Gay and bisexual men and injection drug users (IDU) are the two groups in the United States at greatest risk of acquiring HIV infection . Together, gay and bisexual men and IDU account for 81% of AIDS cases and 66% of all HIV cases among men . If HIV-positive men who reported an unknown or unidentified risk of infection are not included in the calculations, gay and bisexual men and IDU account for 88% of all US HIV cases among men . Gay and bisexual men who are also IDU are the third largest group of men affected by AIDS (cumulatively 8% of the total number). Much of HIV/AIDS research has examined gay and bisexual men or IDU populations separately. Little is known about men who are gay or bisexual and who also inject drugs. Clearly, this population is at risk of HIV infection through sexual and injection transmission, and for HIV-positive gay and bisexual IDU, the risk of being a bridge for transmission to gay and bisexual men who do not inject drugs, as well as to women, is great .
Most of our knowledge about gay and bisexual IDU comes from studies of primarily heterosexual IDU that included gay and bisexual men [3–6]. Most of the studies were focused on HIV-negative IDU rather than HIV-positive IDU. In the studies, gay and bisexual IDU, more than heterosexual IDU, were likely to have higher seropositivity rates [3,4,6,7], to have more sex partners , and to use condoms less . According to two studies, gay and bisexual IDU were most likely to engage in unprotected anal sex and sex with casual partners [7,9]. Similar findings of risky sexual behaviors among HIV-positive IDU indicate the need for interventions to prevent HIV transmission in this population.
Gay and bisexual IDU may also be at risk of transmission through drug use, and the interplay between drugs and sex. The drugs of choice for gay and bisexual IDU are methamphetamine (crystal) or cocaine or both . Certain drugs, such as cocaine, are associated with the need for more frequent injections, which increases transmission risk . Moreover, gay and bisexual IDU are likely to use drugs that enhance sexual desire, such as methamphetamine. In turn, heterosexual IDU commonly use heroin , which tends to depress sexual desire and ability. This preference in drug use suggests that gay and bisexual IDU, compared with heterosexual IDU, are more likely to associate drug use with sexual behavior. Bull and colleagues  found that the concurrence of drugs and sex among gay and bisexual IDU creates a synergistic effect, which results in an increased risk of HIV infection, and for HIV-positive men an increased transmission risk.
Another synergistic effect could result from the interplay of drug use and psychological distress. Negative affect such as depression and anxiety may lead individuals to alleviate these moods through self-gratifying behavior such as unprotected sex or drug use . Depression, anxiety, and hostility have also been associated with higher levels of injection-related risk-taking among drug users . Researchers have also found that psychological distress is associated with increased sexual risk behavior . Moreover, in one study , gay and bisexual men reported higher rates of distress and depression than men from the general population. A better understanding of the psychosocial needs of gay and bisexual IDU is critical for future intervention efforts.
Unfortunately, limitations in the studies of gay and bisexual IDU affect the conclusions that can be drawn from the research. For example, studies have compared gay and bisexual IDU with heterosexual IDU [3,4], (see Crofts et al.  and Bull et al. , for exceptions) rather than comparing gay and bisexual IDU with other gay and bisexual men. Consequently, relatively little has been learned regarding whether gay and bisexual IDU engage in more risk behaviors than do other gay and bisexual men, see Stall and Ostrow  for exceptions. IDU are a hard-to-reach, marginalized, and stigmatized population, which has led researchers to use small convenience samples. No studies have assessed the behavioral profiles of HIV-positive gay and bisexual IDU to determine their risk of re-infection and transmission.
In the Seropositive Urban Men's Intervention Trial , an ethnically diverse sample of HIV-positive gay and bisexual men were interviewed in order to answer the following questions: (i) What are the sociodemographic, sexual risk, and psychological characteristics of HIV-positive gay and bisexual IDU compared with those of men who use non-injection drugs and men who do not use drugs?; and (ii) Do IDU, compared with men who use non-injection drugs, report more drug-use?
Participants and procedures
The data described here were collected as part of the Seropositive Urban Men's Intervention Trial, a randomized controlled intervention trial, funded by the Centers for Disease Control and Prevention, and conducted from 1999 to 2002 (for a more detailed description of the study methods see Wolitski et al. ). The data are from the baseline assessment in which data were collected through audio computer-assisted survey interviewing between March 2000 and June 2001. Active and passive strategies were used to recruit gay and bisexual men from mainstream gay venues, AIDS service organizations, and commercial sex environments. All study participants were at least 18 years old, HIV positive, reported having had sex with at least one partner who was HIV negative or of unknown status, and resided in New York City or San Francisco. A total of 1168 participants completed baseline assessments.
Participants were asked their age, race/ethnicity, level of education, employment status, income, and sexual orientation. Participants were also asked whether they had had a diagnosis of AIDS, identified themselves as barebackers, and had had sex with women during the past 90 days. Sociodemographic characteristics for the total sample are described in Table 1.
