Drug and Alcohol Dependence 76 (2004) 203–212
A comparison of injection and non-injection methamphetamine-using HIV positive men who have sex with men Shirley J. Semple a , Thomas L. Patterson a,b,∗ , Igor Grant a,b b
a Department of Psychiatry (0680), School of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0680, USA Department of Psychiatry, Department of Veterans Affairs Medical Center, San Diego, 116A, 3350 La Jolla Village Drive, San Diego, CA 92161, USA
Received 14 September 2003; received in revised form 14 May 2004; accepted 14 May 2004
Abstract There is a paucity of research on the psychosocial and behavioral characteristics of individuals who inject methamphetamine (meth). The present study compared injection and non-injection users of meth in terms of background characteristics, drug use patterns, health and social problems, sexual risk behavior, and psychosocial factors. The sample consisted of 194 HIV+ Men who have Sex with Men (MSM) who were enrolled in a sexual risk reduction intervention for meth users. Men who injected meth were significantly more likely to be Caucasian, bisexual, homeless, divorced/separated, with lower educational attainment as compared to non-injectors. Injectors also reported more years of meth use, greater frequency and amount of meth use, more social and health problems, including higher prevalence of STDs and Hepatitis C, and more sexual risk behaviors. In terms of psychosocial factors, injection users of meth scored significantly higher on measures of impulsivity and experiences of rejection, and lower on a measure of emotional support. A multivariate logistic regression revealed that educational attainment and experiences of rejection were the factors that best discriminated between injection and non-injection users of meth. The unique characteristics of injection meth users are discussed in relation to the development of effective HIV prevention programs for the target population. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Methamphetamine; HIV-positive; Men who have sex with men; Injection; Psychosocial; Behavioral
1. Introduction In the year 2000, San Diego County recorded 140 meth-related deaths, and 747 emergency department “mentions” (San Diego Association of Governments, 2001). The primary mode of meth use in San Diego County is smoking; however, the percentage of users who inject has increased steadily over the past decade. It is estimated that 20% of meth users in San Diego County prefer to inject (National Institute of Justice, 1999). Rates of injection meth use elsewhere in California are also cause for concern. In a study of 1392 out-of-treatment injection drug users in three California counties, 84% of those who had a history of meth use reported injecting meth in the past 30 days (Molitor et al., 1999).
∗
Corresponding author. Tel.: +1 858 534 3354; fax: +1 858 534 7723. E-mail addresses:
[email protected] (S.J. Semple),
[email protected] (T.L. Patterson),
[email protected] (I. Grant).
Understanding the unique characteristics and behaviors of injection drug users is important to HIV prevention efforts because HIV seropositivity is associated with injection drug use and high risk sexual behaviors. As of 31 December 2001, injection drug use accounted for 25% of the cumulative total of AIDS cases (N = 201,326), and 31,557 cases were attributable to sexual contact with an intravenous drug user (CDC, 2002). In recent years, substance abuse researchers have argued that treatment effectiveness is enhanced if the specific type of drug and characteristics of the user population are taken into consideration. For example, Bull et al. (2002) found that the sexual and drug risk behaviors of IDUs differed among heroin, cocaine, and meth users, and the drug of choice among injectors depended upon characteristics of the user population (e.g., MSM preferred cocaine and meth over heroin). To date, few studies have sought to understand the sexual and drug risk behaviors of individuals who inject meth. One study that compared meth injectors with non-meth users
0376-8716/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2004.05.003
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revealed that injectors had more sex partners, more insertive anal sex with casual partners, more vaginal sex with regular and casual partners, and more trading of sex for money or drugs (Molitor et al., 1999). Matsumoto et al. (2002) compared injectors, smokers, and a group of individuals who had transitioned from smoking to injection. Injection users as compared to the other two groups were significantly more likely to have a diagnosis of meth dependence, a longer duration of meth use, low educational attainment, a family history of alcoholism, and parental absence. Domier et al. (2000) reported that meth injectors were significantly more likely to be unemployed, engaged in heavy use of meth for a longer period of time, had a history of psychological problems, reported more sexual dysfunction, and had more felony convictions as compared to non-injectors. Taken together, these studies indicate that injection users of meth differ from non-injectors in a variety of domains. These differences need to be explored further since they are likely to have important implications for the development of treatment programs for IDU meth users. We utilized existing literature on IDU meth users, and the broader literature pertaining to psychosocial factors and HIV risk among IDUs to guide our selection of psychosocial variables for these analyses. General studies of male IDUs have reported associations between HIV risk behaviors and depression (Mandell et al., 1999; Perdue et al., 2003), impulsivity or emotional control (Seal and Agostinelli, 1994), sensation-seeking (Schaefer et al., 1994), social support (Brook et al., 1998), and social stigma (Brown, 1993). Another body of literature has sought to identify factors associated with the transition from non-injection to injection drug use. Studies of heroin and cocaine users