.79 – 5.37), and higher hostility scores (OR = 1.07 per unit increase; 95% CI 1.01 – 1.13). These characteristics, particularly intensity of drug use and hostility, may be associated with greater resistance to drug treatment and lower success in treatment programs.

Background

Studies of implementation of efficacious human immunodeficiency virus (HIV) prevention interventions are rare, especially in resource-poor settings, but important, because they have the potential to increase the impact of interventions by improving uptake and sustainability. Few studies have focused on provider and organizational factors that may influence uptake and fidelity to core intervention components. Using a hybrid design, we will study the implementation of an efficacious intervention to reduce sexually transmitted infections (STIs) among female sex workers (FSWs) in 12 cities across Mexico. Our protocol will test a ‘train-the-trainer’ implementation model for transporting the Mujer Segura (Healthy Woman) intervention into community-based organizations (CBOs).

Methods

We have partnered with Mexican Foundation for Family Planning (Mexfam), a non-governmental organization that has CBOs throughout Mexico. At each CBO, trained ethnographers will survey CBO staff on characteristics of their organization and on their attitudes toward their CBO and toward the implementation of evidence-based interventions (EBIs). Then, after CBO staff recruit a sample of 80 eligible FSWs and deliver a standard-care, didactic intervention to 40 women randomly selected from that pool, a Mexfam staff person will be trained in the Mujer Segura intervention and will then train other counselors to deliver Mujer Segura to the 40 remaining participating FSWs. FSW participants will receive a baseline behavioral assessment and be tested for HIV and STIs (syphilis, gonorrhea, and chlamydia); they will be reassessed at six months post-intervention to measure for possible intervention effects. At the same time, both qualitative and quantitative data will be collected on the implementation process, including measures of counselors’ fidelity to the intervention model. After data collection at each CBO is complete, the relative efficacy of the Mujer Segura intervention will be analyzed, and across CBOs, correlations will be examined between individual and organizational provider characteristics and intervention efficacy.

Discussion

This cooperative, bi-national research study will provide critical insights into barriers and facilitating factors associated with implementing interventions in CBOs using the ‘train the trainer’ model. Our work builds on similar scale-up strategies that have been effective in the United States. This study has the potential to increase our knowledge of the generalizability of such strategies across health issues, national contexts, and organizational contexts.

Trial registration

NCT01465607

Drug assertiveness skills have been demonstrated effective in reducing substance use behaviors among patients with alcohol- or heroin-use disorders. This study examined the association between drug assertiveness and methamphetamine use, psychological factors, and sexual risk behaviors in a sample of 250 HIV-positive men who have sex with men (MSM) enrolled in a safer sex intervention in San Diego, CA. Less assertiveness in turning down drugs was associated with greater frequency and larger amounts of methamphetamine use, lower self-esteem, higher scores on a measure of sexual sensation-seeking, and greater attendance at risky sexual venues. These data suggest that drug assertiveness training should be incorporated into drug abuse treatment programs and other risk reduction interventions for methamphetamine users.

Substance use has been identified as a risk factor for elevated levels of obsessive–compulsive disorder (OCD). This study examined methamphetamine use and sexual risk behaviors as correlates of OCD in a sample of 245 HIV-positive men having sex with men (MSM) in San Diego, CA. In a logistic regression analysis, OCD was associated with greater frequency of methamphetamine use, more depressive symptoms, seeking out risky venues and risky sexual partners when “high” on methamphetamine, and reporting fewer sex acts in the past 2 months. These data suggest the need for increased awareness and understanding of the role that OCD may play in the drug use behaviors and risky sexual practices of methamphetamine users.

Studies show high rates of psychiatric symptoms among methamphetamine users; however, little information exists regarding methamphetamine use and anxiety. This study investigated psychosocial and behavioral correlates of anxiety symptoms in a sample of 245 HIV-positive men having sex with men (MSM) who were enrolled in a sexual risk reduction intervention. In a multiple regression analysis, anxiety symptoms were associated with homelessness, recent experience of HIV symptoms, injection drug use, lifetime sexual abuse, engaging in risky sexual behaviors, and seeking out partners at risky sexual venues when “high” on methamphetamine. These findings can be used to inform and refine sexual risk reduction interventions and substance use treatment programs for HIV-positive methamphetamine-using MSM.

