Introduction

Crystal methamphetamine (aka “crystal meth,” “Tina,” “crystal”), a highly addictive stimulant, has become integrated into gay male sociosexual contexts, such as circuit parties, sex clubs, Internet dating, and bathhouses.1–3 Use of crystal methamphetamine among men who have sex with men (MSM) gained popularity on the West Coast in the 1990s4 with recent prevalence of 11–53% in Los Angeles5 and 17–22% in San Francisco.4 In recent years, crystal methamphetamine use has spread rapidly to the eastern regions of the United States.1 , 4 , 6 Although South Florida (particularly Miami-Dade and Broward counties) has long been recognized as having intersecting epidemics of HIV and substance abuse among MSM,7–9 little is known about the population’s prevalence of crystal methamphetamine use. Fernandez and colleagues reported that 10% of Hispanic MSM in a 2003–2005 Miami study had used crystal methamphetamine in the past 6 months.9 However, there have been no studies of the prevalence of crystal methamphetamine use among a diverse sample of MSM in South Florida.

MSM who use illicit substances, particularly crystal methamphetamine, represent a group at high risk for HIV/STD infection due to critical associations between risky sexual behaviors and illicit drug use.3 , 5 , 7 , 10 Specifically, users of the drug report an increased number of sex partners,11 an increased number of recent episodes of unprotected sex,3 , 6 , 10 , 11 sex with partners of serodiscordant or unknown HIV status,3 , 10 an increased likelihood of being infected with HIV or other STDs,2 , 4 , 6 and psychological correlates including depression, loneliness, the avoidance of unpleasant emotions and physical pain, and sexual compulsivity.1 , 2 , 4

Previous studies have recognized that knowledge of HIV-positive serostatus leads to a reduction in risk behaviors; however, it is not clear if this holds for HIV-positive MSM who use crystal methamphetamine.10 This paper examines the associations among crystal methamphetamine use, self-reported HIV status, and sexual risk behavior among MSM.

Methods

Cross-sectional data were analyzed from the National HIV Behavioral Surveillance among Men Who Have Sex with Men (NHBS-MSM1) conducted from 2004 to 2005 in Miami-Dade and Broward counties. Venue-based time-space sampling was used to conduct face-to-face interviews with men 18 years of age and older. In addition to the national core NHBS questionnaire,12 staff administered a local questionnaire assessing crystal methamphetamine use, depression, social support, and Internet use to find sex partners. A more detailed description of the NHBS-MSM1 study and methodology has been reported elsewhere.12 , 13

The present analysis describes crystal methamphetamine use among the study sample and assesses study participants’ characteristics, sexual risk behaviors by drug use and HIV status group, and associations between crystal methamphetamine use, HIV status, and sexual risk behaviors, while controlling for demographic and psychosocial factors. All measures are based on self-report and all sexual risk and drug use measures assess behaviors occurring in the 12 months prior to the date of the interview.

Participants were classified into three categories based on drug use: “crystal users” (participants reporting using crystal methamphetamine), “non-crystal drug users” (participants reporting using illicit drugs other than crystal methamphetamine), and “non-drug users” (participants reporting no illicit drug use). Other illicit drugs (including prescription drugs used illegally) included other amphetamines, cocaine, crack, downers (e.g., Valium, Ativan, Xanax), pain killers (e.g., Oxycontin, Percocet), hallucinogens (e.g., LSD), club drugs (e.g., ecstasy, gamma hydroxybutyrate, ketamine), heroin, marijuana, and amyl nitrate. Only participants reporting use of illicit drugs were asked about use of Viagra/Levitra.

Demographic characteristics included age, race/ethnicity, education, sexual orientation, and foreign-born status.

Sexual risk behavior questions about the last sex act addressed partner type (main or non-main), type of sex (anal or oral, insertive or receptive), whether the respondent was high on drugs or alcohol, and condom use. Composite binary variables were created for sexual risk (see Table 1).

Table 1 Bivariate comparisons between crystal methamphetamine users and non-crystal drug users and between crystal methamphetamine users and non-drug users within HIV status groups (N = 946)
Full size table

Internet activity to find sex partners refers to the use of gay/bisexual oriented Internet sites to meet sex partners.

Depression was assessed using the Center for Epidemiologic Studies Depression Scale (10 items); the score was dichotomized to denote “depression” (≥10) and “non-depression” (<10).14Social support was assessed using the Multidimensional Scale of Perceived Social Support (12 items, score 1–5, α = 0.91).15 A higher score indicates more social support.