in the United States, Spain, and England have documented the role of various factors in the transition process. These factors include characteristics of the individual (e.g., gender, age), partner variables (e.g., having a partner who injects), drug use patterns (e.g., age at first use), network factors (e.g., peer pressure), and social factors (e.g., sex trading, violence victimization) (Bravo et al., 2003; Fuller et al., 2002; Griffiths et al., 1994; Neaigus et al., 2001; Van Ameijden et al., 1994). The primary objective of the present study was to compare injection users of meth with their non-injecting counterparts in terms of psychosocial and behavioral factors. This study builds upon existing literature by focusing on an understudied and difficult-to-reach population—HIV-positive, out-of-treatment, IDU, meth-using, MSM. This subgroup of men is “hidden” within both mainstream society and the gay community due to the high levels of stigma associated with their sexual orientation and injection drug use (Lloyd and O’Shea, 1994). In addition, this study focused on a sample of HIV+ MSM whose serostatus places them at risk for transmitting the virus to their sexual partners. Among injectors, the risk of HIV transmission to non-sexual partners can also occur as a result of their injection behaviors. The identification of unique psychosocial and behavioral characteristics of injection meth users should help to inform the
development of effective treatment programs for this target population.
2. Method 2.1. Sample selection These analyses used baseline data from a sample of 194 HIV+ MSM who were enrolled in the EDGE research project at the University of California, San Diego (UCSD). The EDGE is an 8-session, behavioral intervention designed to reduce the sexual risk practices of HIV+ MSM who are active meth users. Eligible participants were HIV+ male adults who self-identified as MSM, and reported having unprotected anal or oral sex with at least one HIV-negative or unknown serostatus male partner during the previous 2 months. To avoid the enrollment of one-time users of meth, eligible participants were also required to have used meth at least twice in the past 2 months. MSM who had HIV+ partners only, and those who reported consistent use of condoms with all HIV-negative and unknown serostatus partners during the previous 2 months were also excluded from study participation because of the intervention’s focus on the prevention of HIV transmission to uninfected individuals. Psychiatric exclusion criteria were minimal. Only individuals with active psychotic or suicidal symptoms were excluded because of the difficulties involved in the clinical management of this population. HIV+ MSM who had known of their seropositivity for less than 2 months were also excluded from study participation because of the likelihood that these men engaged in unprotected sex in the context of assuming themselves to be HIV-negative. 2.2. Recruitment Recruitment sources included gay organizations and groups, HIV-specialty health clinics, gay identified venues (e.g., bars), referrals from care providers, and referrals from enrolled participants. Primary recruitment methods involved street outreach, poster campaigns, and advertisements in the print media. Forty-nine percent of participants were recruited through the poster/media campaign, 25% were recruited through direct contact with outreach workers, 17% were agency-based referrals, and 8% were recruited through word-of-mouth. There were no differences between injectors and non-injectors in terms of recruitment source (2 = 5.9, d.f. = 3, P > .05). 2.3. Procedures The EDGE protocol involved a baseline assessment, five weekly 90-min, one-on-one counseling sessions, three 90-min booster sessions at monthly intervals, and three follow-up assessments at 4, 8, and 12 months post-counseling. The counseling sessions focused on five
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domains (i.e., context of meth use and unsafe sex, condom use, negotiation, HIV disclosure to sex partners, enhancement of social supports). The baseline assessment involved a 90-min interview that covered a range of topics (e.g., patterns of meth use, sexual risk practices, disclosure behaviors). Participants were paid a total of $30 for completing their baseline assessment and first counseling session. 2.4. Measures 2.4.1. Background characteristics Age was coded as a continuous variable. Ethnicity, education, marital status, sexual orientation, and living arrangement were coded as categorical variables: ethnicity (1 = Caucasian, 2 = African American, 3 = Hispanic, 4 = Other); education (1 = Some high school or less, 2 = High school or equivalent; 3 = Some College; 4 = College degree; 5 = Advanced degree); marital status (1 = Married, 2 = Separated/divorced, 3 = Widowed, 4 = Never married); sexual orientation (1 = gay/homosexual, 2 = heterosexual, 3 = bisexual, 4 = not sure); and living arrangement (1= live with spouse, 2= living with steady partner, 3 = live with other adult(s), 4 = live alone, 5 = homeless, 6 = other). Employment status and income were represented by dummy-coded variables (0 = Not employed, 1 = Employed) and (0 = $19,999 or less/year, 1 = more than $19,999/year). 2.4.2. Health status Mean number of months HIV+ and mean number of CD4+ cells were coded as continuous variables. CDC stage was determined using the 1993 revised Centers for Disease Control and Prevention classification criteria (CDC, 1992). Psychiatric status was determined by self-reported psychiatric diagnoses, current use of psychiatric medications, and scores on the Beck Depression Inventory (Beck, 1967, 1976). 2.4.3. Substance use classification system The semi-structured assessment for the genetics of alcoholism (SSAGA) was used to classify the severity of participants’ use of substances. The SSAGA covers a range of psychiatric diagnoses, including psychoactive substance dependence and abuse. Reliability of the SSAGA has been found to be good for substance dependence diagnoses (Bucholz et al., 1994, 1995). In this study, the SSAGA-II Section G (DSM/ICD Drug Diagnosis) was used to determine dependence and abuse in relation meth use. 2.4.4. Meth use variables Intensity of meth use was measured using a summary variable that multiplied number of days used by number of times used per day (duration × frequency). Duration of meth use was measured by the following question: “During the past 30 days, on how many days did you do meth?” Frequency
