HPE 2001 _ Drug _ Use _ and _ Sexual _ Risk _ Behaviors.pdf

Chapter 1: Introduction to the Study

Introduction

Alcohol and drug use among some MSM may result from a reaction to

homophobia, discrimination, or violence they experienced due to their sexual orientation

and can contribute to other mental health problems (CDC, 2013). Alcohol and illegal

drug use in some gay and bisexual men also contributes to increased risk for HIV

infection and other STIs, especially methamphetamines, amyl nitrates (poppers), and

drugs used to treat erectile dysfunction (CDC, 2013). While under the influence of drugs

or alcohol, individuals may increase their risk for HIV transmission by engaging in risky

sexual behaviors or through sharing needles or other injection equipment (CDC, 2013).

Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV

infection sexually (CDC, 2013). In fact, a person is 2 to 5 times more likely to get HIV if

exposed when syphilis sores are present (CDC, 2013). The Syphilis Elimination Effort

(SEE) is a national initiative that unites health care providers, policy makers, community

leaders, and state and local public health agencies to reduce syphilis rates in the United

States (CDC, 2013). In a collaborative effort, there is a unique opportunity to control

syphilis as well as reduce the transmission of HIV (CDC, 2013).

Club drugs are a pharmacologically heterogeneous group of psychoactive drugs

that tend to be abused by teens and young adults at bars, nightclubs, concerts, and parties

(NIDA, 2010). While the effects of each club drug is different, effects common to all

club drugs can include anxiety, panic, depression, euphoria, loss of memory,

hallucinations, and psychotic behavior (FBI, n.d.). Club drugs are sometimes used as date

rape drugs, to make someone unable to say no to or fight back against sexual assault

(NIH, 2010). They can cause serious health problems and sometimes death, and they are

even more dangerous if used with alcohol.

Club drug usage is very popular in MSM, and because of its affiliation with

unprotected sex, young men who have sex with men (YMSM) continue to be at high risk

of acquiring HIV through unprotected sexual encounters (Hall et al., 2007; Wolitski et

al., 2001). As a result of the discrimination and marginalization from ethnic groups and

their communities, some MSM turn to sex or drugs to cope (Diaz et al., 2005), which

increases their risk of becoming infected. Unprotected receptive anal sex is the sexual

behavior that carries the highest risk for HIV acquisition (CDC, 2013).

Notifiable disease surveillance data on syphilis and data from GISP (Gonococcal

Isolate Surveillance Project) are indicate that some STDs in MSM, including men who

have sex with both women and men, are increasing (CDC, 2001, 2009; Fox et al., 2001;

Helms et al., 2007). The rise in STDs among MSM may be associated with an increase in

HIV diagnoses among MSM (Hall et al., 2008).

There has been a dramatic increase in the rate of syphilis in YMSM and the rate

of coinfection with HIV is high (Hitt, 2012). Additionally, syphilis is a sexually

transmitted disease caused by the bacterium Treponema pallidum and can cause long

term complications and/or death if not adequately treated (CDC, 2013). It is transmitted

from person to person by direct contact with syphilis sores, which occur mainly on the

external genitals, vagina, anus, or in the rectum (CDC, 2013). Sores also can occur on the

lips and in the mouth and can be transmitted during vaginal, anal, or oral sexual contact

(CDC, 2013).

Correct and consistent use of latex condoms can reduce the risk of syphilis when

the sore or site of potential exposure is covered, but it is best to abstain from sex while

any sore is present in the genital, anal, or oral area (CDC, 2013). Furthermore, contact

with a sore outside of the area covered by a latex condom can still cause infection (CDC,

2013). The absence of condom usage consistently and correctly is considered unprotected

sex (CDC, 2012). Moreover, risky behaviors such as unprotected sex are increased when

drugs and alcohol are used (CDC, 2012).

Club drug use and unprotected sex are a few of the variables that contribute to the

spread of syphilis, HIV/AIDS, and other STDs. Club drugs encompass a diverse range of

substances that emerged during the 1990s as major drugs of use and abuse in the United

States and elsewhere (Kelly, Parsons, & Wells, 2006). Among MSM, the most commonly

used recreational drugs are often collectively referred to as club drugs (Morgenstern et

al., 2009). These drugs, including cocaine, methamphetamine (crystal meth),

methylenedioxymethampetamine (MDMA, commonly known as “ecstasy”), gamma

hydroxyl-butyric acid (GHB) and its derivatives, ketamine (“Special K”), and d-lysergic

acid diethylamide (LSD) are often used in combination with each other, are a frequent

feature of gay-oriented night clubs, bars, and circuit parties, and are commonly used as an

enhancement to sexual encounters for MSM (Ramo, Grov, Delucchi, Kelly, & Parsons,

2010). The association between club drug use and HIV is complex and involves many

different facets of social, physical, and psychological health (Drumright, Patterson, &

Strathdee, 2006). Therefore, this investigation explored the potential role of club drugs

as an independent risk factor for STD acquisition.

