Factors associated with event-level stimulant use during sex in a sample of older, low-income men who have sex with men in Los Angeles
Introduction
Although recent CDC surveillance data show that HIV incidence is decreasing among some segments of the U.S. population such as women, children, and injection drug users, incidence is increasing among men who have sex with men (MSM) (Centers for Disease Control and Prevention, 2007). Among MSM, there is a strong and consistent correlation between reported use of stimulant drugs and HIV incidence (Plankey et al., 2007). MSM who report using stimulant drugs during sex are more likely to report high-risk behaviors that make them vulnerable to HIV, such as unprotected intercourse (UAI) (Colfax et al., 2004, Colfax et al., 2005, Drumright et al., 2006). Although studies demonstrating associations between stimulant use and UAI are abundant, less is known about the factors that influence specific sexual episodes or events that involve the use of stimulants during sex. Although some studies have examined the episode-specific relationship between drug use during sex and UAI (Colfax et al., 2004, Drumright et al., 2006), few have studied how event-level associations may apply to older, very low-income MSM, particularly those of minority racial/ethnic status. Although new HIV infections primarily are among younger MSM (Centers for Disease Control and Prevention, 2007), HIV prevalence rates are high among older MSM (Centers for Disease Control and Prevention, 2008) and among very poor MSM (Robertson et al., 2004). Identifying demographic, behavioral and contextual factors associated with event-level stimulant use during sex may assist development of HIV and drug treatment interventions specific to transmission risks among older, low-income MSM of diverse racial/ethnic backgrounds.
Demographic factors thought to be associated with stimulant use include race/ethnicity, age, HIV status, and socioeconomic status. Use of powder cocaine and club drugs such as methamphetamine tends to be associated with White individuals (Grov et al., 2006, Zule et al., 2007) and is less common among older, African American men (Halkitis and Palamar, 2008). In general, methamphetamine users tend to be White, HIV positive, and more likely to engage in high-risk sexual behaviors (Copeland and Sorensen, 2001) than users of other drugs. Many studies of methamphetamine and other club drugs focus on younger, higher educated MSM, limiting understanding of factors associated with use of these drugs in older, less educated lower-income MSM. Indigent, marginally housed MSM also have high HIV incidence rates and involvement with stimulant drugs, particularly crack cocaine (Robertson et al., 2004).
Though global and event-level indices describe associations between drugs, sex risks and HIV prevalence, very little information exists to describe the ways these factors may increase risk for HIV transmission in any specific sexual episode in older, very low-income men and men of minority racial and ethnic status. Crack cocaine and methamphetamine-using MSM report high numbers of sexual partners (Campsmith et al., 2000, Molitor et al., 1998) and episodes of exchanging sex for money or drugs (Molitor et al., 1998, Newman et al., 2004). Location of a sexual event, such as a sex club (Halkitis et al., 2001), as well as having sex with an HIV positive or unknown serostatus partner (Colfax et al., 2005), are related to methamphetamine use in particular. Finally, although few studies describe the relationship between type of partner, such as a main or casual partner, and stimulant use during sex among MSM, MSM who have regular boyfriends are more likely to have unprotected sex than MSM who describe themselves as single (Hays et al., 1997).
Measuring drug use and sexual behaviors at the event-level, during a single instance of a behavior, is thought to better represent individuals’ “typical” behaviors and to better assess associations between sex and contextual variables than aggregated data (Leigh and Stall, 1993). Although some studies have examined associations between event-level substance use and unprotected UAI (Colfax et al., 2004, Drumright et al., 2006, Schroder et al., 2007), few have examined event-level correlates of stimulant use during sex in a population of older, very low-income MSM of diverse racial and ethic backgrounds.
This article addresses the following questions: (1) Are there significant associations between demographic variables, such as race, age, HIV status, and homelessness, and the reported use of stimulant drugs while having sex with recent sexual partners; (2) Are there significant associations between behavioral and contextual variables (e.g., number of sexual partners, location of a sexual event, a partner's HIV status) and the use of stimulant drugs during sex with recent sexual partners; (3) Do these associations vary by type of stimulant. We hypothesized that event-level methamphetamine use during sex in this sample of low-income MSM would be associated with being White, younger, HIV positive, and with having an HIV positive partner, a high number of sex partners, having sex in a sex club or other public venue, having sex with male partners, and with having sex with a main or primary partner. We hypothesized that event-level crack use during sex would be associated with being older, Black, homeless, and with having a high number of sex partners.
Section snippets
Participants
Participants were MSM who participated in the Los Angeles site of the NIDA Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP). NIDA SATHCAP is an international, multi-site cooperative agreement between NIDA and the University of California, Los Angeles; University of Illinois, Chicago; Research Triangle Institute; Yale University and The Biomedical Center in St. Petersburg, Russia. The primary goal of the SATHCAP study was to examine the role of drugs in the
Sample characteristics
All 779 participants were men who reported sex with men only or with both men and women, of whom 312 (40%) reported having sex with both men and women in the 6 months preceding the study. Participants were 51% non-Hispanic Black, 24% Hispanic, 20% non-Hispanic White and 5% of another race (“Other”) (see Table 1). The mean age was 42 (range 18–68). More than one-half (63%) earned less than $500 in the past month or reported being homeless during the past year (55%). A total of 299 (38%) of the
Discussion
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
Role of funding source
Funding for the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP) was provided by NIDA Grant U01 17394. NIDA worked collaboratively with cooperative agreement investigators on developing and refining the study design. NIDA had no role in writing this report or in the decision to submit the paper for publication.
Contributors
S. Shoptaw and P. Gorbach designed and implemented the study protocol. A. Ober conceptualized the article, conducted the statistical analysis, and led the interpretation of results and the writing of the article. S. Shoptaw and P. Gorbach contributed to the interpretation of results and to the writing of the article. P. Wang assisted with data preparation and management. R.E. Weiss provided consultation on statistical analyses and contributed to writing the article. All authors contributed to
Conflict of interest
All authors declare that they have no conflicts of interest.
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