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of meth use was measured by the following question: “On a typical day, how many times did you do meth?”. 2.4.5. Sexual risk behavior Sexual risk behavior was defined as unprotected anal, oral, or vaginal sex with HIV-negative, HIV+, or unknown serostatus partners. Three categories of partner type were assessed: steady (e.g., boyfriend); casual (e.g., one-night stand); and anonymous (e.g., someone in the park). For each category of partner type, participants were asked about their use of condoms or other barrier methods in relation to five types of sex acts: receptive anal sex (i.e., “your partner inserted his penis into your anus”); insertive anal sex (i.e., “you inserted your penis into the anus of your partner”); receptive oral sex (i.e., “your partner licked or sucked your genitals”); insertive oral sex (i.e., “you licked or sucked your partner’s genitals”); and insertive vaginal sex (i.e., “you inserted your penis into the vagina of your partner”). Three summary variables were created to represent total number of unprotected anal, oral, and vaginal sex acts during the past 2 months. 2.4.6. Social problems Participants were presented with a list of common social problems associated with meth use (San Diego Association of Governments, 1997). Social problems included family problems, work problems, financial difficulties, violent behavior, legal problems, and the loss of important personal relationships. Participants were asked how often during the previous 2 months, their meth use had resulted in any of these problems. A dichotomously scored response category was used (1 = Yes, 0 = No). A summary variable was created to represent the total number of social problems experienced in the past 2 months. The reliability alpha for this scale in the present sample was 0.87. 2.4.7. Impulsivity Impulsivity assesses the tendency to act without thinking, and without regard for the negative consequences of such actions for self or others (Moeller et al., 2001). The 12-item self-report impulsivity scale developed by Dickman (1990) was utilized in these analyses (Sample item: “I often make up my mind without taking the time to consider the situation from all angles”). Participants responded to each item using true or false categories. The alpha for this scale using the present sample was 0.87. 2.4.8. Sensation seeking The Zuckerman Sensation Seeking Inventory (1971) was used to assess two dimensions of sensation seeking: risktaking tendency, and disinhibition. The risktaking subscale is comprised of 10 items. This dimension captures the desire to seek new experiences by choosing non-conventional friends, activities, and lifestyles. Two choices are presented for each item, and the respondent is instructed to circle the choice that best describes his/her likes or feelings. Sample items include “I often wish I could be a mountain climber” versus
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“I can’t understand people who risk their necks climbing mountains.” The disinhibition subscale is comprised of 10 items, which purport to measure the need to disinhibit behavior in a social context through such activities as partying, and varied sexual experiences. Sample items include “I like wild uninhibited parties” versus “I prefer quiet parties with good conversation.” Cronbach alpha’s for the present sample were: risktaking (α = 0.78) and disinhibition (α = 0.68). 2.4.9. Stigma scales Three dimensions of stigma were assessed in this study: (1) culturally induced expectations of rejection; (2) experiences of rejection; and (3) stigma coping strategies (Link et al., 1997). Expectations of rejection captures anticipated and expected discrimination that can occur without having been mistreatment by others. This dimension was measured by eight items that asked participants about their beliefs regarding the way others think about meth users and their expectations for how others treat meth users (e.g., “Most people hold negative stereotypes about people who use meth”). Experiences of rejection was measured by six items. Participants were asked to report on actual experiences of rejection, ranging from minor slights to major life events, such as the loss of friends and family members (e.g., “I have lost friends because they found out about my meth use”). Stigma coping strategies are actions that individuals take in order to minimize the real or perceived effects of stigma (Goffman, 1963). This dimension of stigma was measured by nine items (e.g., “I try to hide all signs of my meth use to avoid negative reactions from others”). All items were measured on a 4-point scale (1 = Strongly Disagree; 2 = Disagree; 3 = Agree; 4 = Strongly Agree). A mean score was calculated for each stigma scale. Alpha coefficients of reliability for each scale were: culturally induced expectations of rejection (α = 0.83); experiences of rejection (α = 0.87); and stigma coping strategies (α = 0.76). 2.4.10. Emotional support Emotional support was measured using the inventory developed by Schaefer et al. (1981). Participants were provided with a list of 16 network members (i.e., mate, three closest friends), and asked to rate each person on four items that assess reliability, trustworthiness, caring, and confidant qualities. Each item was rated on a 5-point scale ranging from 1 (not at all) to 5 (extremely). Satisfaction with emotional support was averaged across all network members to obtain a summary score. The alpha for social support in this study was 0.94.