Background

The SEE was developed and spearheaded by the Centers for Disease Control and

Prevention (CDC) in October 1999 as a part of a national initiative (The Department of

Public Health [DPH], n.d.). The CDC was responsible for the development of the

research design, intervention, and materials used to collect information from participants

in order to reduce the syphilis rates in the United States. The tool itself was designed to

assess the local social, behavioral, and institutional factors related to the persistence of

syphilis within the high morbidity areas of Metro Atlanta (DPH, n.d.). The SEE is a

national initiative that brings health care providers, policy makers, community leaders,

and state and local public health agencies together to reduce syphilis rates in the United

States (CDC, 2011). According to the CDC, syphilis disproportionately affects a small

percentage of the population, and research has shown that these are often isolated groups

involved in high risk activities such as illicit drug use, exchanging sex for money or

drugs, unprotected sexual intercourse, and having multiple sex partners (Georgia

Department of Public Health [GDPH], n.d.). In assessing the STD trends, two Georgia

counties ranked in the top 20 cities and counties for having the highest rate for primary

and secondary syphilis infection in the United States with the rates steadily increasing

over the past 5 years (CDC, 2011). Fulton ranked sixth in the country and Dekalb

followed ranking 19th (CDC, 2011). There are programs designed to combat the high

STD rates in a collaborative effort; one of the most notable is the Comprehensive STD

Prevention System (CSPS). CSPS is a grant-funded program that is intended to execute

the mission of the Division of Public Health’s STD section, which ultimately prevents

STDs and their complications (GDPH, n.d.).

Syphilis is caused by the spirochete Treponema pallidum and is spread primarily

through sexual contact (Mattei, Beachkofsky, Gilson, & Wisco, 2012). When left

untreated, it progresses to other stages; primary and secondary syphilis are symptomatic

stages, latency can last for years and can be asymptomatic, and late syphilis can also be a

late symptomatic stage (Holmes, 2008). In the United States, rates of primary and

secondary syphilis reached historic lows in 2000, but in 2001 the increase began among

males and has continued (CDC, 2009).

In an analysis presented at the 2010 National STD Prevention Conference, the

rate of new HIV diagnoses among MSM was found to be more than 44 times that of other

men and more than 40 times that of women (Purcell et al., 2010), and the rate of primary

and secondary syphilis among MSM is estimated at more than 46 times that of other men

and more than 71 times that of women (CDC, 2010). The CDC is looking to increase

access to syphilis screening for MSM, especially for those who are HIV infected. It is

working at the national level and with the state and local partners to identify and

implement the most cost effective and scalable interventions in the geographic areas hit

the hardest by HIV and among the most severely affected populations within those areas

(CDC, 2013). As of June 2011, the CDC announced a new 5-year HIV prevention

funding opportunity that better aligns HIV prevention funding to the current geographic

burden of the U.S. HIV epidemic. The CDC provides funding to health departments in

states, territories, and selected cities based on the number of people living with HIV

diagnosis in the area (CDC, 2013).

Drug use among MSM is becoming quite widespread. The National Alliance of

State and Territorial AIDS Directors (NASTAD; 2005) in the United States have

described the increased use of crystal methamphetamine among MSM as a public health

crisis. However, in other areas, drug use among MSM and its implications in the rising of

STI and HIV rates are more patchy (Rusch et al., 2004; Slavin, 2004; Wilkins et al.,

2002). There are reasons to be concerned about recreational drug use among MSM: The

drug use culture is changing, the nature of the association between substance abuse and

sexual risk behavior remains unclear, and there is likely to be increased need for health

service interventions to address the impacts of rising recreational drug use in this

population likely to require the expertise and joint effort of sexual health, mental health,

and substance abuse professionals (NASTAD, 2005).

Previous researchers have found a correlation of club drugs use among MSM in

areas along the West Coast, but there is limited information on the East Coast,

particularly in the South Atlantic Region. In order to fulfill this gap in literature, my

study was composed of secondary data taken from Georgia, specifically the Metro

Atlanta area. I examined club drug use among MSM to determine if there was some

correlation between its use and sexual risk taking.

Problem Statement

Researchers of previous studies have shown that when compared with the general

population, gay and bisexual men are one of the populations who are more likely to use

alcohol and drugs and have higher rates of substance abuse (CDC, 2013). Their alcohol

and drug use can be a reaction to homophobia, discrimination, or violence they

experienced due to their sexual orientation and can contribute to other mental health

problems (CDC, 2013). In some gay and bisexual men, alcohol and illegal drug use also

contributes to increased risk for HIV infection and other STIs (CDC, 2013).

Among MSM, the most commonly used recreational drugs are often collectively

referred to as club drugs (Morgenstern et al., 2009). Furthermore, the CDC estimates that

1.2 million people in the United States are living with HIV infection (CDC, 2012) and an

estimated 50,000 people were newly infected annually. Consequently, in 2006, MSM

comprised approximately 53% of all new HIV infections, 12% were injection drug users

(IDU), and 4% were both MSM and IDU (Hall et al., 2008). Potential reasons for the

syphilis increase among HIV–infected individuals include improvements in HIV therapy

leading to increased wellbeing and reduced mortality, burnout over safer sex practices,

false assurance from HIV serosorting, and recreational drug use (Marazzo, 2007;

Truoung et al., 2006).

Purpose of the Study

The purpose of this quantitative research was to examine the relationship between

club drug use and sexual risk taking among MSM in the Metro Atlanta area (Fulton and

Dekalb Counties) who have been infected with syphilis. This is an area where primary

and secondary (P&S) syphilis has had a steady increase in cases from 2001 to 2009

(CDC, 2012). During 2010, overall rates of P&S decreased for the first time since 2000

(CDC, 2010); however, rates among men continued to increase, making it the 10th

consecutive year of increasing rates among men (CDC, 2012).

Research Questions and Hypotheses

This research was guided by two research questions. Each research question has a

respective null, alternative hypothesis, and a mode of analysis.

Research Question 1: Is there an association between club drug use (cocaine,

nitrates/poppers, ecstasy, methamphetamines, and Viagra) among MSM who test positive

for syphilis in the Metro Atlanta area (Fulton and Dekalb counties) and engaging in risky

sexual behavior (i.e., having sex with an anonymous partner, having sex while

intoxicated or high, having sex with someone known to inject drugs, or exchanging sex

for drugs/money) while controlling for injection drug use and a history of imprisonment

and previous STIs?

