Skip Navigation LinksHome > April 2007 - Volume 34 - Issue 4 > Interest in a Methamphetamine Intervention Among Men Who Hav...
Sexually Transmitted Diseases:
doi: 10.1097/01.olq.0000233643.66138.b9
Note

Interest in a Methamphetamine Intervention Among Men Who Have Sex With Men

Menza, Timothy W. BA*; Colfax, Grant MD†; Shoptaw, Stephen PhD‡; Fleming, Mark BA§; Guzman, Robert MPH†; Klausner, Jeffrey D. MD, MPH†; Gorbach, Pamina MHS, DrPH∥; Golden, Matthew R. MD, MPH¶

Free Access

IN 2003, MEN WHO HAVE SEX with men (MSM) accounted for 49% of all new HIV infections and 53% of new diagnoses of AIDS in the United States.1 Although the prevalence of high-risk sexual behavior and the incidence of HIV declined in the late 1980s and early 1990s,2,3 surveillance data reveal an ongoing resurgence in the spread of bacterial sexually transmitted diseases (STDs) and, possibly, HIV among MSM.4–22 Data on trends in methamphetamine use in MSM indicate that use of the drug increased concurrently with observed rates of STD,23 and recent random digit dial studies found that 17% of San Francisco MSM24 and 6% of sexually active Seattle MSM25 used methamphetamines in the preceding 12 months.

Numerous studies have associated methamphetamine use with incident HIV infection12,26–28 and a wide spectrum of HIV-related risk behaviors.29–39 Amphetamine use during sex independently enhances the likelihood that sex will involve unprotected anal intercourse with a partner of unknown or discordant HIV status40; and MSM engage in riskier sex during periods characterized by increased use of methamphetamine, poppers, or sniffed cocaine relative to periods during which use of these drugs is less frequent.41 Additionally, researchers have demonstrated that methamphetamine increases sexual behavior in rats.42–45 These findings indicate that methamphetamine use may increase sexual risk behaviors that facilitate HIV acquisition and transmission.

Trials of both cognitive behavioral therapy and contingency management suggest that these interventions may be effective in reducing methamphetamine use and high-risk sex in treatment-seeking MSM.46,47 (Contingency management is a therapeutic approach in which patients receive incentives or rewards for meeting specific behavioral goals.48) To date, interventions to decrease the use of methamphetamines have not been tested outside the context of drug treatment or integrated into the existing public health infrastructure.49 As part of a public health effort to develop an intervention to decrease methamphetamine use in high-risk MSM, we surveyed methamphetamine-using MSM seen at 2 public health STD clinics and evaluated their interest in a program to help them stop or reduce their methamphetamine use.

We approached men who reported having had sex (oral or anal) with one or more men in the past year and who reported methamphetamine use in the preceding 6 months seen in the Public Health–Seattle and King County STD Clinic or the San Francisco City Clinic for participation in the study. Study subjects attended the clinics for routine clinical evaluation or STD and HIV testing and were not seeking referrals to drug treatment programs. Assessment of methamphetamine use is part of routine clinical evaluations. Men were recruited between December 2003 and January 2005. We excluded men who were under 18 years of age, who did not speak English, and whom staff believed could not provide informed consent. Although the study population included men who reported sex exclusively with other men and men who reported sex with both men and women, for simplicity, we refer to the population as MSM. Institutional Review Boards at each participating institution approved the study. All participants provided written informed consent.

The survey was an anonymous, 27-item, self-administered, written questionnaire. It recorded demographic information and sex and methamphetamine use behaviors. Four items assessed motivation to reduce or stop methamphetamine use and used a 5-point Likert scale (not at all, slightly, moderately, considerably, extremely): 1) “How troubled or bothered have you been in the past 30 days by problems from your meth use?”; 2) “To what extent would you like to stop or cut back on how much you use meth?”; 3) “If there were a program available to help you decrease or stop your meth use, how likely would it be that you would go to it?”; and 4) “How much more likely would you be to go to such a program if you got $20 each time you attended?”

We identified predictors of extreme or considerable interest in attending a program to reduce or stop methamphetamine use. All recorded variables were examined in bivariate logistic regression models. Variables found to be significant (P <0.05) in these models were entered into a multiple logistic regression model. All data were analyzed using STATA 8.2 (Stata Corp., College Station, TX).