3. Results 3.1. Sample description The majority of men in this sample were Caucasian (58.1%), never married (83.3%), unemployed (71.7%),
living alone or with other adults in a non-sexual relationship (34.8 and 31.3%, respectively), with modest levels of educational attainment (78.8% had some college or less). Participants ranged in age from 20 to 61, with a mean of 35.9 years (S.D. = 7.0). All participants self-identified as Men Who Have Sex with Men (MSM), and reported at least one incident of unprotected anal, oral, or vaginal sex during the previous 2 months. Participants also reported using meth at least twice during the previous 30 days. Ninety-five percent of the sample met diagnostic criteria for meth dependence. The majority of men self-identified as either homosexual or bisexual (77.3 and 20.2%, respectively). One participant indicated that he was heterosexual and three were unsure as to their sexual orientation. A comparison of the background characteristics of men who injected meth during the past 2 months with men who did not inject meth during this time period yielded a number of differences. Men who injected meth were significantly more likely to be Caucasian, bisexual, homeless, divorced/separated, and to have less than a high school education as compared to their non-injecting counterparts. The two groups did not differ in terms of age, employment status, income, or substance use classification. Table 1 displays sample characteristics by injection status. 3.2. Physical health status Twenty percent of the sample reported more than one possible route of viral exposure. Eighty-nine percent of participants indicated that unprotected sex was the most likely route of exposure. Twenty-four percent identified intravenous drug use as the most likely source of infection. As expected, injection meth users were significantly more likely to report intravenous drug use as the primary mode of HIV infection (45.1% versus 7.1%, χ2 = 38.3, P < .001), whereas non-injection users were more likely to report unprotected sex as the primary mode of HIV infection (94.6% versus 81.7%, χ2 = 8.2, P < .01). On average, participants were HIV+ for 6.7 years (S.D. = 5.4). The two groups did not differ significantly on this variable (7.6 versus 6.0 years, t = 2.1, P < .05). Participants CD4+ cell counts ranged from 0 to 1800 (M = 455.4, S.D. = 270.6). No significant differences in CD4+ cell count were found between injectors and non-injectors (472.2 versus 444.1, t = 0.64, P > .05). Approximately, 30% of the sample had an AIDS diagnosis (CDC-C). Other CDC classifications included: CDC-A (32%); CDC-B (19%), and Don’t Know (19%). Chi-square analyses revealed that injectors and non-injectors did not differ in terms of CDC classification. Injection and non-injection users did, however, differ in terms of two health variables. Injection users were significantly more likely to have a diagnosis of Hepatitis C as compared to non-injection users. Injection users were also more likely to have had a sexually transmitted disease in the past 2 months (see Table 1).