Null Hypothesis 1 (H1o): There is no significant association between club drug

use (cocaine, nitrates/poppers, ecstasy, methamphetamines, and Viagra) among MSM

who test positive for syphilis in the Metro Atlanta area (Fulton and Dekalb counties) and

engaging in risky sexual behavior (i.e., having sex with an anonymous partner, having

sex while intoxicated or high, having sex with someone known to inject drugs, or

exchanging sex for drugs/money) while controlling for injection drug use and a history of

imprisonment and previous STIs.

Alternative Hypothesis 1 (H1a): There is a significant association between club

drug use (cocaine, nitrates/poppers, ecstasy, methamphetamines, and Viagra) among

MSM who test positive for syphilis in the Metro Atlanta area (Fulton and Dekalb

counties) and engaging in risky sexual behavior (i.e., having sex with an anonymous

partner, having sex while intoxicated or high, having sex with someone known to inject

drugs, or exchanging sex for drugs/money) while controlling for injection drug use and a

history of imprisonment and previous STIs.

These associations will be tested by employing a multivariate linear regression

analysis to determine whether club drug use as reported on the supplemental interview

record (SIR) is predictive of engaging in unprotected sex.

Research Question 2: Does type of drug use (i.e., club drugs, injection drugs,

heroine or crack cocaine, or no drug use) predict engaging in risky sexual behavior (i.e.,

having sex with an anonymous partner, having sex while intoxicated or high, having sex

with someone known to inject drugs, or exchanging sex for drugs/money) among MSM

who test positive for syphilis in the Metro Atlanta area (Fulton and Dekalb counties)?

Null Hypothesis 2 (H20): Type of drug use (i.e., club drugs, injection drugs,

heroine or crack cocaine, or no drug use) does not predict engaging in risky sexual

behavior (i.e., having sex with an anonymous partner, having sex while intoxicated or

high, having sex with someone known to inject drugs, or exchanging sex for

drugs/money) among MSM who test positive for syphilis in the Metro Atlanta area

(Fulton and Dekalb counties).

Alternative Hypothesis 2 (H2a): Type of drug use (i.e., club drugs, injection

drugs, heroine or crack cocaine, or no drug use) does predict engaging in risky sexual

behavior (i.e., having sex with an anonymous partner, having sex while intoxicated or

high, having sex with someone known to inject drugs, or exchanging sex for

drugs/money) among MSM who test positive for syphilis in the Metro Atlanta area

(Fulton and Dekalb counties).

These results were obtained by performing a hierarchical regression analysis on

the results of club drug and other drug use as reported on the SIR to determine if one set

of drugs were more likely to predict engaging in unprotected sex.

Theoretical Foundation

Over the past 2 decades research has been conducted in an attempt to determine

how drug abuse begins and its progression. The risk and protective factor theory was

developed by Hawkins and Catalano on the basis of an extensive review of research on

substance use and other problem behaviors among youth (as cited in Temple & Stuart,

2009). As it relates to human disease, this theory suggested that substance abuse and

other problem behaviors can be made less severe by reducing the number of risk factors

and strengthening protective factors within individuals (Temple & Stuart, 2009). Risk

factors include anything within an individual or the individual’s family, peers, or

community that increases the likelihood of developing a problem with substance use

(Temple & Stuart, 2009). In opposition, protective factors are those that decrease the

probability of developing problematic substance use (Temple & Stuart, 2009).

Drug use among MSM is not an all or nothing phenomenon. According to

Santos, Das, and Colfax (2011), there needs to be more emphasis on addressing the

specific patterns of noninjection substance abuse among substance using MSM

(SUMSM), and what implications these patterns have for intervention approaches. Most

SUMSM are not drug dependent, but rather use episodically (i.e., using substances less

than weekly; Santos et al., 2011).

In my research, I evaluated drug use among MSM and the risk factors that have

been presented. The work of previous researchers has shown that both young MSM (aged

16-25) and older MSM (46 and older) engaged in risky sexual behaviors; however, they

differed in the types of sexual risk behavior in which they engaged (Salomon et al.,

2009). Older MSM face their own unique set of challenges, and some of the issues play a

role in their risky sex behavior (Heath et al., 2012). Psychologically, they have concerns

about living up to the idealized standard of younger gay men, desirability, feelings of

worthlessness, depression, and isolation (Heath et al., 2012). It is these factors that may

result in older MSM “trading off” safe sex in order to fulfill their emotional needs (Heath

et al., 2012). Physiologically, older MSM struggle with erectile dysfunction, which is

exacerbated by condom use. Older MSM are also more likely to have used inhaled

nitrates/poppers and to have injected drugs including heroin and steroids, putting them at

risk for HIV and other communicable diseases (Salomon et al., 2009).

In a 2008 the national HIV behavioral surveillance (NHBS) study of New York

City, MSM were recruited at social venues, and researchers found there were high levels

of HIV prevalence, sexual risk behaviors, and substance use (NHBS, 2010). In global

analyses, there was a strong association between noninjection drug use (particularly hard

drug use including cocaine, poppers, and crystal meth), and sexual risk: MSM who used

hard drugs in the past year were over twice as likely to engage in unprotected anal

intercourse (UAI) and nearly three times as likely to engage in UAI with a casual or

exchange partner (NHBS, 2010). In event specific analyses, there were racial/ethnic

differences in the association between concurrent substance use and sexual risk, with the

association especially strong for Hispanic MSM (NHBS, 2010).

