THE USE OF VIAGRA (SILDENAFIL CITRATE), introduced in 1998 to treat erectile dysfunction, as a “recreational drug” by gay/bisexual men has raised concern about a variety of health risks, primarily, its association with sexual risk behavior, but also its potentially dangerous pharmacologic interactions when used with inhalant nitrites (a drug commonly used by gay/bisexual men during sexual activity) or with antiretrovirals.1,2 The popularity of Viagra use by men who have sex with men (MSM) may be the result of its capacity to allow multiple sexual partners within limited time periods (e.g., at sex clubs, at circuit parties, when on a crystal run) and to counter impotence secondary to use of methamphetamines, cocaine, or other “club drugs,” making it possible to engage in anal intercourse over the extended periods of time associated with stimulant drug-associated sexual activity.3
Studies of gay/bisexual circuit party attendees,4 public sexually transmitted disease (STD) clinic services users,5 HIV-seropositive MSM,6 a gym-based sample of London gay/bisexual men,7 and a sample of San Francisco MSM intercepted and interviewed through street outreach efforts8 have related Viagra use to increased likelihood of engaging in sexual risk behavior for HIV/STDs and/or being HIV-positive. Viagra was found to be obtained through sources other than medical health providers, associated with the use of other illicit drugs and used in conjunction with such substances. Even the most diverse sample among these studies, derived from Stop AIDS outreach workers conducting brief street-based interviews, is limited with respect to generalizability as a result of the selectivity of the sample population. Thus, we used a population-based sample of San Francisco MSM to examine the prevalence of Viagra use and its association with various patterns of behavior, including sexual risk.
Data were collected in San Francisco from May 2002 to January 2003 as part of the Urban Men’s Health Study 2002. We obtained a community-based household probability sample using random digit dial (RDD; N = 879). The sampling methodology has been described previously9,10; a more detailed report is available from the first author. Westat Corporation conducted the sample development and telephone interviews. The mail survey was carried out by the University of California San Francisco’s (UCSF’s) Health Survey Research Unit. MSM were defined broadly (sex of any kind with another male since age 14 or men who defined themselves as gay/bisexual if never sexually active)10,11 so as to include men who were more closeted. Participants were provided informed consent with procedures approved by UCSF’s and Westat’s Institutional Review Boards. Advance letters were sent to sampled households with obtainable addresses (49% of RDD sample). These letters provided a toll-free number to call if respondents had questions. On request, Westat provided a letter detailing information about the study accompanied by California’s Experimental Subject’s Bill of Rights and a one-page memo explaining the scope of the certificate of confidentiality. Each participant was interviewed by telephone and followed within a week by a mailed self-administered questionnaire. Viagra use was incorporated into a series of items on use of recreational drugs in the mailed questionnaire. All other data in this report were collected during the telephone interview. The telephone survey had a cooperation rate of 74% and the mail survey a return rate of 81%. Respondents received $25 for the telephone interview and another $25 for returning the completed mail questionnaire. All data are weighted to adjust for probability of selection differences. Statistical analyses were performed using the STATA SVYTAB and SVYMEAN procedures.
Recent Viagra use (within the past 6 months) was reported by 29.3% of the sample. Within this timeframe, 11.7% had only used it once or twice; 7.2% had used it three to six times, 3.6% had used it seven to 12 times, and 6.8% had used it more than 12 times. Use of Viagra was not associated with age, race, education, annual personal income, or with being in a primary relationship. It was, however, associated with HIV seropositivity, with 39.4% of HIV-positive MSM reporting recent use versus 26.9% of HIV-negative MSM and 5.4% of those whose HIV status was unknown (P = 0.0001). Similarly, MSM reporting having been checked for STDs within the prior 12 months were more likely to report Viagra use (38.8% vs. 23.1%, P <0.0001), and those men reporting having been diagnosed with an STD within the prior 12 months were also more likely to report recent Viagra use (52.2% vs. 27.6%, P = 0.0002).
Compared with nonusers, recent Viagra users had more male sexual partners within the prior 12 months (mean: 26.2 vs. 9.6, P = 0.005), had engaged in unprotected insertive anal intercourse with more partners (mean: 4.7 vs. 1.0, P <0.001), and had engaged in unprotected receptive anal intercourse with more partners (mean: 3.8 vs. 1.4, P = 0.056). Viagra use dramatically increases in prevalence among MSM with at least four partners (14.9% for 0–3 partners, 43.3% for 4+ partners, P <0.0001). Similarly, as shown in Table 1, elevated prevalence of Viagra use manifests among men who report having unprotected anal sex (both receptive and insertive) with two or more partners. Although Viagra use is associated with unprotected receptive anal sex by a nonpositive respondent with an HIV-positive partner, this is likely the result of its greater prevalence of use among seropositive gay/bisexual men.
We found Viagra use to be associated with attendance at venues that provide opportunities for multiple sexual partners within a limited period of time: circuit parties and sex clubs or bathhouses. The use of Viagra is also associated with the use of other recreational drugs, particularly stimulant drugs and “club drugs” (see Table 2).