Background

Previous research among drug-using men who have sex with men (MSM) indicates that trading sex for methamphetamine may be common.

Objectives

This study identified background characteristics, substance use variables, contextual factors, and sexual risk behaviors associated with trading sex for methamphetamine in a sample of HIV-positive MSM. Baseline data were gathered from 155 participants who were enrolled in a sexual risk-reduction intervention. Logistic regression was used to compare MSM who traded sex for methamphetamine with men who did not.

Results

Forty-three percent of the sample reported trading sex for methamphetamine in the past 2 months. Trading sex for methamphetamine was associated with being a binge user, homelessness, having an income of less than $20,000 per year, being less assertive at turning down drugs, engaging in more anal sex without a condom, and seeking out risky sex partners when high on methamphetamine.

Conclusions and Scientific Significance

These data suggest that the trading of sex for methamphetamine may be a primary source of new HIV infections within and outside of the MSM community, necessitating targeted interventions with this vulnerable subgroup.

Background

Although men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Mexico, data on current risk behaviors in this population are lacking. This study investigated the prevalence and correlates of unprotected anal intercourse (UAI) in a sample of 260 MSM in Tijuana, Mexico.

Methods

In June 2010, men attending a gay pride celebration were invited to complete a sexual risk survey. Men who reported UAI with a male partner in the past year were compared with men who reported only protected anal sex during the same period.

Results

Mean age of participants was 29.7; 54% had a high school diploma or less; and 43% were unemployed. In the past year, 55% had been tested for HIV, 21% reported using illicit drugs before or during sex, and 94% had sex only with men. Overall, 50% reported having UAI with another male in the past year. Factors independently associated with UAI in the past year were unemployment (AOR = 1.87), attending adult movie theaters (AOR = 2.21), using illicit drugs before or during sex (AOR = 2.43), and not having a recent HIV test (AOR = 1.85).

Conclusions

Interventions to promote HIV testing and condom use among men who have sex with men may want to consider venue-specific approaches, as well as focus on drug-use issues in the context of unsafe sex.

In 2008, 400 males ≥ 18 years old who paid or traded for sex with a female sex worker (FSW) in Tijuana, Mexico, in the past 4 months completed surveys and HIV/STI testing; 30 also completed qualitative interviews. To analyze environmental HIV vulnerability among male clients of FSWs in Tijuana, Mexico, we used mixed methods to investigate correlates of clients who met FSWs in nightlife venues and clients’ perspectives on venue-based risks. Logistic regression identified micro-level correlates of meeting FSWs in nightlife venues, which were triangulated with clients’ narratives regarding macro-level influences. In a multivariate model, offering increased pay for unprotected sex and binge drinking were micro-level factors that were independently associated with meeting FSWs in nightlife venues versus other places. In qualitative interviews, clients characterized nightlife venues as high risk due to the following macro-level features: social norms dictating heavy alcohol consumption; economic exploitation by establishment owners; and poor enforcement of sex work regulations in nightlife venues. Structural interventions in nightlife venues are needed to address venue-based risks.

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.

Male clients of female sex workers (FSWs) may act as a bridge to the general population contributing to the spread of HIV and other sexually transmitted infections in the United States and Mexico. This study used cross-sectional data to identify psychosexual and social cognitive factors associated with sexual risk behavior in a bi-national sample of 300 male clients of FSWs recruited in Tijuana, Mexico from June to October, 2008. In a multiple regression analysis, the number of unprotected vaginal sex acts with FSWs was associated with higher sexual compulsivity scores, lower self-efficacy for condom use, greater use of illicit drugs, and more financial need. Behavioral interventions are urgently needed to assist clients of FSWs in reducing high-risk behaviors in an effort to prevent the spread of HIV/STIs in this high-risk population and their sexual partners.

Background

Sex work is partially regulated in Tijuana, but little is known of its health effects. A recent behavioral intervention among female sex workers (FSWs) decreased incidence of HIV/STIs by 40%. We evaluated effects of sex worker regulation on condom use among FSWs randomized to this intervention.

Methods

FSWs aged ≥18 years who reported unprotected sex with ≥1 client in the last 2 months and whether they were registered with Tijuana’s Municipal Health Department underwent a brief, theory-based behavioral intervention to increase condom use. At baseline and 6 months, women underwent interviews and testing for HIV, syphilis, C. trachomatis and N. gonorrhoeae. Negative binomial regression was used to determine the effect of registration on numbers of unprotected sex acts and cumulative HIV/STI incidence.