The STD Surveillance Network (SSuN) was established in 2005 to improve the

capacity of national, state, and local STD programs to detect, monitor, and respond

rapidly to trends in STDs through enhanced collection, reporting, analysis,

visualization, and interpretation of disease information (Rietmeijer et al., 2009). In

2011, the proportion of MSM who presented to SSuN clinics with P&S syphilis

infection who also were infected with HIV ranged from 14.3% in Los Angeles to 65%

in Baltimore (CDC, 2012 [Figure X]). The median site-specific proportion co-infected

with HIV was 40.4% (CDC, 2012). P&S syphilis was identified by provider diagnosis

and HIV was identified by laboratory report, self-report, or provider diagnosis (CDC,

2012).

Nature of the Study

Sexual risk behaviors are contributing factors for syphilis and other STIs in MSM.

Unprotected receptive anal sex is the sexual behavior that carries the highest risk for

contracting HIV (CDC, 2012). However, oral, anal, vaginal, or penile syphilis sores

make it easier to transmit HIV infection (CDC, 2013). In fact, a person is 2 to 5 times

more likely to get HIV if exposed when syphilis sores are present (CDC, 2013). There

may be some correlation between club drugs and other drug use and high risk sexual

practices that could contribute to rising rates of HIV and other STIs among MSM.

This quantitative, correlational study, therefore, sought to determine if there is any

association between club drug use and sexual risk taking among MSM in Atlanta. There

were several variables associated with this research study. Club drug use was the

independent variable. Sexual behavior/sexual risk taking were the dependent variables.

The information for this study involved the use of secondary data collected from

the State of Georgia’s STD Department. The data came from interviews conducted with

MSM who have tested positive for syphilis. During the consensual interviews (which

were standard procedures for collecting information from syphilis patients), MSM

answered a series of questions as they relate to drug use as well as sexual behavior. The

study associations were tested by using a hierarchical regression analysis to determine

whether club drug use as reported on the SIR is predictive of engaging in unprotected

sex.

Definition of Terms

Acute retroviral syndrome: A condition in which HIV infected people develop

glandular fever-like illness with fever, rash, joint pains, and enlarged lymph nodes

(UNAIDS, 2008).

AIDS: AIDS stands for acquired immunodeficiency syndrome and is a

surveillance definition based on signs, symptoms, infections, and cancers associated with

the deficiency of the immune system that stems from infection with HIV (UNAIDS,

2008).

Barebacking: Commonly defined as intended UAI outside of a “negotiated

safety” association. Negotiated safety arrangements may include open discussion of risk

factors (such as HIV serostatus) prior to sex, the establishment of ground rules for sex

both within and outside a regular sexual association, or agreement on indications for and

frequency of repeat HIV testing (Ayling & Mewse, 2011).

Circuit parties: The phenomenon of the many men who travel on an annual basis

to attend these parties in various areas, domestic and international (Colfax et al., 2001;

Mansergh et al., 2001).

HIV: Human Immunodeficiency Virus, which can lead to acquired immune

deficiency syndrome, or AIDS (CDC, 2012).

MSM: An acronym for the widely used phrase for men who have sex with men. It

categories behavior that emerged in the HIV literature in the 1990s and has since become

more widely adopted (Young & Meyer, 2005). It also identifies a group of men who have

an elevated risk for HIV transmission because of their behavioral risk factors (Young &

Meyer, 2005).

Raves: Parties with loud, electronic techno-rock music, laser light shows, and all-

night dancing held in clandestine locations, including warehouses, nightclubs, and farm

fields (CDC, 2010).

Seroconversion: The development of antibodies to HIV and usually takes place

between 1 and 6 weeks after HIV infection has happened (UNAIDS, 2008).

Definition of Variables

Club drugs: A variety of drugs that have different physiological effects and

mechanisms of action but are called club drugs because they are closely linked to the

dance club scene (Fernandez et al., 2005). Club drugs are often used in social contexts

where sex is the primary object of participation (Bochow, 1998) because they are thought

to enhance sexual pleasure or to have direct aphrodisiac effects (Fernandez et al., 2005).

According to Parsons, Halkitis, and Bimbi, (2006), the most popular club drugs used by

MSM are cocaine, methylenedioxymethamphetamine (MDMA/ecstasy),

methamphetamines, gamma hydroxybutyrate (GHB), amyl nitrates, and more recently

Viagra. The SIR used during the interview was used to capture any use of drugs by MSM

who had tested positive for syphilis and were also at risk for contracting HIV.

Specifically, injection drug use was notated with a yes or no answer. The next step

permitted the selection of five of the aforementioned drugs listed. The MSM’s drug(s) of

choice were indicated with a check mark beside it. This variable was scored individually

and dichotomously, yes/no, depending on the presence or absence of a check mark on the

use of any club drug on the interview record.

Cocaine: The most widely used club drug in New York City (NYC) clubs (Kelly

& Parsons, 2008). It is a Schedule II drug under the Controlled Substances Act of 1970,

meaning that it has a high potential for abuse, but it can also be administered by a doctor

for legitimate medical uses, such as local anesthesia for some eye, ear, and throat

surgeries (U.S. D.E.A., 2010). Cocaine can be snorted through the nose, where it is

absorbed into the bloodstream, injected, where it is released directly into the blood, and

smoked, where absorption into the bloodstream is as rapid as by injection (U.S.D.E.A.,

2010). An indication for cocaine use by the MSM was made on the SIR by placing a

check mark beside it during the interview process if there was any usage. This variable

was scored dichotomously, yes/no, depending on the presence or absence of a check

mark on the interview record.

