Persistent use of methamphetamine is the single biggest risk factor for HIV seroconversion among gay and bisexual men, according to a new study published in the Journal of Acquired Immune Deficiency Syndromes. Using subjects from across the U.S., including Puerto Rico and Guam, researchers found that over 12 months of follow-up, 14% of study participants reported using meth, and 2.5% tested positive for HIV (115 new infections). More than a third of study participants (36%) seroconverting for HIV were persistent users of methamphetamine.
Led by Christian Grov, Ph.D., M.P.H., of the City University of New York, researchers recruited subjects in 2017 and 2018 through ads in gay hookup apps. Study subjects were all HIV negative, between 16 and 49 years old, and not taking pre-exposure prophylaxis (PrEP), though some started PrEP during the survey period. Ninety-eight percent of the 4,786 participants were cisgender men, 54% were white, and 41% were college educated. On recruitment, participants took an oral HIV self-test and were asked about their use of methamphetamine. These assessments were repeated after 12 months.
In an email to TheBody, Grov explained the study’s definition of “persistent” meth use as slightly vague, because researchers measured a year prior to enrollment, though their enrollment survey only asked about the prior three months. “We detected meth use at baseline and again a year later; more specifically, subjects who reported meth use within the three months prior to enrollment and reported use at sometime between enrollment and the month 12 assessment.” This is as opposed to the other groups, which included non-users; subjects in whom researchers detected meth use prior to enrollment, but none during follow-up; and those who reported using during the 12-month study but not during the three months prior to enrollment.
Data showed rates of persistent meth use, as defined by researchers, were highest in states in the West (12%), followed by the Southeast (9%), Midwest (7%), and Northeast (5%). Meth use was highest among subjects in the 36 to 45 age group (persistent use, 16%).
Grov told TheBody that he didn’t set out to explore the risk of meth specifically; they were looking more broadly at risk factors for seroconversion among gay and bisexual men.
“We didn’t expect meth to be such a big factor,” Grov said. “But now it flags us to study (meth use) more carefully.”
The study is ongoing: Researchers just finished the 24-month data collections, and 36-month assessment starts later this fall, Grov said. In addition, researchers will begin looking at changes in substance use and PrEP use, plus any effects of the COVID-19 health crisis. Grov said his team will be looking closer at measures of substance use (e.g., route of administration, injection, snorting, booty bump) in follow-up assessments.
In their notes, the authors wrote, “PrEP can greatly reduce the biological risks of HIV infection; however, more data are needed to understand how methamphetamine may serve as a barrier to PrEP initiation, adherence, and long-term retention in care.”
“It Made Me Feel Like Superman”
The study adds to a growing body of evidence showing that meth use among men who have sex with men (MSM) can lead to riskier sexual practices, which can increase the risk of HIV transmission. The drug is an addictive stimulant that increases sexual libido and lowers inhibition. It also creates a powerful dopamine release, which is part of the addiction. Injecting the drug while sharing needles also increases the risk of HIV transmission.
Although use of meth has declined in the general U.S. population, it is again rising among gay and bisexual men. Studies have shown that gay men are four times more likely to try meth than straight men.
In their 2006 study, “Crystal Methamphetamine and Sexual Sociality in an Urban Gay Subculture: An Elective Affinity,” Perry Halkitis, Ph.D., M.P.H., and Adam Green, Ph.D., M.A., stated that methamphetamine is used “strategically by gay and bisexual men to negotiate sexual sociality and increase sexual pleasure.”
One person who might agree with that assessment is Los Angeles student Alex Possner, 30. In 2009, on a hookup, his partner introduced the 19-year-old to meth, which Possner said got him “addicted from the first cloud.”
“I experienced euphoria, sexual arousal, and it made me feel like superman,” Possner told TheBody. Wanting to recreate that feeling led to smoking meth two days a week, then four, plus more hooking up—and after a year, shooting meth, which led to “a new level of crazy,” and at one point, homelessness.
Possner has been sober since March, after the latest of 13 inpatient rehabs. He said sobriety is likely to stick because, this time, he actually wanted to stop. “The other times [in rehab] were to appease my parents. One time, within an hour after leaving rehab, I was at my dealer’s house, smoking.”
Possner is lucky, he said, that he’s still HIV negative, even after sharing a needle with someone who was HIV positive. He attributes staying negative to going on PrEP. He was an early adopter, back in 2013, part of a trial at the Los Angeles LGBTQ Center. “I still have survivor’s guilt though. Out of five of us users in a posse, I’m the only one who is negative.”
As for advice to young gay men who may be lured by meth, he admitted that a Just Say No approach might not work. “I had all the education on the dangers of meth when I was 14. I needed to learn it all for myself, though. I was young and thought I was invulnerable.” He also attributed the “benefits” of meth as a portal to a self-esteem loop, where the drug made him feel hot, which led to more hookups, which made him feel hotter, which led to more meth use to start the cycle over again. “I didn’t have any self-confidence growing up. I was teased as a teen. [Meth] made me feel desirable and helped me lose weight and get the acceptance I always wanted. Who would want to stop that?”
This experience tracks with what social scientists say about the nexus of sex, meth, and gay identity. As Michael Arndt, a sober companion for CAST Centers, said, “Crystal meth touches on two things the gay culture struggles with—vanity and sex. We feel intense pressure to be thin or fit, and an emphasis on sex is a major emphasis in our culture. There is this unspoken, and unfortunately mainstream, message that if you are gay and want to be a part of the culture, you have to be hot and have plenty of sex.”
In a Ted Talk, writer Johann Hari, speaking generally about addictive behavior, said that addictions are rooted in a lack of connection. Research with gay and bisexual male meth users seems to confirm this.
The COVID Crisis and Isolation Could Make the Meth Crisis Worse
The lack of connection during the COVID crisis is a concern of men’s health advocates like Oscar Lopez, CEO and founder of the Latinx LGBTQ advocacy organization Poderosos.
“Not just isolation, but poverty and despair from losing jobs, are making people take more risks, and I worry that we will lose many more people due to [risky] hookups,” Lopez told The Body.
Now, with many counseling and support groups meeting online, one important element of connection has been lost, Lopez adds. And HIV testing, which could be an important conduit to discussions about substance use, is now impersonal. “Every HIV/AIDS organization I know of is now hands-off due to COVID. They will send you to outside labs and call you back with results. The human connection is gone. COVID has made a bad situation worse.”
Though it didn’t break down use by sexual orientation, a recent report by lab Millennium Health showed that meth use increased in the early days of COVID isolation this year.
Lopez noted that even before COVID, community-based organizations often fell short getting to the root of why gay and bisexual men and other MSMs are drawn to meth and other substances. “Prevention programs are often: Let’s treat you, and let’s get you out, like a machine. There’s not enough deep counseling to see what they’re not getting elsewhere that they’re seeking with meth. And I’m especially worried for MSM and trans people.”
On the plus side, Lopez said, the growing meth crisis is at least on the radar of organizations with funding that could make a difference, and discussions about harm reduction include areas outside of larger metropolitan cities like New York and Los Angeles.