One hundred one men completed the survey in Seattle and 75 men completed the survey in San Francisco. Two men from Seattle were excluded from analysis; one had sex exclusively with women and the other had not used methamphetamines in the preceding 6 months. Table 1 summarizes the demographic characteristics, patterns of methamphetamine use, and sexual behavior of the 174 MSM included in the sample.

Table 1
Table 1
Image Tools

Twelve percent of men had previously been in treatment for methamphetamine use and 71% had attempted to stop using methamphetamines. Thirty-six percent were extremely or considerably troubled by their methamphetamine use in the preceding 30 days, 62% were extremely or considerably interested in stopping or reducing their methamphetamine use, and 52% were extremely or considerably interested in attending a methamphetamine intervention program. Sixty-eight percent of men surveyed reported being extremely or considerably more interested in an intervention program if a $20 incentive was offered each time they attended.

Compared with men who never used methamphetamine during unprotected anal intercourse, men who used methamphetamine often or always during unprotected sex were more likely to report being considerably or extremely interested in a program to reduce or stop methamphetamine use (Table 2). Men interested in such a program were more likely to have tried to stop using methamphetamine in the past. Compared with men who were not at all troubled by their methamphetamine use in the past 30 days, men who were considerably or extremely troubled were more likely to be considerably or extremely interested in a methamphetamine intervention program. Men who were considerably or extremely interested in cutting back or stopping their methamphetamine use were more likely to be considerably or extremely interested in attending an intervention program relative to men with less interest in cutting back or stopping use.

Table 2
Table 2
Image Tools

STD clinics serve large numbers of methamphetamine-using MSM at high risk for acquiring or transmitting HIV.24,50 We found that of 174 such men seen in one of 2 public health STD clinics, most had tried to stop using methamphetamines, very few had ever been in substance abuse treatment, almost two-thirds were interested in decreasing or stopping their use of methamphetamines, and half were interested in participating in a methamphetamine intervention program. Interest in such a program increased if it was presented as including a monetary incentive, a component of previously studied programs that appear to be effective.47,51–66 In this population, strong interest in attending an intervention program was predicted by frequent use of methamphetamine during unprotected anal intercourse, being troubled by methamphetamine use, having tried to stop using methamphetamines, and by greater interest in decreasing or stopping methamphetamine use.

Convenience sampling may limit the external validity of our findings. As a result, we cannot generalize our findings to all nontreatment-seeking, methamphetamine-using MSM seen in STD clinics, the group we might seek to enroll in a future intervention study. Nevertheless, many MSM in this population are interested in attending a methamphetamine intervention program. Moreover, recruitment of these men over a 1-year period with very limited resources demonstrates that such clinics can access methamphetamine-using MSM in substantial numbers; whether such men would actually participate in a program to help them decrease or stop their methamphetamine use remains to be proven. Additionally, there are no data to indicate the proportion of nontreatment-seeking MSM who enroll in such a program would complete the program.

Providing incentives to substance users for abstinence is controversial. Drug treatment programs that use contingency management do not use cash as reinforcement; instead, these programs use vouchers that may be exchanged for goods or services. Numerous studies have found that contingency management reduces substance use and its associated morbidity in a number of populations.47,51–66 The cost of voucher-based reinforcement programs, however, may limit their widespread use, and additional research on the efficacy and cost-effectiveness of contingency management programs is warranted.

Although trials suggest that contingency management and cognitive behavioral therapy may be effective in reducing methamphetamine use and high-risk sexual behavior, there is little experimental evidence for the effectiveness of interventions for methamphetamine use among nontreatment-seeking MSM; and, currently, no pharmacologic agents exist for the treatment of methamphetamine dependence. The National Institute on Drug Abuse has identified the link between drug abuse, specifically methamphetamine, and HIV infection as a research priority.67 Given the large number of high-risk methamphetamine-using MSM seen in STD clinics, the high level of interest in an intervention that incorporates monetary reward found in this study, and the success of voucher-based reinforcement strategies in numerous populations for an array of problem behaviors, we believe that public health contingency management programs administered to MSM at high risk for HIV and STD acquisition and transmission merit further evaluation.