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Table 1 Characteristics of injection meth users and non-injection meth users (N = 194) Variable
Non-injection users (N = 112)
Test statistic
73.3% 1.2 24.4 1.2
91.1% 2.7 6.3 0.0
χ2 = 15.1
3
P < .01
Living arrangement Living with spouse Living with steady partner Living with other adult(s) Living alone Homeless Other
3.7% 12.2 25.6 35.4 18.3 4.9
5.4% 14.3 36.6 34.8 7.1 1.8
χ2 = 14.4
5
P < .05
Ethnicity Caucasian African American Hispanic Other
65.1% 15.1 7.0 12.8
52.7% 21.4 22.3 3.6
χ2 = 15.1
3
P < .01
Education Some high school or less High school or equivalent Some college College degree Advanced agree
22.0% 30.5 32.9 11.0 3.7
9.8% 19.6 43.8 17.0 9.8
χ2 = 12.0
4
P < .01
Annual income $ 19,999 or less $ 20,000 or more
81.7% 18.3
75.0% 25.0
χ2 = 1.2
1
P > .05
Sexual orientation Homosexual Heterosexual Bisexual Not sure
68.3% 0.0 30.5 1.2
84.8% .9 12.5 1.8
χ2 = 10.1
3
P < .05
0.0% 0.0 100.0
3.6% 4.8 9.6
χ2 = 5.4
2
P > .05
35.6 (7.2) (20–55) 31.3%
t = 0.92 χ2 = 1.1
192 1
P > .05 P > .05
Demographics Marital status Never married Married Divorced/separated Widowed
Substance use classification Not dependent Abuse Dependent Mean age in years (S.D.) (range) Percent employed
Injections users (N = 82)
36.5 (6.8) (21–61) 24.4%
d.f.
P-value
Physical health status Mode of contraction Sexual contact Drug use Transfusion Don’t know
81.7% 45.1 3.7 4.9
94.6% 7.1 2.7 4.5
χ2 χ2 χ2 χ2
CDC classification A1–A3 B1–B3 C1–C3 Don’t know
24.2% 18.2 33.3 24.2
38.6% 21.7 25.3 14.5
χ2 = 5.3
12.5 29.5% 70.0 (59.5) (2.2–237.2) 444.1 (222.1) (0–1065)
χ2 = 21.9 χ2 =6.6 t = 1.9 t = 0.64
1 172 158
P P P P
13.9 (9.5) (0–44) 50.9% 33.0%
t = 0.82 χ2 = 0.05 χ2 = 0.56
174 1 1
P > .05 P > .05 P > .05
Have diagnosis of Hepatitis C Had sexually transmitted disease in past 2 months Mean number of months HIV+ (S.D.) (range) Mean number of CD4+ cells (S.D.) (range) Psychiatric health status Depressive symptoms Percent with a psychiatric diagnosis Currently taking psychiatric medications
42.0 47.6% 89.3 (69.7) (2.0–240.5) 472.2 (331.7) (0–1800) 15.1 (8.4) (0–38) 52.4% 28.0%
= 8.2 = 38.3 = 0.16 = 0.02
< .01 < .001 > .05 > .05
1 1 1 1
P P P P
3
P > .05
1
< .001 < .01 > .05 > .05
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3.3. Psychiatric health status Approximately 60% of the sample reported having been under the care of a psychologist or psychiatrist. Fifty-two percent reported that they had a psychiatric diagnosis. Among those participants, the most common psychiatric diagnoses were (in rank order): depression (65.7%), bipolar disorder (21.2%), and anxiety (5.1%). Thirty-one percent of the sample were currently taking psychiatric medications. The most frequently reported psychiatric medications were paxil, trazadone, wellbutrin, and prozac. The overall mean score on the Beck Depression Inventory was 14.4 (S.D. = 9.1). A comparison between injectors and non-injectors yielded no significant differences in terms of these psychiatric variables. 3.4. Patterns of meth use Participants were asked about their past and current use of meth. A number of group differences were observed. Injectors were significantly younger than non-injectors in terms of the age at which they first used meth (22.6 versus 24.8 years, t = 1.9, P < .05). Participants’ reasons for starting to use meth also differed according to their injection status. Injectors were significantly more likely than non-injectors to endorse the following reasons for starting to use meth: to get high (61.0% versus 41.1%, χ2 = 7.5, P < .01); to escape (43.9% versus 25.0%, χ2 = 7.7, P < .01); to cope with mood (39.0% versus 20.5%, χ2 = 7.9, P < .01); and to relieve boredom (40.2% versus 24.2%, χ2 = 5.8, P < .01). Group differences in terms of current reasons for meth use were also revealed. Injectors were significantly more likely than non-injectors to report the following reasons for their current use of meth: to cope with mood (63.4% versus 49.1%, χ2 = 3.9, P < .05); to cope with HIV symptoms (37.8% versus 18.8%, χ2 = 8.8, P < .01) and to feel more self-confident (50.0% versus 34.8%, χ2 = 4.5, P < .05). The number of years of meth use also differed between the two groups. Injectors reported using meth for an average of 13.8 years, whereas non-injectors reported using meth an average of 10.8 years (t = 2.6, P
