Published on November 2, 2007
Cathy J. Reback, Ph.D.Friends Research InstituteVan Ness Recovery House/Prevention DivisionUCLA Integrated Substance Abuse Programs: Cathy J. Reback, Ph.D. Friends Research Institute Van Ness Recovery House/Prevention Division UCLA Integrated Substance Abuse Programs Behavioral Interventions for Gay and Bisexual Male Methamphetamine Users These studies were supported by NIDA grant #RO1 DA 11031, CSAT grant #1 KD T1 12043, County of Los Angeles, Department of Health Services, Office of AIDS Programs and Policy contract # H-211853, UARP grant #MU04-FRII-704. UCLA Integrated Substance Abuse ProgramsSteven Shoptaw, Ph.D. Sherry Larkins, Ph.D. James A. Peck, PsyD. : UCLA Integrated Substance Abuse Programs Steven Shoptaw, Ph.D. Sherry Larkins, Ph.D. James A. Peck, PsyD. Acknowledgements Overview: Overview Methamphetamine use and HIV infection A continuum of behavioral interventions Drug abuse treatments dramatically reduce methamphetamine use and high-risk sex Reductions are sustained! Next steps Policy implications Background: Background Methamphetamine is widely used in gay and bisexual male communities (Reback, 1997; Colfax et al., 2000; Gorman & Carroll, 2000) Methamphetamine, for gay and bisexual men, is closely connected to sexual identity & sexual expression (Reback, 1997; Stall et al., 2001; Semple et al., 2002) Sexual behaviors associated with methamphetamine use present extreme HIV risks (Molitor et al., 1998; Mattison et al., 2001; Mansergh et al., 2001; Reback et al., 2004) _ Changes in sexual behaviors _ Changes in decision-making processes Gay and bisexual male methamphetamine users are at multiple risk for HIV infection or re-infection (Reback & Grella, 1999) The Los Angeles AIDS Epidemic:Cumulative Male AIDS Cases: The Los Angeles AIDS Epidemic: Cumulative Male AIDS Cases Los Angeles* United States** MSM 76% 46% MSM and IDU 7% 6% IDU 5% 12% Other 12% 36% *January 2005 HIV Epidemiology Report, LA County **2004 HIV/AIDS Surveillance Report, CDC Methamphetamine and HIV in MSM: A Time-to-Event Association? : Methamphetamine and HIV in MSM: A Time-to-Event Association? * Deren et al., 1998, Molitor et al., 1998; ** Reback et al., in prep, *** Reback, 1997; **** Shoptaw et al., 2002; ****VNRH, unpublished data The Formative StudyThe Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeleswww.uclaisap.org: The Formative Study The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeles www.uclaisap.org Slide8: The Meaning of Identities Gay/Bisexual Identity Methamphetamine User Identity HIV Identity The Crystal Sex Experience: The Crystal Sex Experience All participants discussed the enhancement of their sexual activities while on crystal: _ Heightened sensory experiences _ Disinhibiting effects _ Duration of sexual arousal _ Intensified orgasms _ Inability to achieve erection or orgasm “I’m not sexually excited unless I’m under the influence. . . . I don’t have sex without crystal.” Jerry, 29 years old, white, HIV+ Sexual Risks:Partner Responsibility: Sexual Risks: Partner Responsibility Many participants described social norms that allow high-risk activities to occur: _ HIV status is not talked about _ Participants said they assume everyone is HIV-positive _ Their sexual partner(s) must tell them what is and is not permissible _ The responsibility for using a condom is placed on the other Study Findings:What did we learn? What can we build on?: Study Findings: What did we learn? What can we build on? The identities of gay, HIV, and methamphetamine user were inter-related and said to influence drug use and sexual risk-taking. All participants used crystal during their sexual activities. All participants discussed the enhancement of their sexual experiences while on crystal. Sex was seen as more intense, heightened, prolonged and uninhibited. Several HIV-infected participants discussed the advantages of using crystal to manage AIDS-related conditions or effects. Study Findings, continued: Study Findings, continued Nearly half (44%) of the interview participants were introduced to crystal by a male sex partner; 84% were introduced to crystal within a gay-related social situation. Nearly all participants relied on gay drug dealers and met sex partners through gay-related institutions. Crystal was made readily available and accessible through gay institutions for individuals of all socio-economic levels. The use of crystal in the gay community was facilitated through various gay institutions such as telephone sex lines, personal ads, computer networks, circuit parties, bars and clubs. The positive effects associated with crystal use complement valued aspects of gay culture; gay identity was inextricably linked to sex. A Continuum of Treatment Options That Respond to A Continuum of Use: A Continuum of Treatment Options That Respond to A Continuum of Use Use Abuse Dependence Addiction Prevention / Harm Reduction Early Intervention Outpatient Drug Treatment Residential Harm Reduction: Harm Reduction Street Outreach Public Sex Environment Commercial Sex Venues Street Outreach: Street Outreach Sites: bars, cruising areas, parks, coffee houses, street corners, inexpensive hotels, bus stops, abandoned buildings, parking lots, fast food stands, mini markets Strategies of Outreach: Strategies of Outreach Empower not enable Working with clients on their own agenda Being client-centered Being value clear Suspended judgment Public Sex Environments: Public Sex Environments Park / Cruising Area _ No membership fee _ No entrance fee _ No condoms are provided _ Very unsafe environment for anonymous sex _ Atmosphere of excitement and danger, risk police entrapment and gay bashing _ Average stay, 30 minutes - 1 hour Commercial Sex Venues: Commercial Sex Venues Bathhouse _ Membership fee, $25/3 months _ Entrance fee, $8-30/8 hours _ Condoms are provided _ Very safe environment for anonymous sex _ Party atmosphere (restaurant, gymnasium) _ Average stay, 6-8 hours Sex Club _ Membership