Gay men, methamphetamine and HIV: some issues explored at the Toronto conference

HIV-negative gay men who use the recreational drug methamphetamine are twice as likely as men who do not use the drug to become infected with HIV, according to research presented to the Sixteenth International AIDS Conference in Toronto last week. But the researchers also found that the use of poppers (amyl nitrate), which are legally available and common on gay scenes in industrialised countries, lead to a similar increase in the risk of becoming infected with HIV.

Methamphetamine use by gay men was also the subject of other, smaller studies presented to the conference, one of which found that gay men often use the drug to self-medicate for mental health problems. Another found that patterns of HIV serostatus disclosure whilst under the influence of methamphetamine influenced the types of risky sex gay men engaged in, and a further study found that methamphetamine users had problems adhering to their HIV medication, accessing HIV care, and that healthcare providers often did not assess the needs of methamphetamine users.

Previous research, mostly from the United States, has found a connection between the use of methamphetamine and risky sex amongst gay men. The drug can lower sexual inhibitions and increase sexual desire. As its use can lead to erectile dysfunction, it has been suggested that users are more likely to be receptive partners in anal sex, or use drugs to counter erectile dysfunction.

Investigators from the Multicenter AIDS Cohort Study (MACS) in the US wished to determine the effects of recreational drug use on HIV seroconversion. A total of 4,003 HIV-negative gay men were included in their analysis. At six-monthly intervals, the men were asked about their recreational drug use habits and their recent sexual behaviour.

Unsurprisingly, unprotected receptive anal sex was the primary sexual risk activity for HIV seroconversion. The investigators then included recreational drug use in their model. They found that men who used methamphetamine had an increased hazard ratio of 1.5 of becoming infected with HIV compared to men who did not use the drug. In addition, men who used poppers had a hazard ratio of HIV seroconversion of 2.5 compared to non-users. The use of erectile dysfunction drugs with methamphetamine and poppers led to a four-fold increase in the hazard ratio of becoming infected with HIV. No tests for statistical significance were provided by the investigators.

When the investigators included the number of recent sexual partners in their analysis, they found that the more partners users of methamphetamine and poppers had, the greater their hazard ratio of becoming HIV-positive. Users of the two drugs who had only one recent sexual partner had a hazard ratio of 3.2 of becoming HIV-positive compared to non-users of these drugs, but this increased to a hazard ratio of 15.8 for men who used the two drugs and had five or more sexual partners. Once again, no evidence regarding statistical significance was provided by the investigators.

A small study conducted in Vancouver that was also presented to the International AIDS Conference, found that gay men who used methamphetamine were often self-medicating for chronic mental health problems. In late 2005/early 2006, investigators interviewed 26 gay men who had previously had a problem with methamphetamine use. The men had a median age of 36, most (21) were white, twelve were HIV-positive and eleven had a university degree. The median duration of methamphetamine use was five years.

Mental health disorders were spontaneously mentioned by 19 of the men, with depression being the most common. Many of the men with mental health problems said that they had started to use methamphetamine, or increased their use of the drug, because of their mental health problems.

A separate study presented to the conference was also based on interviews with a small number of gay methamphetamine users. Although gay men still had risky sex under the influence of methamphetamine after disclosing their HIV status, it was not as risky as the sex that occurred between men who did not disclose.

Investigators from New York University interviewed 19 gay men who used methamphetamine about the disclosure of HIV infection status whilst under the influence of the drug. They found that if one partner disclosed his HIV status, the other was likely to do the same. Successful disclosure was most likely to occur if the men had made contact remotely prior to meeting, for example online. Men who disclosed, even if they were of a different HIV status, were less likely to exchange semen during risky sex whilst under the influence of methamphetamine than men who did not disclose.

The investigators also found that disclosure was often associated with one-on-one sexual encounters, whereas non-disclosure was often in the context of sex in public environments such as sex parties and unprotected sex with multiple partners. Men who did not disclose and then engaged in risky sex reported subsequent worry and psychological disturbance about their risk behaviour.

Finally, investigators at the University of Washington in the US interviewed 25 HIV-positive methamphetamine users about how they functioned day-to-day. Users often reported “survival sex” to obtain money or shelter because of their methamphetamine habit, and missing doses of HIV-medication. One study participant told the investigators “when I was tweakin’ my meds were the last thing on my mind…probably why I got resistance.” It also became clear from the interviews that methamphetamine use could become so problematic that it interfered with accessing HIV care. One patient reported: “I missed some appointments and my doc doesn’t like that.” However, another individual reported that, despite obviously looking like a methamphetamine user, nobody at the clinic had referred him to services to help him stop use of the drug.