Crack: The street name given to the form of cocaine that has been processed to

make a rock crystal that produces vapors when heated and is smoked. The crackling

sound produced by the rock as it is heated is how the term crack was so named (NIDA,

2013). An indication for crack use by the MSM was made on the SIR by placing a check

mark beside it during the interview process if there was any usage. This variable was

scored dichotomously, yes/no, depending on the presence or absence of a check mark on

the interview record.

Ecstasy: Methylamphetamine MDMA is a social drug often used in attaining an

optimal social and personal experience. It has been nicknamed as the Love Drug and its

most desirable effects are the perceived closeness and feelings of open and

nonjudgmental communication with others (Blowers, n.d.). It is commonly consumed in

an oral tablet and produces a high that lasts up to 6 hours but the residual effects

potentially remain much longer. Users report typical doses of one or two tablets for

desired effects (Boot, McGregor, & Hall, 2000). An indication for ecstasy use by the

MSM was made on the SIR by placing a check mark beside it during the interview

process if there was any usage. This variable was scored dichotomously, yes/no,

depending on the presence or absence of a check mark on the interview record.

Heroin: An opiate drug that is synthesized from morphine, which is a naturally

occurring substance extracted from the seed pod of the Asian opium poppy plant (NIDA,

2010). Its appearance is usually a white or brown powder or as a black sticky substance,

known as “black tar heroin” (NIDA, 2010). Heroin is a highly addictive drug and can

lead to other severe health problems. It can be introduced into the body by injection,

snorting/sniffing, or by smoking. Injecting and snorting provide passageways to the

bloodstream whereas smoking propels smoke into the lungs (NIDA, 2010). It is

estimated that about 23% of Heroin users become addicted to it because of its ability to

cause decreased physiological and psychological responses in its users (NIDA, 2010). An

indication for Heroin was made on the SIR by placing a check mark beside it during the

interview process if there was any usage. This variable was scored dichotomously,

yes/no, depending on the presence or absence of a check mark on the interview record.

Methamphetamine: A stimulant with the alternate names of Meth, Speed, Ice, and

Tina that increases motor activity, anorexia, increased confidence levels, euphoria, and

increased libido when used in moderation and erectile dysfunction when used in high

doses (McKim, 2003; National Institutes on Drug Abuse, 2002). The U.S. Food and Drug

Administration categorize it as a Schedule II amphetamine because of its high potential

for abuse and psychological or physical dependence (CDC, 2007). An indication for

methamphetamine use was made on the SIR by placing a check mark beside it during the

interview process if there was any usage. This variable was scored dichotomously,

yes/no, depending on the presence or absence of a check mark on the interview record.

Nitrates: Nitrite inhalants (poppers) are peripheral vasodilators used by MSM to

facilitate and enhance sexual intercourse (Romanelli, Smith, Thornton, & Pomeroy,

2004). Recent seroincidence studies estimate that up to 28% of contemporary HIV

infections among MSM can be associated with nitrite inhalant use (Buchbinder et al.,

2005). An indication of nitrite use was made on the SIR by placing a check mark beside

it during the interview process if there was any usage. This variable was scored

dichotomously, yes/no, depending on the presence or absence of a check mark on the

interview record.

Viagra: (Sildenafil) is used to treat erectile dysfunction (impotence, inability to

get or keep an erection) in men (PubMed Health, 2010). It is associated with high risk

sexual behavior independently, but its behavioral risks are greater when combined with

methamphetamine (Spindler, 2007). An indication of Viagra use was made on the SIR by

placing a check mark beside it during the interview process if there was any usage. This

variable was scored dichotomously, yes/no, depending on the presence or absence of a

check mark on the interview record.

Assumptions

This research was a secondary data analysis based on participants who provided

their answers via interviews conducted by Communicable Disease Specialist in Fulton

and Dekalb Counties. The information (data) was stored on electronic files at the Georgia

Department of Public Health office. It was the assumption that the instrument used to

collect the research provided an accurate measure of the variables under study and has

some consistent meaning and correlation within the culture of MSM and club drug use. It

was also assumed that the participants were truthful in their responses regarding any drug

use as well as their sexual behaviors.

It was assumed that substance use increase sexual risks. Many epidemiological

studies include documental information on the association between substance use and

sexual risk behaviors (Wolf & Maisto, 2009). Most MSM who engage in substance use

are not drug-dependent, but rather use episodically (i.e., using substances less than

weekly; Santos et al., 2011). Episodic patterns are associated with high-risk sexual

behaviors, suggesting that while perhaps less concerning from a drug-dependence

perspective, they may contribute significantly to HIV transmission rates among SUMSM

(Wolf & Maisto, 2009).

Scope and Delimitations

The initial data collection was comprised of MSM in the Metro Atlanta, Georgia

area (Dekalb and Fulton Counties) who had previously tested positive for syphilis and

were participants in a Syphilis Elimination Effort (SEE; Georgia Department of Human

Resources, n.d.) based on routine questionnaires. These questionnaires were done in

public health agencies for all people who had tested positive for primary or secondary

syphilis. The information in the analytic database relating to any type of drug use is based

on the voluntary consent of the participant, and they have not been validated for

accuracy. As a result, the study may not reflect a large number of participants who

actually engaged in club drug use, or some may have engaged in drug use but denied that

use, which would make it impossible to determine if drug usage was the cause of their

STI.

The study does not represent the behaviors indicative of MSM, HIV positive

MSM, or any other identity or sexually scripted group within the broader definition of

MSM. Information from the original study (which was designed to reduce syphilis rates)

was used to gather information to assist in determining if the sexual behavior of MSM

who had tested positive for syphilis were influenced by the consumption of club drugs.