Despite concerns having been raised over the past few years about the potential relationship among Viagra use, drug use, and sexual risk behavior, it does not appear to have altered trends that were evident in less representative samples 2 years before this study. The prevalence of use is comparable to that found in earlier public STD clinic and street intercept samples of MSM; our study also demonstrates the degree to which its use crosses all age, race, and socioeconomic status groups. However, these findings also suggest that its use is most highly concentrated within a sexual subculture of gay and bisexual men who use illicit substances to enhance sexual experiences or performance. Viagra use may have become a fixture for some as a sexual performance drug (rather than as a medically justified sexual aid) within this sexual culture comparable to the use of other illicit drugs. Other recreationally used drugs (e.g., crystal methamphetamine) may enhance sensation or disinhibition but negatively impact erectile capacity, leading to the use of Viagra to counter such side effects.3 The effects of sildenafil are thereby complicated by its use in conjunction with other substances. Viagra’s pharmacologic effects potentiate sexual activity with greater numbers of partners and/or for more prolonged time periods, which may be risk factors for HIV and other STDs. The lengthening window of pharmacologic efficacy of other PDE5 inhibitor impotence drugs (i.e., Levitra/vardenafil, and Cialis/tadalafil) raises serious concerns about the degree to which their use/abuse in specific sexual environments and the sexual risk behavior associated with them may prove to be even more problematic for the transmission of such infections.
To date, health education appears to have had limited efficacy in deterring unsupervised Viagra use. In-depth qualitative research may be necessary to identify potential avenues of altering this problematic behavior and devising more effective messages for this risky population. Managing this health problem will require a multifaceted approach, including, but not limited to 1) asking physicians to conduct more rigorous patient evaluations and serve as public health educators on the potential dangers in PDE5 inhibitor misuse; 2) ensuring that educational materials about Viagra are consistently offered by trusted providers of information on recreational drugs and HIV risk to MSM; and 3) pressuring the pharmaceutical industry to be more circumspect in its promotion of these medications and to include more extensive cautionary information in their packaging about the use and misuse of these substances. Some limitations in this study and interpretations of its findings should be noted. Despite the unique nature of this population-based sample, this is a sample of urban MSM residents and cannot be generalized to those living in small cities, suburbs, or rural areas. Furthermore, the methods used to generate this sample may have underrepresented MSM of color as well as younger MSM. Because survey items did not include screening for erectile dysfunction, it is unknown to what degree legitimate Viagra use has inflated the prevalence figures in this sample. However, the pattern of its use and association with multiple behavioral (vs. demographic) variables strongly suggests that for most participants, there was a nonprescription source for this medication. This survey did not ask about the contexts in which sildenafil was used, the concurrent use of other recreational drugs, and the sexual behaviors that took place within those contexts. As a result of this and the cross-sectional nature of the data, the study findings cannot provide causal interpretations for patterns of risk behavior.
1.Muirhead G, Wulff M, Fielding A, Kleinermans D, Buss N. Pharmacokinetic interactions between sildenafil and saquinavir/ritonavir. Br J Clin Pharmacol 2000; 50:99–107.
2.Merry C, Barry M, Ryan M. Interaction of sildenafil and indinavir when co-administered to HIV-positive patients. AIDS 1999; 13:F101–107.
3.Romanelli F, Smith K. Recreational use of sildenafil by HIV-positive and -negative homosexual/bisexual males. Ann Pharmacother 2004; 38:1024–1030. Available at: www.theannals.com
4.Colfax G, 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.
5.Kim A, Kent C, Klausner J. Increased risk of HIV and sexually transmitted disease transmission among gay or bisexual men who use Viagra, San Francisco 2000–2001. AIDS 2002; 16:142–158.
6.Purcell D, Wolitski R, Bailey C, et al. Viagra use and sexual risk among HIV-seropositive men who have sex with men. International Conference on AIDS; July 7–12, 2002; Barcelona, Spain; Abstract no. WePeE6536.
7.Sher L, Bolding G, Maguire M, Elford J. Viagra use and sexual risk behaviour among gay men in London. AIDS 2000; 14:2051–2053.
8.Chu P, McFarland W, Gibson S, et al. Viagra use in a community-recruited sample of men who have sex with men, San Francisco. J Acquir Immun Defic Syndr 2003; 33:191–193.
9.Binson D, Moskowitz J, Mills T, et al. Sampling men who have sex with men: strategies for a telephone survey in urban areas in the United States. Proc Section Surv Res Methods Am Stat Assoc 1996; 1:68–72.
10.Catania J, Osmond D, Stall R, et al. The continuing HIV epidemic among men who have sex with men. Am J Public Health 2001; 91:907–914.
11.Mills T, Stall R, Pollack L, et al. Health-related characteristics of men who have sex with men: A comparison of those living in ‘gay ghettos’ with those living elsewhere. Am J Public Health 2001; 91:980–983.