Statistical Analyses

Participants were described by self-reported HIV status and crystal methamphetamine use. T tests were used to test for differences in means. Kruskal–Wallis tests were used for continuous variables with non-normal distributions, and the medians and interquartile ranges (IQR) were reported. Chi-square tests or Fisher’s exact tests were used for categorical variables. Per Bonferroni adjustment, we consider any comparison with a p value ≤0.002 to be significant.

Results

Descriptive Comparisons by HIV and Crystal Use Status

Of the 946 respondents, 168 (18%) reported crystal methamphetamine use (all but two crystal users reported use of other drugs) and 165 (17%) reported being HIV-positive; HIV-positive respondents were more likely to report crystal methamphetamine use than HIV-negative respondents (32% vs. 15%, p < .0001). Primarily, participants were in their 30s and 40s (61%), Hispanic (42%) and non-Hispanic white (41%), had greater than a high school education (78.5%), and were US born (64%). HIV-positive participants were slightly older and slightly more likely to be non-Hispanic white. There were no differences in these demographic characteristics by crystal methamphetamine use (data not shown).

Sexual Risk Behaviors by HIV and Crystal Methamphetamine Use Status

Among the sample’s HIV-positive men, crystal users compared to non-crystal users (non-crystal drug users and non-drug users) reported a higher rate of unprotected insertive and receptive anal sex at last sex act with a non-main partner. Among HIV-negative men, crystal users were more likely to report unprotected insertive anal sex with a non-main partner than their non-drug using counterparts. Both HIV-positive and HIV-negative crystal users were more likely to report being high on drugs/alcohol during their last sex act with a non-main partner than non-crystal users and non-drug users. HIV-positive and HIV-negative crystal users reported more use of Viagra/Levitra than their counterparts who used illicit drugs other than crystal methamphetamine. While none of the HIV-positive non-crystal drug users reported injecting drugs, approximately one-fifth (21%) of the HIV-positive crystal users reported injecting drugs. Both HIV-negative and HIV-positive crystal users were more likely than non-crystal users to use the Internet to find sex partners and to have been diagnosed with an STD. There were no significant differences between HIV-positive and HIV-negative crystal users and non-crystal users in perceived social support and depression. Crystal users (compared to non-drug users) were more likely to have a higher number of non-main partners and to have reported unprotected anal sex (insertive or receptive) with at least one main and one non-main partner.

Discussion

Three findings emerged from this analysis. First, 18% of respondents reported crystal methamphetamine use in the previous 12 months, among the highest of previously reported use rates in the USA.1 , 4–6 , 10 Second, crystal methamphetamine use is associated with elevated sexual risk behaviors among both HIV-negative and HIV-positive men. Third, we found evidence of continuing risk behaviors among HIV-positive crystal methamphetamine users with both their main and non-main sex partners.

The NHBS core questionnaire asked about all amphetamine use. While most of the amphetamine users in the national sample are likely crystal methamphetamine users,6 it is possible that the NHBS core questionnaire data present a somewhat lower rate of amphetamine use than that which is occurring (87.5% of crystal users in our sample reported using amphetamines on the core questionnaire).

Our results demonstrate that crystal methamphetamine users were more likely to engage in high-risk sexual behaviors than non-users, including having multiple non-main sex partners, unprotected insertive and receptive anal sex, and sex while high on alcohol or drugs. Our finding that crystal methamphetamine users were more likely to report use of Viagra/Levitra than other drug users is consistent with previous studies’ findings that crystal methamphetamine users may be at increased risk for sexual dysfunction and that MSM who use erectile dysfunction drugs with crystal methamphetamine have a high prevalence of HIV and engage in HIV-risk behaviors.3 Our finding that crystal methamphetamine users were more likely (compared to other drug users and non-drug users) to report using the Internet to find sex partners is consistent with previous studies and suggests Internet-based prevention should be considered for MSM crystal users.

Our finding that crystal methamphetamine users were more likely to report being HIV-positive than non-crystal users is consistent with other studies reporting an association between crystal methamphetamine use and HIV seropositivity.2 , 4 , 6

Several study limitations should be recognized. These data are from a sample of men recruited from public venues in Miami-Dade and Broward counties and are not necessarily representative of MSM in these counties or other areas. These data are self-reported and, as such, stigmatized behaviors may have been underreported. The analysis was cross-sectional, so time order could not be established.

In conclusion, the high rates of crystal methamphetamine use presented in this study confirm the migration of this drug to the MSM community in South Florida. These findings raise additional concerns because of high-risk sexual behaviors which remain constant across both HIV-positive and HIV-negative crystal methamphetamine-using MSM.