Marijuana and prescription drugs are not included in this study because they were not

included on the SIR that was used to collect the original information. No data were

gathered from those MSM who tested negative for syphilis who might be HIV positive

and may also engage in club drug use.

Limitations

The information from this study was secondary and was limited to MSM who

tested positive for syphilis. The interview questionnaire and the study design were

developed by the State STD prevention unit and collected by state and county staff. This

was an ecological, descriptive study explaining the targeted population in the two

counties of Georgia and cannot be generalized to any other county or the state. There

was no opportunity to gain information in regards to the participant’s reasoning for

engaging in club drug use. The only information indicated is whether or not they used

drugs and the type that was used.

Significance

The results of this study could add to existing knowledge about whether club drug

use is a significant risk factor for sexual risk behavior among MSM with syphilis. The

public health community can use this new knowledge for the purpose of developing

interventions and policies to reduce club drug use and also increase condom usage.

Based upon an improved understanding of the association between club drugs and

unprotected sex, there is an opportunity for a reduction in the transmission of STIs like

syphilis. A decrease in syphilis rates may also contribute to a decrease in HIV rates as

well as transmission to children. Noninjection drug use has been identified as an

independent risk factor for HIV (Parry et al., 2008) and is thought to facilitate risky

sexual practices via impaired cognition and increased sexual desire (Drumright & Colfax,

2009; Parry, Carney, Peterson, Dewing, & Needle, 2003; Parry & Pithey, 2006).

Because of the increased prevalence of drug use and associated risk of HIV transmission,

developing effective interventions for drug-using MSM has a high public health priority

(Morgenstern et al., 2009).

Summary

Since the beginning of the AIDS epidemic, researchers in the United States have

demonstrated that MSM continue to engage in risk-taking behaviors with their sexual

partners (CDC, 2004a; Chen et al., 2002; Halkitis et al., 2004; Wilton, 2001). Drug use is

a widespread problem in the MSM community (Cochran, Ackerman, Mays, & Ross,

2004) with an estimated use as high as 19% among gay and bisexual men, with drug-

related problems estimated at 5.7% (Cochran et al., 2004). Club drugs are the most

commonly used recreational drugs among MSM and are often used in combination with

other drugs, are a frequent feature of gay-oriented nightclubs, bars, and circuit parties,

and are commonly used as an enhancement to sexual encounters for MSM (Halkitis &

Parsons, 2002). Drug use, particularly stimulants, can reduce inhibitions (including those

for unsafe sex) and increase sexual drive and it has been consistently linked to HIV-

associated risk among MSM (Colfax et al., 2005; Halkitis & Parsons, 2002).

Because of the increased prevalence of drug use and the risk of HIV transmission

associated with it, there was great need to develop effective interventions for drug-using

MSM (Mongenstern et al., 2009). However, there were questions that had yet to be

answered about the associations between club drug use (cocaine, nitrates/poppers,

ecstasy, methamphetamines, and Viagra) and unprotected sex among MSM in the Metro

Atlanta area (Fulton and Dekalb Counties). Another unanswered question involved

studying the magnitude of the association of club drug use in the same geographical area

compared to other drug use (heroin, crack) or no drug use with engaging in unprotected

sex. To further explore this research project, Chapter 2 provides a detailed review of the

literature and provides more information on MSM behavior and drug use. Chapter 3

encompasses the method of study and provides insight to the research questions and

study hypotheses. Chapter 4 details the data analysis process used in this study as well as

the results. Chapter 5 outlines the study results, discussions, conclusions, and

recommendations.

Chapter 2: Literature Review

Introduction!

This study was a secondary data analysis that tested the effects that club drugs

have on MSMs’ risky sexual behaviors. Club drugs are associated with sexual behavior

for several reasons, including the following: clubs and parties often provide more

opportunities for hook-ups, all drugs and alcohol intoxication diminish decision making

abilities, and club settings typically encourage sexy style and excessive behaviors (LGBT

Drug Rehab, 2010-2013).

After presenting my literature search strategy and theoretical foundation, I present

an overview of MSM and drug use and the risk factors that are involved. The literature

review on MSM and drug use provides information that will lend support to the topic. I

also present information on the effects that individual club drugs have on the body and on

sexual performance to provide a background as to why MSM may have chosen to use one

particular club drug over another or why they prefer a certain combination. This

information is followed by a chapter summary and transition to Chapter 3. There is a gap

in the literature involving drug use of MSM and the effects that they have on

participation in risky sexual behavior (Wolf & Maisto, 2009). I focused on particular

drugs that will be used to further examine such an association and fill the literature gap.

The club drugs under study are methamphetamines, nitrates/poppers, ecstasy, cocaine,

and Viagra. A pattern of use of heroin and crack has been studied and compared to club

drug use.

Literature Search Strategy

The information collected for this research was accessed through Walden

University’s library via Thoreau, which provided the opportunity to search multiple

databases simultaneously. The search criteria used to retrieve articles for this research

were based on the use of the key words MSM, HIV, MSM and HIV, MSM and Club

drugs, Club Drugs, Ecstasy, Sexual Risk Behaviors, Sexual Risk Behaviors and MSM,

MSM and multiple partners, Risk and Protective Factors, STIs, Syphilis, and Exchange

Sex. The accessed studies contained information that was pertinent to MSM and their

sexual risk behaviors and their risk for acquiring HIV and other STIs. The information

presented in my research came from peer reviewed journals and is the most

comprehensive information that is relevant to my study within the past 5 years.