Back to Top | Article Outline

References

1. HIV/AIDS Surveillance Report, 2003. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2004.

2. van Griensven GJ, de Vroome EM, Goudsmit J, Coutinho RA. Changes in sexual behaviour and the fall in incidence of HIV infection among homosexual men. BMJ 1989; 298:218–221.

3. Kingsley LA, Zhou SY, Bacellar H, et al. Temporal trends in human immunodeficiency virus type 1 seroconversion 1984–1989. A report from the Multicenter AIDS Cohort Study (MACS). Am J Epidemiol 1991; 134:331–339.

4. Centers for Disease Control and Prevention. Gonorrhea among men who have sex with men—Selected sexually transmitted diseases clinics, 1993–1996. JAMA 1997; 278:1228–1229.

5. Centers for Disease Control and Prevention. Increases in unsafe sex and rectal gonorrhea among men who have sex with men—San Francisco, California, 1994–1997. JAMA 1999; 281:696–697.

6. Outbreak of syphilis among men who have sex with men—Southern California, 2000. MMWR Morb Mortal Wkly Rep 2001; 50:117–120.

7. Chen SY, Gibson S, Katz MH, et al. Continuing increases in sexual risk behavior and sexually transmitted diseases among men who have sex with men: San Francisco, Calif, 1999–2001, USA. Am J Public Health 2002; 92:1387–1388.

8. Williams LA, Klausner JD, Whittington WL, Handsfield HH, Celum C, Holmes KK. Elimination and reintroduction of primary and secondary syphilis. Am J Public Health 1999; 89:1093–1097.

9. Macdonald N, Dougan S, McGarrigle CA, et al. Recent trends in diagnoses of HIV and other sexually transmitted infections in England and Wales among men who have sex with men. Sex Transm Infect 2004; 80:492–497.

10. Centers for Disease Control and Prevention. HIV incidence among young men who have sex with men—seven US cities, 1994–2000. JAMA 2001; 286:297–299.

11. Bluthenthal RN, Kral AH, Gee L, et al. Trends in HIV seroprevalence and risk among gay and bisexual men who inject drugs in San Francisco, 1988 to 2000. J Acquir Immun Defic Syndr 2001; 28:264–269.

12. Burcham JL, Tindall B, Marmor M, Cooper DA, Berry G, Penny R. Incidence and risk factors for human immunodeficiency virus seroconversion in a cohort of Sydney homosexual men. Med J Aust 1989; 150:634–639.

13. Catania JA, Osmond D, Stall RD, et al. The continuing HIV epidemic among men who have sex with men. Am J Public Health 2001; 91:907–914.

14. Dukers NH, Spaargaren J, Geskus RB, Beijnen J, Coutinho RA, Fennema HS. HIV incidence on the increase among homosexual men attending an Amsterdam sexually transmitted disease clinic: Using a novel approach for detecting recent infections. AIDS 2002; 16:F19–24.

15. Hogg RS, Weber AE, Chan K, et al. Increasing incidence of HIV infections among young gay and bisexual men in Vancouver. AIDS 2001; 15:1321–1322.

16. Katz MH, Schwarcz SK, Kellogg TA, et al. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco. Am J Public Health 2002; 92:388–394.

17. Koblin BA, Torian LV, Guilin V, Ren L, MacKellar DA, Valleroy LA. High prevalence of HIV infection among young men who have sex with men in New York City. AIDS 2000; 14:1793–1800.

18. Wolitski RJ, Valdiserri RO, Denning PH, Levine WC. Are we headed for a resurgence of the HIV epidemic among men who have sex with men? Am J Public Health 2001; 91:883–888.

19. Torian LV, Weisfuse IB, Makki HA, et al. Trends in HIV seroprevalence in men who have sex with men: New York City Department of Health sexually transmitted disease clinics, 1988–1993. AIDS 1996; 10:187–192.

20. Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and associated risks in young men who have sex with men. Young Men's Survey Study Group. JAMA 2000; 284:198–204.

21. van Griensven GJ, Hessol NA, Koblin BA, et al. Epidemiology of human immunodeficiency virus type 1 infection among homosexual men participating in hepatitis B vaccine trials in Amsterdam, New York City, and San Francisco, 1978–1990. Am J Epidemiol 1993; 137:909–915.

22. Calzavara L, Burchell AN, Major C, et al. Increases in HIV incidence among men who have sex with men undergoing repeat diagnostic HIV testing in Ontario, Canada. AIDS 2002; 16:1655–1661.