Results

Of 187 women, 83 (44%) were registered. Lack of registration was associated with higher rates of unprotected sex (rate ratio: 1.7, 95% CI: 1.2–2.3), compared to FSWs who were registered, after controlling for potential confounders.

Conclusions

Registration predicted increased condom use among FSWs enrolled in a behavioral intervention. Public health programs designed to improve condom use among FSWs may benefit from understanding the impact of existing regulation systems on HIV risk behaviors.

Identifying psychosocial factors associated with sexual risk behavior among methamphetamine users is essential to enhancing HIV/STI prevention. Our 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/visitation issues. Categories of positive life events included: birth or pregnancy involving self or significant other; positive relationship event; and 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.

Background

Tijuana, situated adjacent to San Diego, CA on the US-Mexico border, is experiencing an emerging HIV epidemic, with prevalence among female sex workers (FSWs) having risen in recent years from <1% to 6%. Comparable data on FSWs’ clients are lacking. We explored correlates of unprotected sex with FSWs among male clients in Tijuana.

Methods

In 2008, males from San Diego (N=189) and Tijuana (N=211) aged 18 or older who had paid or traded for sex with a FSW in Tijuana during the past 4 months were recruited in Tijuana’s red light district. Participants underwent psychosocial interviews and were tested for HIV, syphilis (Treponema pallidum), gonorrhea (Neisseria gonorrhoeae), and Chlamydia (Chlamydia trachomatis).

Results

Of 394 men, median age was 36 years, 42.1% were married, and 39.3% were unemployed. Ethnic composition was 13.2% white, 79.4% Hispanic and 7.4% black or other. Half (50.3%) reported unprotected vaginal or anal sex with FSWs in Tijuana in the past 4 months. High proportions reported using drugs during sex (66%), and 36% reported frequenting the same FSW. Factors independently associated with unprotected sex with FSWs were using drugs during sex, visiting the same FSW, being married, and being unemployed.

Conclusions

FSWs’ clients represent an STI/HIV transmission “bridge” through unprotected sex with FSWs, wives and other partners. Tailored interventions to promote consistent condom use are needed for clients, especially within the context of drug use and ongoing relations with particular FSWs.

Methamphetamine (MA) use has been found to be associated with increased risk of HIV and sexually transmitted infections (STI) among men having sex with men, but it is unknown whether those who inject MA are at greater risk for these infections than those who administer MA by other routes. Furthermore, comparable data from heterosexual MA users are lacking. We investigated whether the HIV and STI risks of male and female heterosexual MA users who inject MA differ from those of comparable users who do not inject. Between 2001 and 2005, we interviewed 452 HIV-negative men and women aged 18 and older who had recently used MA and engaged in unprotected sex. Their mean age was 36.6 years; 68% were male; ethnicity was 49.4% Caucasian, 26.8% African-American, and 12.8% Hispanic. Logistic regression identified factors associated with injecting MA. Compared to non-IDU, IDU were more likely to: be Caucasian; be homeless; have used MA for a longer period and used more grams of MA in the last 30 days; have a history of felony conviction; and report a recent STI. HIV and STI prevention interventions should be tailored according to MA users’ method of administration.

This study describes factors associated with methamphetamine initiation in a racially diverse sample of 340 methamphetamine-using, HIV-positive gay and bisexual men. A factor analysis was conducted on reasons for initiation, and four factors were identified: to party, to cope, for energy, and to improve self-esteem. Methamphetamine to party accounted for more than one-third of the variance in the factor analysis. Methamphetamine to cope captured almost 9% of the variance, methamphetamine for energy accounted for approximately 8% of the variance, and methamphetamine for self esteem accounted for approximately 7% of the variance. Regression analyses revealed differential associations between methamphetamine initiation factors and HIV risk behaviors. Methamphetamine for self esteem predicted binge methamphetamine use, while methamphetamine to cope was associated with injecting methamphetamine. Using methamphetamine for energy was associated with number of illicit drugs used and using methamphetamine to party was associated with having a greater number of STIs. These findings suggest that methamphetamine initiation among gay and bisexual men is multifaceted, which could have implications for intervention development.