Sexual risk behaviors
Participants were asked whether they had engaged, during the past 90 days, in sex (protected or unprotected) with partners who were HIV negative or of unknown serostatus. The reports of unprotected anal and oral intercourse with casual partners who were HIV-negative or were of unknown status were of particular interest. The main independent variables were thus unprotected anal intercourse, unprotected insertive anal intercourse, unprotected receptive anal intercourse, and unprotected insertive oral intercourse. These variables were calculated separately for casual partners who were HIV negative and for casual partners of unknown serostatus. Assessments were made by the use of instruments that had been used in earlier investigations of the sexual behaviors of HIV-positive gay and bisexual men . Participants were also asked whether they had engaged, during the past 90 days, in specific sexual activities (e.g. public cruising) or attended sex-related events (e.g. sex club, bathhouse, barebacking party).
Participants were asked whether they had ever injected drugs. Those who answered yes were then asked whether they had used drugs during the past 90 days. Participants who reported injection drug use during the past 90 days were asked to answer yes or no to the use of specific drugs: cocaine, heroin (by itself), heroin and cocaine, and methamphetamine. Participants were also asked the number of times, during the past 90 days, that they had injected drugs before or during sex, borrowed used needles, and lent needles.
Participants were asked whether they had used non-injection recreational drugs during the past 90 days. Participants who answered yes were asked to answer yes or no to the use of the following drugs: amphetamines (speed), barbiturates or tranquilizers, cocaine, ecstasy [3–4 methylenedioxymethamphetamine (MDMA)], special K (ketamine), marijuana (pot), poppers (amyl nitrate), gamma hydroxybutyrate, and methamphetamine. Although the chemical structure of methamphetamine is similar to that of amphetamine, methamphetamine has more pronounced effects on the central nervous system, and is more commonly abused. Therefore, we asked the men to report amphetamine and methamphetamine use separately.
To measure psychological distress, we used the 18-item Brief Symptoms Inventory , which includes subscales that measure depression (α = 0.89), anxiety (α = 0.86), and hostility (α = 0.89). Responses were based on a five-point Likert scale ranging from ‘not at all’ to ‘extremely’. Loneliness was assessed by using a four-item version of the UCLA Loneliness Scale , which yielded an alpha of 0.60. Participants were also asked whether they had been sexually abused as children.
First we examined the prevalence of injection drug use and the types of drugs injected. Then we conducted bivariate analyses (chi-square tests) to help us understand differences in the demographics, sexual risk behaviors, and illicit drug use of men who had injected within the past year and those who had not. Then we conducted bivariate analyses to understand the differences in the demographics, sexual risk behaviors, and psychological distress of IDU, men who use non-injection drugs, and men who do not use drugs. Finally, bivariate analyses (chi-square tests and analysis of variance) were performed to elucidate the differences in the illicit drug use of IDU and men who use non-injection drugs.
Of the 1168 men, 236 (20%) reported having ever injected drugs. Of those 236 men, 75 (32%) had injected during the past 90 days, 30 (13%) had injected more than 90 days ago, but within the past year, and 131 men (55%) had last injected more than a year ago. Among men who had injected during the past 90 days, methamphetamines (n = 49; 65%) and amphetamines (speed) (n = 43; 57%) were most commonly used. Other injected drugs were cocaine (n = 12; 16%), heroin only (n = 11; 15%), and heroin and cocaine together (n = 8; 11%). Of the 236 men, 83% reported having injected drugs before or during sex, and 23% had borrowed needles during the past 90 days.
Men who last injected drugs more than a year ago may be different from men who are current or recent injectors. Therefore, preliminary analyses compared men who had injected within the past year and men who last injected more than a year ago. The differences, which were in sociodemographic characteristics, unprotected sex, and drug use, were minor. Therefore, all men who had ever injected drugs were grouped for later analyses.
Of the men who had never injected drugs (n = 922), 500 (54%) reported using non-injection drugs during the past 90 days, and 422 (46%) reported not using drugs. The main analyses compared IDU, non-IDU, and non-users.
Comparing injection drug users with non-injection drug users and non-users
IDU differed significantly from non-IDU in all characteristics except age, race/ethnicity, and identifying as barebackers (Table 1). IDU, compared with non-IDU, reported less education and less income, and fewer were employed. They also were more likely to identify themselves as bisexual and to have had an AIDS diagnosis. Except for education, these differences were also true between IDU and non-users. In addition to these differences, more of the IDU were white and identified as barebackers than the non-users.