Theoretical Foundation

David Hawkins and Richard Catalano developed the risk and protective factor

theory based on their research on substance use and other problem behaviors among

youth (as cited in Temple & Stuart, 2009). According to this theory, substance abuse and

other problem behaviors can be mitigated by limiting the number or preventing the

development of risk factors and by bolstering protective factors within individuals

(Temple & Stuart, 2009). Researchers suggest that although gay institutions, such as bars

or dance clubs, serve as safe venues for sexual expression, socialization, and

dissemination of information, they also be a host site for the facilitation of HIV risk

behaviors such as drug use, unsafe sex, or the combination of drug use during sex (Green,

2003; Kelly, Carpiano, Easterbrook, & Parsons, 2012).

I decided to use the risk and protective factor theory as a means to review a

pattern of drug use among MSM and to highlight some risk factors involved, which

contributes to the acquisition of STDs. After the risk factors have been identified,

protective factors are often implemented to circumvent the problem that contributed to

the substance use.

Sexual Risk Behaviors

According to the CDC (2013), sexual behaviors that are risk factors for STIs

including having unprotected vaginal, anal, or oral sexual contact, having multiple sex

partners, using drugs and alcohol, and engaging in commercial or coerced sex. The CDC

estimates that, annually, 55, 400 people in the United States get new infections (2011). In

2011, there was an epidemiologic shift in syphilis rates differing from its 2002 rates when

older men (30-39) had the highest rates; increasing cases have been reported in young

MSM (CDC, 2003, 2011). However, MSM accounted for 72% of all P&S syphilis cases

in 2011 (Su et al., 2011). Black, Hispanic, and other racial/ethnic minorities are

disproportionately affected by P&S syphilis in the United States, with black Americans

accounting for most of P&S syphilis among individuals who are not MSM (CDC, 2011).

The sexual practices of MSM comprise a wide area, and there are a number of

health issues that are of concern. Changes in HIV risk behaviors have been seen over

time, which put MSM and their partners at risk. In 2010, MSM accounted for 63% of all

new HIV infections and MSM who use drugs account for another 3% (CDC, 2012).

Because some MSM also have girlfriends and wives, females are at risk also, and

according to baseline data, condom use with them is low and anal sex is quite common

(Biswas et al., n.d.). The dynamics of nondisclosure or inconsistent or incorrect condom

usage by MSM are placing their partners at risk in spite of their own knowledge of HIV

(Biswas et al., n.d.). Despite the many awareness messages already in place for MSM,

there are risk factors (i.e., an unawareness of their partners risk factors, unprotected

vaginal sex, unprotected anal sex, sexual abuse, injection drug and other substance use,

and sexually transmitted diseases) that contribute to prevention challenges for women

(CDC, 2013). All of these risk factors can contribute to the acquisition of HIV.

The surest way to avoid transmission of sexually transmitted infections, including

syphilis, is to abstain from sexual contact or to be in a long term mutually monogamous

association with a partner who has been tested and is known to be uninfected (CDC,

2013). Should infection occur, there are no home remedies or over the counter drugs that

will cure syphilis, but it is easy to cure in its early stages (P&S) with a single injection of

long acting Benzathine penicillin G (2.4 million units administered intramuscularly;

CDC, 2013). Adult MSM associations that are considered to be serious with feelings of

intimacy, trust, and closeness have been suggested by researchers as explanations for the

higher rates of unprotected sex (Davidovich et al., 2004; Theodore et al., 2004; Zea et al.,

2009). Explanations for such behavior are that there is greater trust and familiarity with

serious partners, the perception that condoms interfere with intimacy, and the negotiation

of agreements about acceptable sexual behaviors for the partners as a strategy to increase

safety (Davidovich et al., 2004; Hays et al., 1997; Theodore et al., 2004). According to

Brickman et al. (2008), other factors associated with increased rates of STIs include the

loss of fear regarding HIV transmission because of the increased manageability of the

infection, the use of the internet as an efficient way to find sex partners, increasing use of

erectile dysfunction agents, and possibly the expanding role of oral sex in STI

transmission (Cochran, Ackerman, Mays, & Ross, 2004).

Sex With Anonymous Partners

Methamphetamine use is posing a significant problem among MSM and has

become a public health concern. Its use is associated with high risk sexual behaviors, and

among those, which are listed, are casual and anonymous partners (UCLA Integrated

Substance Abuse Programs, 2006-2012). According to Semple et al. (2004), sexual

behavior that occurs with anonymous partners is an important, yet understudied area in

prevention research. By definition, anonymous partners are unknown to each other, and

the sexual encounters usually take place in parks, bathhouses, public restrooms, beaches,

porn shops, adult theaters, and “on the street” (Semple et al., 2004). In a previous study

of 133 HIV positive gay and bisexual men, the researchers found less use of condoms for

anal sex among HIV positive men who had only anonymous partners as compared to

those who had only steady or casual partners (Semple et al., 2004). The lack of condom

use among HIV positive men and their anonymous partners cause further public health

concern. First, if an anonymous partner who is assumed to be HIV positive, but is

actually negative, engages in sexual risk behavior with an HIV positive partner, viral

transmission is possible (Semple et al., 2004). Second, HIV positive gay and bisexual

men who have unprotected sex with HIV positive anonymous partners may be setting

themselves up for reinfection with a drug resistant strain of the virus (Kelly et al., 1998),

particularly if the anonymous partner has had multiple sex partners in the past. It is

behaviors such as these that contribute to the increase in the number of positive HIV

cases within the MSM population.

In my research, I assessed the sex partner information as provided by each

participant, paying close attention to those who indicated that they had sex with

anonymous partners. From this information I was able to obtain a more accurate account

of the number of people who engaged in such behavior. This analysis can be used to

provide the feedback that could support the need for more public health prevention

strategies in the area of the dangers of MSM and anonymous sex partners through

education and awareness.