This study examined the association between sexual risk behavior and co-administration of methamphetamine with other drugs in a sample of 341 HIV-positive MSM. Those who reported methamphetamine co-administration in the past two months (65%) reported significantly more unprotected anal and oral sex and a greater number of casual, anonymous, and paid sex partners in this timeframe compared to men who used methamphetamine alone. Two primary patterns of co-administration were identified: 1) drug combinations motivated by sexual performance and enhancement (e.g., methamphetamine, poppers, sildenafil) and 2) “party drug” combinations (e.g., methamphetamine, GHB, ketamine). Implications for further research and possible applications to risk-reduction interventions are discussed.

This study examined demographic characteristics, sexual risk behaviors, sexual beliefs, and substance use patterns in HIV-positive, methamphetamine-using men who have sex with both men and women (MSMW) (n = 50) as compared to men who have sex with men only (MSM) (n = 150). Separate logistic regressions were conducted to predict group membership. In the final model, of 12 variables, eight were independently associated with group membership. Factors independently associated with MSMW were acquiring HIV through injection drug use, being an injection drug user, using hallucinogens, using crack, being less likely to have sex at a bathhouse, being less likely to be the receptive partner when high on methamphetamine, having greater intentions to use condoms for oral sex, and having more negative attitudes about HIV disclosure. These results suggest that, among HIV-positive methamphetamine users, MSMW differ significantly from MSM in terms of their HIV risk behaviors. Studies of gay men and HIV often also include bisexual men, grouping them all together as MSM, which may obscure important differences between MSMW and MSM. It is important that future studies consider MSM and MSMW separately in order to expand our knowledge about differential HIV prevention needs for both groups. This study showed that there were important differences in primary and secondary prevention needs of MSM and MSMW. These findings have implications for both primary and secondary HIV prevention among these high-risk populations.

This study identified sociodemographic factors, drug using practices, sexual behaviors, and motivational factors associated with binge (a period of uninterrupted) methamphetamine (MA) use among heterosexual MA users.

Sample and Method

The FASTLANE study provided cross-sectional data collected by audio-CASI between June 2001 and August 2004 from 451 HIV-negative MA users in San Diego, CA USA who had engaged in unprotected sex and used MA in the previous two months.

Results

The study sample was 67.8% male, 49.4% Caucasian, 26.8% African-American, and 12.8% Hispanic with a mean age of 36.6 years; 183 (40.5%) reported binge use in the past 2 months. Compared with non-binge users, binge users of MA were more likely to report risky drug use and sex behaviors and differed in motivations to initiate and currently use MA. The final logistic regression model for binge use included more days of MA use in the last month, ever treated for MA use, injection drug use, higher Beck Depression Inventory score, “experimentation” as a motivation for initiating MA use, and engaging in sex marathons while high on MA. HIV prevention efforts should differentiate and address these differences in motivations for MA use and the associated HIV-risk sex and drug use behaviors as key targets for effective intervention.

The present study examined the applicability of the Social Ecological Model for explaining condom use in a sample of female sex workers (FSWs) (N=435) participating in a behavioral intervention to increase condom use in Tijuana, Mexico. Using a multi-group path analysis, we compared women who work in bar settings (n=233) to those who worked on the street (n=202) with regard to an individual factor (self efficacy), an interpersonal factor (client financial incentives), and a structural factor (condom access). Competing models showed differential impacts of these factors in the two venue-based groups. Having access to condoms was associated with greater self-efficacy and less unprotected sex in women who worked in bars. Among street-based FSWs, having clients offer monetary incentives for unprotected sex was related to greater unprotected sex while having access to condoms was not. Understanding the contextual factors associated with condom use among subgroups of FSWs has important implications for the development of HIV prevention interventions.

Objectives

To determine sociodemographic and behavioral correlates of HIV infection among male clients of FSWs in Tijuana.

Methods

400 men aged 18 or older who had paid or traded for sex with a FSW in Tijuana during the past 4 months were recruited in Tijuana’s “zone of tolerance,” where prostitution is practiced openly under a municipal permit system. Efforts were made to balance the sample between residents of the U.S. (San Diego County) and of Mexico (Tijuana). Participants underwent interviews and testing for HIV, syphilis, gonorrhea, and Chlamydia. Logistic regression identified correlates of HIV infection.

