Elsevier

Drug and Alcohol Dependence

Volume 53, Issue 3, 1 February 1999, Pages 197-205
Drug and Alcohol Dependence

Non-injection substance use correlates with risky sex among men having sex with men: data from HIVNET1

https://doi.org/10.1016/S0376-8716(98)00134-3Get rights and content

Abstract

Associations between substance use and sexual behavior were examined among 3220 seronegative men who have sex with men (MSM) in a HIV vaccine preparedness study. Relationships between current and past substance use and current sexual risk were evaluated using crude odds ratios and logistic regression to adjust for confounding variables. Heroin and injection drug use were uncommon (<2%). Substances most often used were alcohol (89%), marijuana (49%), nitrite inhalants (29%), amphetamines or similarly acting stimulants (21%), cocaine 14% and hallucinogens (14%). Increased adjusted odds for unprotected sex were significantly associated with current heavy alcohol use (OR 1.66; CI 1.18, 2.33), past alcohol problems (OR 1.25; CI 1.05, 1.48), and current drug use (OR 1.26; CI 1.08, 1.48). When associations with specific drugs and nitrite inhalants were examined separately, current use of cocaine and other stimulants (OR 1.25; CI 1.01, 1.55), hallucinogens (OR 1.40; CI 1.10, 1.77), and nitrite inhalants (some (OR 1.61; CI 1.35, 1.92); heavy (OR 2.18; CI 1.48, 3.20)), were independently associated with unprotected sex. Those with past drug use or past heavy alcohol use but not currently using demonstrated no increase in sexual risk, suggesting an important role for substance-focused interventions in risk reduction efforts among MSM.

Introduction

Participation in high risk sexual behavior and infection with HIV continue to occur among men who have sex with men (MSM) despite widespread dissemination of information about how the virus is transmitted. The reasons for engaging in high risk behavior are undoubtedly complex, however data collected over a period of more than 20 years indicate that alcohol and non-injecting drug use are contributing factors (Saghir and Robins, 1973, Stall et al., 1986, Skinner, 1994, MacQueen et al., 1996, Chesney et al., 1998, Ferrando et al., 1998), though not all studies agree (Gold and Skinner, 1992, Weatherburn et al., 1993, Buchbinder et al., 1996), and some agree only in part (Ostrow et al., 1990, Page-Shafer et al., 1997).

Studies that have shown clear associations include a cross-sectional evaluation of 800 gay men in San Francisco (Stall et al., 1986), where higher levels of alcohol and drug use were associated with higher levels of risky sexual behavior and a case-control study (McCusker et al., 1990) in Boston. In addition, each of these authors found that men who reported a history of both risky sex and use of alcohol or marijuana, but who later stopped using, were more likely to report less risky sexual behavior than men who continued to use.

Other papers showing associations between alcohol and drug use and sexual risk are from the Multicenter AIDS Cohort Study (MACS). In one, Ostrow et al. (1990)examined associations between risky sexual behavior and substance use among 3916 gay men who completed baseline and the first 6-month follow-up. They found a significant relationship between inhalant use and sexual risk after controlling for age, educational level and number of high risk partners, but found no relationship between use of alcohol or drugs and risky sex. Another paper (Ostrow et al., 1993) focusing on 1005 gay men who were part of the MACS at the Chicago site found that those who combined nitrite inhalant use with other drugs reported highest risk activity. Nitrite use was associated with lapse from safer sexual practices among nonmonagamous men, and with HIV seroconversion. A third paper, again from the MACS and using HIV seroconversion as an endpoint found that heavy drinking, moderate to heavy drug use, and younger age were all related to seroconversion (Penkower et al., 1991), similar to findings reported by others (Seage et al., 1992). Unlike most studies in the drug abuse literature, the increased risk that was demonstrated in all of these MSM studies resulted almost entirely from alcohol or non-injection drug use.

In summary, most studies show a relationship between alcohol or drug use and increased sexual risk among MSM, but it is clear that these relationships are complex and difficult to evaluate. Disparate findings can be explained in many ways including inability to evaluate substance use patterns in the context of the sexual encounter, comparing populations with different ages or cultural features, and limitations in power resulting from small sample sizes which make it impossible to evaluate possible confounds such as demographic characteristics of participants or the independent contribution of different substances or levels of use. These problems are described in detail by Leigh and Stall (1993), and have been discussed by other authors as well (Weatherburn et al., 1993).

This paper will present data about this complex area by examining the relationship between alcohol and drug use and risky sexual behavior, mainly unprotected anal intercourse, from a large study of high risk MSM. The findings add to earlier work primarily because the size of the sample, and the level of detail regarding alcohol and drug use patterns, provided enough statistical power to control for some of the potential confounds that limit interpretation of data in other studies. The data were collected from MSM recruited for participation in the Vaccine Preparedness Study (VPS) of the HIV Network for Prevention Trials (HIVNET). The VPS was a recent large multisite study that used a uniform protocol and risk assessment instruments and recruited MSM who reported any receptive or insertive (protected or unprotected) anal intercourse during the prior 12 months. The VPS is one of the largest studies done to date that evaluates sexual risk among seronegative MSM, and it has data about not only the type and amount of drugs and alcohol that were used in the last 6 months, but also about the presence/absence of past alcohol or drug problems.

Section snippets

Sites

The VPS was a multi-site study whose primary objectives were to perform biologic and behavioral studies in preparation for efficacy trials of HIV vaccines and other HIV prevention interventions. The cohort includes MSM, injection drug users (IDUs), and women at risk for HIV through heterosexual contact. The present analysis is limited to baseline data on 3212 HIV seronegative MSM who were recruited at six sites between April and October, 1995. The sites selected for the MSM parts of the VPS

Demographic, sexual risk and substance use patterns

At baseline, the median age of the participants was 32 (range 18–73). 75% were White, 7% Black, 13% Hispanic, 3% Asian/Pacific Islander, and 2% Native American or ‘other’. A total of 59% had college or post-graduate education, 29% some college, 10% were high school graduates, and only 2% had less than a high school education. A total of 72% were working full time, 13% part time, 11% were unemployed, and 4% were classified as ‘other’. Alcohol was used by 89% of participants, marijuana by 49%,

Discussion

The major findings of this study are that certain patterns of alcohol and non-injection drug use, specifically last 6 month heavy alcohol use and any last 6 month use of hallucinogens, stimulants and inhalants are independently associated with higher sexual risk. Equally important is the lack of increase in sexual risk among those with past problem alcohol or drug use who were not currently using or, in the case or alcohol, were using at lower levels. This finding implies that stopping or

Acknowledgements

The following institutions and persons participated in the Vaccine Preparedness Study Protocol Team, HIVNET. Domestic Master Contractor-Abt Associates Inc: G. Seage, M. Gross; Statistical Center-University of Washington and Fred Hutchinson Cancer Research Center: T. Fleming, S. Self; Laboratory Contractor-Viral and Rickettsial Disease Laboratory, California Department of Health Services: H. Sheppard, M. Ascher; Repository Contractor-Biomedical Research Inc: J. Leef; National Institute of

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