MSM often engage in sexual risks that could have negative influences on their

health also putting them at risk for HIV infection. Gay, bisexual, and other MSM

represent approximately 2% of the U.S. population, yet they are the population most

severely affected by HIV (CDC, 2012). Sexual risk behaviors account for most HIV

infections in MSM; unprotected receptive anal sex is the sexual behavior that carries the

highest risk for HIV acquisition (CDC, 2012). Theoretically, high sensation seekers are

more likely to engage in sexual risk than low sensation seekers because they have a

greater value for high risk activities and a higher threshold for determining what is

subjectively risky (Hoyle et al., 2000). Therefore, settings such as gay bars or bathhouses,

sexually oriented events, or a particular partner may present opportunities for sexual risk

and cognitively release the person from sexual norms. In a study conducted by Grov

(2012) involving sexual behavior and HIV status disclosure, samples were recruited from

bars/clubs, bathhouses, and on Craigslist to determine if they differed from each other in

behavior and demographic characteristics. According to the results, men recruited in

bathhouses were the most likely to report that they never discussed their HIV status with

their sex partners. They also reported high number of recent male sex partners (Mdn=7)

and had the smallest proportion of male sex partners that were the same HIV status

(51%), compared with men in bars/clubs (74%) and men from Craigslist (84%) (Grov,

2012).

Substance use may play a role in risk taking processes. My research provides the

opportunity to gather information about participants and to identify risks that might make

them more vulnerable to contracting HIV and STDs. The risk factors can be found in the

Sexual Preferences section of the SIR and include questions such as whether the

participants has had sex with a male, had sex with a female, had sex with an anonymous

sex partner, had sex while intoxicated and/or high on drugs, had sex with a person known

to be an IDU, or exchanged drugs/money for sex. These risk factors were not examined;

they are for information only.

MSM are often users of mind-altering substances, both legal and illegal. Studies

have shown that, when compared to the general population, gay and bisexual men,

lesbian, and transgender individuals are more likely to use alcohol and drugs, have higher

rates of substance abuse, and are more likely to continue drinking into later life (Ostrow

& Stall, 2008). In a population-based study of urban gay men 6 months prior to being

interviewed, 20% of the men reported using poppers (the popular name for various alkyl

nitrites, including isobutyl nitrite, butyl nitrite, and amyl nitrite; DanceSafe, n.d.), 12%

reported using MDMA, and 10% reported using methamphetamines; HIV-infected men

were more likely to report use of multiple drugs and frequent drug use (Stall et al., 2001).

Alcohol and drug use among some MSM can be a reaction to homophobia,

discrimination, or violence they experienced due to their sexual orientation and can

contribute to other mental health problems (CDC, 2010). It can also contribute to

increased risk for HIV infection and other STIs, especially methamphetamines, amyl

nitrates (poppers) and drugs used to treat erectile dysfunction (CDC, 2010). Individuals

under the influence of drugs may increase their risk for HIV transmission by engaging in

risky sexual behaviors or through sharing needles or other injection equipment (CDC,

2010). Previous researchers demonstrated a consistent association between substance use

and sexual risk behavior among MSM (Wells et al., 2011); however, there is a dearth of

information available on the topic in Georgia. Beyond annual events, such as circuit

parties, drug use is common in gay communities and at specific gay venues. In San

Francisco, approximately 50% of MSM who frequented gay venues, such as bars, dance

clubs, parks, and sex clubs, reported having used crystal methamphetamine in the past 3

months (Heredia, 2003). In New York City, 52% and 20% of MSM who frequented

dance clubs reported using ecstasy and crystal methamphetamine, respectively, in the

prior year (Grov, Bimbi, Nanin, & Parsons, 2006; Klitzman, Greenberg, Pollack, &

Dolezal, 2002). MSM who use substances are more likely to engage in sexual risk

behavior (Shoptaw & Reback, 2007; Spindler et al., 2007) and are more likely to be

HIV+ or test positive for a sexually transmitted infection (Drumright & Colfax, 2009;

(Spindler et al., 2007).

Situations affect the concurrency of sexual behavior and substance use and predict

risky sexual behavior (Celentano et al. 2006; Purcell et al., 2005) and HIV/STI

transmission (Carey et al., 2009; Koblin et al., 2006). By using the research questions that

guide this current study, I sought to determine the association between club drug use

(cocaine, nitrates/poppers, ecstasy, methamphetamines, and Viagra) and unprotected sex

among MSM in the Metro Atlanta Area (Dekalb and Fulton Counties). According to the

2011 Sexually Transmitted Diseases Surveillance, Fulton County ranked number 4 and

Dekalb County ranked number 35 in terms of P&S syphilis by reported cases in the

United States (Table 32; CDC, 2012). This information indicates that syphilis is still on

the rise in Georgia. Giving these high rates, it is evident that there are some risk

behaviors taking place in Atlanta, but because the population is understudied, there is no

evidence indicating that substance abuse was a factor. The existing literature was used to

construct the research questions by defining the magnitude of the association between the

aforementioned club drugs compared to other drugs (heroin, crack) or even no drug use at

all as a predictor of engaging in sexual risk behaviors.

MSM Having Sex With Known Drug Users

Drug use plays a large role in the spread of HIV. In the United States, injection

drug use is a leading cause of HIV infection (US Dept. of Health & Human Services,

2011). Injection drug users can get HIV from sharing used needles or other equipment

(works) with an infected person (US Dept. of Health & Human Services, 2011). HIV can

then be passed on to sex and drug using partners (US Dept. of Health & