Drug treatment best hope for meth-using MSMs
Researchers want to get word out about problem
(Editor’s note: This is the second in a two-part series about the increase in methamphetamine and stimulant use among gay and bisexual men across the country and how this is tied to increased HIV risk and incidence in various communities.)
New unpublished and published research show that gay and bisexual men who use methamphetamine have a greater prevalence of HIV infection than men who have sex with men (MSM) who do not use the drug. This finding has led some researchers to speculate that methamphetamine use could result in a resurgence of the virus among MSM. And it highlights the need for targeted substance abuse programs directed toward MSM who use methamphetamine.
"I see HIV in my community, and it’s in drug users and drug-using gay men," says Steve Shoptaw, PhD, principal investigator with the Friends Research Institute in Los Angeles. Shoptaw also is an associate research psychologist at the University of California-Los Angeles. "If 62% of the guys are infected by the time they show up for [substance abuse] treatment, then that tells me there’s a high concentration of the virus where these guys interact," he says.
Drug treatment significantly reduces HIV-related sexual risk behaviors immediately, and those reductions are observed at a one-year follow-up, according to Shoptaw’s most recent research. "We see, on average, men coming in and reporting three or four instances of unprotected anal receptive intercourse with someone other than their primary partner at baseline in 30 days prior to their first visit," he says. "After treatment, at one-year follow-up, it’s [less than] one instance."
Methamphetamine use also has dropped after the treatment intervention, Shoptaw notes. "At baseline, there were nine to 10 average days out of 30 of meth use, and at a 52-week follow-up, there were three to 3.5 days."
Taking drug use out of the picture
These findings make it starkly clear that for certain MSM populations, one of the first HIV prevention strategies may be to encourage men to enter substance abuse treatment. "When you pull the drug out of the picture, the men make different decisions about their sexual behavior," Shoptaw says.
Shoptaw and colleagues have observed methamphetamine-abusing MSM since 1996, listening carefully as the men sometimes outline their own HIV-prevention and drug-management strategies. "And all of those men have fallen and become dependent or needed intervention, and so at this point, I no longer say you should be doing harm reduction or encourage lower amounts of use because there’s not a lot of benefit to that. We should be coming out strong, emphasizing the value of abstinence," Shoptaw says.
To that purpose, the Friends Health Center has developed a treatment manual and behavioral intervention program for methamphetamine-abusing MSM. The program provides detailed interventions directed to this particular substance abusing population.
Crystal meth addiction is hard to beat: The drug creates a strong dependence because a person with low self-esteem may feel like the king of the world, says Perry N. Halkitis, PhD, assistant professor of psychology at New York University and co-director of the Center for HIV Educational Studies & Training in New York City. "My personal opinion is harm reduction is not going to work, and it needs to be a clean-cut break," he says. "People can realize they have a problem and go to a meeting, but eventually dependence is not going to be eliminated with a harm reduction approach."
Halkitis recommends substance abuse treatment in the form of cognitive-based therapy programs that use motivational interviewing that gets people to think about their behavior and motivates them to change. "The other thing we’re working on here is to treat the addiction through medications because we know what the substances do to release pleasure neurotransmitters in the brain," he says. "And when you’re stressed, your brain fires other receptors that cause pain, which you counter by doing drugs."
But the pharmaceutical approach always raises the question of whether it’s prudent to treat drug addiction with other drugs, Halkitis adds. Clinicians need to start probing and find out more about methamphetamine use in their areas because substance abuse and mental health services do not collect data on meth use in New York City and other areas, he says. "Clinicians need to be aware of symptoms of substance abuse," Halkitis says. And clinicians working with MSM patients need to catch the substance abuse early as methamphetamine typically begins as weekend party behavior, but eventually spreads to everyday use and addiction, he adds.
While not every expert on methamphetamine use among MSM would agree that total drug abstinence is the only solution, there is some agreement that some substance abuse treatment is necessary as part of an HIV prevention strategy. "Some treatment and harm reduction need to be offered," says Michael C. Clatts, PhD, medical anthropologist and an associate professor of public health in the Department of Sociomedical Science at Columbia University in New York City. Clatts also is the director of the Institute for International Research on Youth At Risk at the National Development Research Institutes in New York City. "Current [substance abuse] treatment models don’t have good efficacy and come at a big expense at a clinical level," he says. "They break people down and try to rebuild them."
For this reason, Clatts says he’d recommend putting a public health emphasis on harm reduction education.