23. McNall M, Remafedi G. Relationship of amphetamine and other substance use to unprotected intercourse among young men who have sex with men. Arch Pediatr Adolesc Med 1999; 153:1130–1135.

24. HIV/AIDS Epidemiology Annual Report. San Francisco Department of Public Health, 2004.

25. Brewer D, Golden M, Handsfield H. Unsafe sexual behavior and correlates of risk in a probability sample of men who have sex with men in the era of highly active antiretroviral therapy. Sex Transm Dis 2006; 33(4):250–255.

26. Chesney MA, Barrett DC, Stall R. Histories of substance use and risk behavior: Precursors to HIV seroconversion in homosexual men. Am J Public Health 1998; 88:113–116.

27. Page-Shafer K, Veugelers PJ, Moss AR, Strathdee S, Kaldor JM, van Griensven GJ. Sexual risk behavior and risk factors for HIV-1 seroconversion in homosexual men participating in the Tricontinental Seroconverter Study, 1982–1994. Am J Epidemiol 1997; 146:531–542.

28. Buchacz K, McFarland W, Kellogg TA, et al. Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco. AIDS 2005; 19:1423–1424.

29. Hirshfield S, Remien RH, Walavalkar I, Chiasson MA. Crystal methamphetamine use predicts incident STD infection among men who have sex with men recruited online: A nested case–control study. J Med Internet Res 2004; 6:e41.

30. Hirshfield S, Remien RH, Humberstone M, Walavalkar I, Chiasson MA. Substance use and high-risk sex among men who have sex with men: A national online study in the USA. AIDS Care 2004; 16:1036–1047.

31. Mansergh G, Colfax GN, Marks G, Rader M, Guzman R, Buchbinder S. The Circuit Party Men's Health Survey: Findings and implications for gay and bisexual men. Am J Public Health 2001; 91:953–958.

32. Molitor F, Truax SR, Ruiz JD, Sun RK. Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users. West J Med 1998; 168:93–97.

33. Paul JP, Pollack L, Osmond D, Catania JA. Viagra (sildenafil) use in a population-based sample of US men who have sex with men. Sex Transm Dis 2005; 32:531–533.

34. Colfax GN, Mansergh G, Guzman R, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: A venue-based comparison. J Acquir Immun Defic Syndr 2001; 28:373–379.

35. Stone E, Heagerty P, Vittinghoff E, et al. Correlates of condom failure in a sexually active cohort of men who have sex with men. J Acquir Immun Defic Syndr Hum Retrovirol 1999; 20:495–501.

36. Rusch M, Lampinen TM, Schilder A, Hogg RS. Unprotected anal intercourse associated with recreational drug use among young men who have sex with men depends on partner type and intercourse role. Sex Transm Dis 2004; 31:492–498.

37. Romanelli F, Smith KM. Recreational use of sildenafil by HIV-positive and -negative homosexual/bisexual males. Ann Pharmacother 2004; 38:1024–1030.

38. Harris NV, Thiede H, McGough JP, Gordon D. Risk factors for HIV infection among injection drug users: Results of blinded surveys in drug treatment centers, King County, Washington 1988–1991. J Acquir Immun Defic Syndr 1993; 6:1275–1282.

39. Wong W, Chaw JK, Kent CK, Klausner JD. Risk factors for early syphilis among gay and bisexual men seen in an STD clinic: San Francisco, 2002–2003. Sex Transm Dis 2005; 32:458–463.

40. Colfax G, Vittinghoff E, Husnik MJ, et al. Substance use and sexual risk: A participant- and episode-level analysis among a cohort of men who have sex with men. Am J Epidemiol 2004; 159:1002–1012.

41. Colfax G, Coates TJ, Husnik MJ, et al. Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. J Urban Health 2005; 82(suppl 1):i62–70.

42. Robinson TE, Berridge KC. Addiction. Annu Rev Psychol 2003; 54:25–53.

43. Fiorino DF, Phillips AG. Facilitation of sexual behavior in male rats following d-amphetamine-induced behavioral sensitization. Psychopharmacology (Berl) 1999; 142:200–208.

44. Fiorino DF, Phillips AG. Facilitation of sexual behavior and enhanced dopamine efflux in the nucleus accumbens of male rats after D-amphetamine-induced behavioral sensitization. J Neurosci 1999; 19:456–463.