fee, $20/5 months _ Entrance fee, $5-12/unlimited time _ Condoms are provided _ Very safe environment for anonymous sex _ Dimly lit atmosphere _ Average stay, 3-6 hours Health Education and Risk Reduction: Health Education and Risk Reduction Individual-level Interventions: Peer counseling Group-level Interventions: Skills Building Groups Support Groups Art Exploration as an Example of Innovative Support Groups Use of art to explore issues surrounding methamphetamine use, HIV and harm reduction Production of street-based ‘zine, Twacked, three times a year The Good, The Bad, and The Twacked: A ‘Zine from the Guys of the Boulevard: The Good, The Bad, and The Twacked: A ‘Zine from the Guys of the Boulevard Early Interventions: Early Interventions Motivational Interviewing Harm Reduction Counseling Drop-in Groups Intensive Outpatient: Intensive Outpatient Cognitive Behavioral Therapy Contingency Management Combined CBT + CM Friends Health Center Objective: Friends Health Center Objective To evaluate the comparative efficacy of behavioral drug abuse treatments in gay and bisexual, methamphetamine-dependent men in Los Angeles: Methamphetamine use High-risk sexual behaviors Slide27: A Gay-specific Cognitive Behavioral Therapy Intervention Standard CBT GCBT External Triggers: Sporting Events Gay Pride Festival Concerts Bathhouse Movies Halloween Relapse Justification: “I just got injured. “My friend just died [of I might as well use.” AIDS] and using will make me forget for awhile.” One Day at a Time: “Tomorrow something “I seroconverted even will happen to ruin though I knew about this.” safer sex.” Specific Topics: ] Coming Out All Over Again: Reconstructing Your Gay Identity ] Being Gay and Doing Gay ] Preventing Relapse to High-risk Sex ] Living in an HIV World ] Several session that involve “Aunt Tina” Slide28: Friends Health Center Study Design 2 Week Baseline 16 Week 1st Follow-up 6 Months 12 Months 2nd Follow-up CM CBT CM + CBT GCBT Screen Randomization and Baseline Follow-up Follow-up Follow-up Science and Social Quandary:Efficacy and Effectiveness: Science and Social Quandary: Efficacy and Effectiveness Potent and Uncommon Moderate and Common Slide30: Client Demographic Characteristics (N = 162) Variable Category N % Ethnicity Caucasian/white 129 80 Hispanic/Latino 21 13 African American 5 3 Other 7 4 Sexual Identity Gay 155 96 Bisexual 7 4 HIV Status HIV+ 98 60 HIV- 64 40 Age Mean 36.6 years Education Mean 14.7 years Outcomes by Condition : Outcomes by Condition Contingency Management: Contingency Management Significantly longer retention Significantly more “clean urine” Significantly longer stretches of consecutive clean urine samples Unprotected Receptive Anal Intercourse by Condition to Treatment Completion: Unprotected Receptive Anal Intercourse by Condition to Treatment Completion GCBT significant over all conditions (F(3,382)=5.76, p<.001 Mean # of URAI in previous 30 days Unprotected Receptive Anal Intercourse by Condition to 1-year F/U: Unprotected Receptive Anal Intercourse by Condition to 1-year F/U 2(3)=6.75, p<.01 Mean # of URAI in past 30 days Treatment Specific Outcomes: Treatment Specific Outcomes Treatment seeking gay and bisexual methamphetamine abusers: _ Combined CM and CBT intervention produces maximal short-term reductions in drug use and moderate effect on high-risk sex _ Gay-specific, CBT condition (I.e., GCBT) produces maximal short-term high-risk sex reductions; moderate drug use reductions Slide37: Study Findings · Interventions employing contingencies (CM and CM+CBT) performed best in reducing drug use during the treatment period · Intervention integrating gay-specific cultural norms and values performed (GCBT) best in reducing sexual risk during the treatment period · One-year follow-up data show a positive general treatment effect in both drug use and sexual risk reductions, but no treatment-specific effects Moving From Research to Community: Moving From Research to Community Evidenced-based Approaches for Addressing Methamphetamine Use Among Urban Gay and Bisexual Males Methamphetamine Abuse Treatment is HIV Prevention : Methamphetamine Abuse Treatment is HIV Prevention Funded by Universitywide AIDS Research Program and the California State Office of AIDS grant #MU04-FRII-704. Community Concerns: Community Concerns Too long Too expensive Objectives: Objectives 1. Adopt, tailor and transfer an evidenced-based, gay-specific, manual-driven cognitive behavioral therapy intervention for methamphetamine-abusing gay and bisexual men for use in a community-based HIV prevention setting; 2. Optimize the gay-specific cognitive behavioral therapy intervention by coupling it with a contingency management intervention (maximum payout $233) to create one behavioral intervention for producing sustained HIV sexual and drug risk reductions; and 3. Develop a continuing care intervention to support and maintain longer-term behavior change subsequent to the outpatient intervention. Summary: Summary Meet the user where they are at, i.e., treatment seeking vs. non-treatment seeking Assess methamphetamine use/abuse/dependence/addiction Have treatment options available Concomitant focus on sexual and drug risk behaviors Form collaborations between community providers and research and/or academic institutions Policy Implications: Policy Implications Methamphetamine abuse treatment should be part of comprehensive HIV prevention efforts for MSM; Concomitant focus on sexual and drug behaviors reduces HIV risk behaviors; Interventions that limit drug use can be used to mediate sexual risks in venues outside of traditional drug abuse treatment settings such as STD clinics, commercial sex venues and community centers; Intervention options such as contingency management and motivational interviewing can be made available to MSM who are interested in reducing but not eliminating the drug use; Methamphetamine abuse treatment is HIV prevention
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