Sexual risk behaviors
In terms of sexual risk behaviors, we wanted to know whether HIV-positive IDU, compared with other groups of HIV-positive men, were at greater risk of transmitting HIV. In general, IDU and non-IDU reported similar sexual risk behaviors, with one exception (Table 1). The prevalence of unprotected insertive oral intercourse was significantly lower among IDU. Most differences were between IDU and non-users: more IDU reported unprotected anal intercourse with HIV-negative casual partners and unprotected sexual behaviors with casual partners of unknown serostatus. In particular, more IDU reported unprotected anal intercourse, both insertive and receptive, when they did not know the partner's status. In sum, HIV-positive gay and bisexual IDU do not seem to engage in more sexual risk behaviors than do gay and bisexual men who use non-injection drugs, but they do engage in more unprotected sex than non-users, both with partners who are HIV negative and those of unknown serostatus. The groups did not differ significantly in other sexual activities, such as public cruising and attending sex clubs and barebacking parties.
We examined differences in mental health indicators between IDU and the two groups that did not inject drugs. We used one-way analysis of variance to determine the existence of group differences, and Scheffé post-hoc tests to examine which groups differed significantly from one another (Table 1). IDU, compared with the other two groups, reported more anxiety and hostility. On the scales for depression and loneliness, IDU scored higher than non-users, but their scores were similar to those of non-IDU. IDU also reported being sexually abused more often as children than were non-IDU and non-users.
Comparing injection drug users and non-injection drug users
We compared the non-injection drug use of IDU with the non-IDU. Of the IDU, 163 (69%) also reported the use of non-injection drugs during the past 90 days (Table 2). On the basis of chi-square tests, a significantly higher proportion of IDU, compared with non-IDU, reported the use of amphetamines, barbiturates or tranquilizers, gamma hydroxybutyrate and methamphetamines. More non-IDU used poppers than IDU.
Summary of findings
Our findings indicate that among HIV-positive gay and bisexual men more IDU engaged in unprotected sexual behaviors, used non-injection drugs, and experienced greater psychological distress. There are thus a number of public health challenges for this group: a high risk of drug use, a high risk of HIV transmission to male and female sexual partners, the need to alleviate psychological distress, the acquisition of other sexually transmitted diseases, and potential re-infection with HIV. Public health practitioners and community activists have been advocating for more focused prevention for HIV-positive individuals since the introduction of new HIV treatments in the mid to late 1990s [22–24], and community-based organizations may want to target gay and bisexual IDU specifically as part of their prevention efforts with HIV-positive individuals.
Gay and bisexual IDU reported the lowest socioeconomic status (based on less education, employment, and income) compared with other men in the sample. Low socioeconomic status may be related to more difficulties in accessing healthcare, diminished coping abilities, and a greater sense of marginalization among IDU who already feel the stigma of being gay or bisexual. More of the IDU reported having sex with women, and had had a diagnosis of AIDS. They may thus feel further marginalized from the mainstream gay community and may be more likely to transmit HIV to female partners.
Gay or bisexual IDU differed from other gay or bisexual men on several indicators of psychological distress. IDU were significantly more likely to report childhood sexual abuse, anxiety, and feelings of hostility. They were also more likely than non-users to report depression and loneliness. Negative affect may also make it difficult for individuals to practice self-regulatory behaviors such as practising safe sex . Despite earlier studies of sexual and injection risk behaviors among gay and bisexual men, little is known about the psychosocial needs of seropositive gay and bisexual IDU. It is difficult to determine whether IDU may be self-medicating their psychological distress through substance use, or whether their substance use leads to distress. These men's sense of marginalization and their high level of psychological distress indicate the role that public health can play by providing outreach services and increasing support networks to ameliorate some of these issues. Research on how HIV-positive IDU cope with such varied concerns and from whom they seek support would be helpful in developing interventions.
More IDU, compared with non-users, reported unprotected sexual behaviors with partners who were of unknown serostatus and HIV-negative partners. This finding suggests that any prevention intervention with HIV-positive gay and bisexual IDU must address sexual risk behaviors within the contexts in which they occur. Earlier studies suggested that sexual risk behaviors were more critical than injection risk for HIV transmission in this population . In at least one study , gay and bisexual IDU reported unprotected sex concurrent with drug use and a preference for having sex when high. Our findings are similar: HIV-positive gay and bisexual IDU reported increased unprotected sex and increased drug use, although follow-up research is needed to examine in more detail the interaction of these two behaviors. Concurrent drug-use and sexual behaviors may be common to HIV-positive gay and bisexual IDU in particular situations.