Results

Mean age was 36.6. One quarter had injected drugs within the previous 4 months. Lifetime use of heroin, cocaine and methamphetamine was 36%, 50% and 64%, respectively. Men had frequented FSWs for an average of 11 years, visiting FSWs an average of 26 times last year. In the past four months, one half reported having unprotected sex with an FSW; 46% reported frequently being high when having sex with an FSW. Prevalence of HIV, syphilis, gonorrhea, and Chlamydia was 4%, 2%, 2.5% and 7.5%; 14.2% were positive for at least one infection. Factors independently associated with HIV infection were living in Mexico, ever using methamphetamine, living alone, and testing positive for syphilis.

Conclusions

Male clients of FSWs in Tijuana had a high sex and drug risk profile. While STI prevalence was lower than among FSWs, HIV prevalence was comparable, suggesting the need for interventions among clients to prevent spread of HIV and STIs.

Background

Despite increased awareness and attention towards methamphetamine (MA) use among men who have sex with men (MSM), few studies have examined behaviors and effects of MA use among heterosexual populations.

Objective

To learn whether behaviors and effects of MA use among heterosexuals differ according to gender.

Methods

We examined gender differences in sociodemographic characteristics, drug use practices, sexual behaviors, and consequences and motivations for methamphetamine (MA) use among 452 HIV-negative MA users (306 men, 146 women) who had engaged in unprotected sex and used MA in the previous two months.

Results

Females in the sample were younger and more likely to be married, to have been diagnosed with an STI in the last two months, and to report having been introduced to MA by a sexual partner. Women were also more likely to experience depressive symptoms and to report using MA “to lose weight.” Men were more likely to engage in sex marathons while high on MA and to use MA “to enhance sexual pleasure.”

Conclusion

These differences suggest the importance of crafting gender-specific intervention messages, and they may contribute to identifying individuals at risk for initiating MA use.

Scientific Significance

Our findings contribute to our knowledge of gender differences in behaviors and effects of MA use among heterosexuals. Future studies would benefit from collection of longitudinal data (to assess causal relationships) and use of a control group (to distinguish correlates of MA use from those of drug use in general).

A sexual marathon is defined as prolonged sexual activity over hours and even days. This exploratory study examined the phenomenon of sexual marathons in a sample of 341 HIV-positive methamphetamine-using men who have sex with men (MSM) in San Diego, CA. Eighty-four percent of the sample reported engaging in marathon sex while high on methamphetamine. MSM who engaged in sexual marathons and those who did not were compared in terms of background characteristics, methamphetamine use variables, alcohol and illicit drug use, sexual risk behaviors, and psychosocial factors. Men who engaged in marathon sex used significantly more illicit drugs, were more likely to use sildenafil (Viagra®) and amyl nitrates, and scored higher on a sexual compulsivity scale compared to men who did not engage in marathon sex. In multivariate analyses, use of sildenafil in the past two months was significantly correlated with participation in sexual marathons. Findings are discussed in terms of their implications for HIV/STI prevention and intervention.

Ethnic differences in measures of substance use, sexual risk behaviors, and psychosocial factors (depression, stigma, self-esteem) were examined in a sample of 402 heterosexual methamphetamine users (55.0% Caucasian, 29.9% African American, 15.1% Latino/a) who participated in a sexual risk reduction intervention between June 2001 and March 2005 in San Diego, California. Participants were primarily male (67%), non-college graduates (72%), and low income (66%). African Americans were older when they first used methamphetamine and had used fewer grams in the past 30 days; Caucasians were more likely to inject. A larger percentage of African Americans reported anonymous sex partners in the past two months. African Americans reported lower levels of social stigma, and Caucasians reported lower self-esteem. Limitations and potential applications of these findings to prevention and treatment programs for ethnic minority populations are discussed.

Substance use has been identified as a risk factor for elevated levels of obsessive–compulsive disorder (OCD). This study examined methamphetamine use and sexual risk behaviors as correlates of OCD in a sample of 245 HIV-positive men having sex with men (MSM) in San Diego, CA. In a logistic regression analysis, OCD was associated with greater frequency of methamphetamine use, more depressive symptoms, seeking out risky venues and risky sexual partners when “high” on methamphetamine, and reporting fewer sex acts in the past 2 months. These data suggest the need for increased awareness and understanding of the role that OCD may play in the drug use behaviors and risky sexual practices of methamphetamine users.