45. Bignami G. Pharmacologic influences on mating behavior in the male rat. Effects of d-amphetamine, LSD-25, strychnine, nicotine and various anticholinergic agents. Psychopharmacologia 1966; 10:44–58.

46. Rawson RA, Marinelli-Casey P, Anglin MD, et al. A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction 2004; 99:708–717.

47. Shoptaw S, Reback CJ, Peck JA, et al. Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men. Drug Alcohol Depend 2005; 78:125–134.

48. Higgins ST, Alessi SM, Dantona RL. Voucher-based incentives. A substance abuse treatment innovation. Addict Behav 2002; 27:887–910.

49. Carroll KM, Rounsaville BJ. Bridging the gap: A hybrid model to link efficacy and effectiveness research in substance abuse treatment. Psychiatr Serv 2003; 54:333–339.

50. Golden MR, Brewer DD, Kurth A, Holmes KK, Handsfield HH. Importance of sex partner HIV status in HIV risk assessment among men who have sex with men. J Acquir Immun Defic Syndr 2004; 36:734–742.

51. Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction 2006; 101:192–203.

52. Higgins ST, Delaney DD, Budney AJ, et al. A behavioral approach to achieving initial cocaine abstinence. Am J Psychiatry 1991; 148:1218–1224.

53. Higgins ST, Budney AJ, Bickel WK, Hughes JR, Foerg F, Badger G. Achieving cocaine abstinence with a behavioral approach. Am J Psychiatry 1993; 150:763–769.

54. Higgins ST, Budney AJ, Bickel WK. Applying behavioral concepts and principles to the treatment of cocaine dependence. Drug Alcohol Depend 1994; 34:87–97.

55. Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R, Badger GJ. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen Psychiatry 1994; 51:568–576.

56. Higgins ST, Sigmon SC, Wong CJ, et al. Community reinforcement therapy for cocaine-dependent outpatients. Arch Gen Psychiatry 2003; 60:1043–1052.

57. Higgins ST, Wong CJ, Badger GJ, Ogden DE, Dantona RL. Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consult Clin Psychol 2000; 68:64–72.

58. Bickel WK, Amass L, Higgins ST, Badger GJ, Esch RA. Effects of adding behavioral treatment to opioid detoxification with buprenorphine. J Consult Clin Psychol 1997; 65:803–810.

59. Dallery J, Silverman K, Chutuape MA, Bigelow GE, Stitzer ML. Voucher-based reinforcement of opiate plus cocaine abstinence in treatment-resistant methadone patients: Effects of reinforcer magnitude. Exp Clin Psychopharmacol 2001; 9:317–325.

60. Petry NM, Martin B, Cooney JL, Kranzler HR. Give them prizes, and they will come: Contingency management for treatment of alcohol dependence. J Consult Clin Psychol 2000; 68:250–257.

61. Budney AJ, Higgins ST, Radonovich KJ, Novy PL. Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. J Consult Clin Psychol 2000; 68:1051–1061.

62. Budney AJ, Higgins ST, Delaney DD, Kent L, Bickel WK. Contingent reinforcement of abstinence with individuals abusing cocaine and marijuana. J Appl Behav Anal 1991; 24:657–665.

63. Silverman K, Wong CJ, Higgins ST, et al. Increasing opiate abstinence through voucher-based reinforcement therapy. Drug Alcohol Depend 1996; 41:157–165.

64. Roll JM, Higgins ST, Badger GJ. An experimental comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar. J Appl Behav Anal 1996; 29:495–504; quiz 504–495.

65. Roll JM, Higgins ST. A within-subject comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar. Drug Alcohol Depend 2000; 58:103–109.

66. Donatelle RJ, Prows SL, Champeau D, Hudson D. Randomised controlled trial using social support and financial incentives for high risk pregnant smokers: Significant other supporter (SOS) program. Tob Control 2000; 9(suppl 3):III67–69.

67. National Institutes of Health. Program announcement: Non-injection drug abuse and HIV/AIDS (PAS-06-054). Available at: http://grants.nih.gov/grants/guide/pa-files/PAS-06-054.html. Accessed March 25, 2006.

© Copyright 2007 American Sexually Transmitted Diseases Association

Login