This study confirms earlier research  in that IDU named methamphetamines and speed/amphetamines as their most commonly injected drugs (commonly used by gay and bisexual men for sexual enhancement ). In contrast, heterosexual IDU tend to name heroin as their drug of choice . These preferences suggest that the world of injection drug use is not monolithic but that it comprises subcultures. The concurrence of drug use and sex seems strongly associated with the subculture of gay and bisexual IDU. Ethnographic studies may shed light on the interaction of specific types of drugs and sexual behaviors, as well as the types of sex partners with whom drugs are used. Comparisons of the recreational drug use of IDU and non-IDU reveal that IDU reported significantly more use of speed/amphetamine, barbiturates or tranquilizers, gamma hydroxybutyrate, and methamphetamine. Methamphetamine and speed/amphetamine were commonly used non-injection drugs. This finding raises the possibility that gay and bisexual men begin their use of amphetamines and methamphetamines in a non-injection form, but that it may lead some men to injection drug use. Conducting longitudinal research to track changes in amphetamine and methamphetamine use among gay and bisexual men may help to describe trends and patterns that may, in turn, point to helpful interventions.
The following are limitations of the study. First, we used a cross-sectional design and opportunistic sampling in only two cities. Consequently, causal inferences and generalizations to other gay and bisexual men in other cities cannot be made. Although we examined the interaction of drug use and unprotected sexual behaviors, this investigation was not designed to explain this interaction fully. Another limitation is that comparisons of drug use were limited to the past 90 days, and data on the frequency of drug use was not reported. Because of the small cell size, we could not determine whether the psychological distress experienced by gay and homosexual men IDU was clinically significant, but only that gay and bisexual IDU were comparatively higher on distress than other gay and bisexual men.
Our study contributes both to research and prevention efforts for HIV-positive gay and bisexual IDU populations. Gay and bisexual IDU have multiple risks: polysubstance use, mental health problems, childhood sexual abuse, unemployment, and sexual risk behaviors. Research has shown that patterns of multiple health problems exist among gay and bisexual men who are not IDU. A recent study proposed an additive, or syndemic, effect . That is, men who reported more health problems also reported more risk behaviors. Although we did not evaluate an additive effect, our findings imply that among gay and bisexual men, IDU may have a greater number of physical and mental problems. These problems may interact and may also be related to increased risk behaviors. Further research on gay and bisexual IDU is needed to attempt to replicate the findings of the present study, with a particular focus on the interaction or ‘syndemic’ effect of multiple risk factors. In addition, other issues not included in this study such as physical violence and the lack of housing must be examined to determine whether an additive effect exists between these problems and greater sexual risk.
HIV prevention programmes for HIV-positive gay and bisexual IDU may also be more effective if they address these men's multiple health concerns. For example, the polysubstance use among gay and bisexual IDU may make it difficult for these men to understand or give priority to HIV prevention messages. In one study of HIV-positive heterosexual IDU, more than 60% gave higher priority to other concerns (e.g. food, housing) than to HIV prevention . This finding implies that prevention efforts may be more effective with HIV-positive gay and bisexual IDU if prevention efforts help to remedy other health issues that concern these men. Other studies have suggested other approaches, such as a comprehensive, multicomponent HIV prevention programme or multiple programmes that collaborate to alleviate the complex variety of health problems . Substance abuse treatment programmes, for example, not only should promote the prevention of substance abuse, but should also integrate case management services that would refer individuals to the appropriate agencies for housing and food, counseling for mental health issues, and HIV prevention education services into their programmes.
This population may respond well to prevention case management, a client-centered activity that promotes the reduction of HIV risk behaviors by clients with multiple, complex problems. Prevention case management is a combination of HIV prevention counseling and traditional case management . Another potential intervention for HIV-positive gay and bisexual IDU is a peer-based intervention. Loneliness is often associated with social skills deficit. A group-based intervention that includes attention to social skills building, and allows individuals to interact with peers may address some of the loneliness reported by gay and bisexual IDU in this study. Peers may find it easier to reach and be accepted by IDU, to bring HIV prevention messages to them, and to assist them in establishing social support networks.
Gay and bisexual men and IDU are at greatest risk of acquiring HIV, yet there has been comparatively little research on gay and bisexual IDU. Being either gay or bisexual and an IDU implies double stigma. Therefore, the risk behaviors of gay or bisexual IDU might be expected to differ from those of other gay and bisexual men. Our sample was one of the largest to date of HIV-positive gay and bisexual IDU, an often neglected group in research, and our study provides a unique perspective on IDU by comparing them with other groups of HIV-positive gay and bisexual men. Our findings suggest that among HIV-positive gay and bisexual men, more IDU are comparatively marginalized (i.e. by low socioeconomic status, lack of education) and are likely to participate in sexual high-risk behaviors, to abuse substances, and to experience more psychological distress. The effectiveness of HIV prevention efforts for this population may be increased by ameliorating the various health concerns of the population in conjunction with an HIV prevention programme. In conclusion, this study is an initial step in illuminating the issues and needs of HIV-positive gay or bisexual IDU. The public health challenges that this group presents are formidable. Their high risk of transmitting HIV and acquiring other sexually transmitted diseases while under the influence of drugs makes highly effective interventions a high priority for prevention researchers and community organizations.
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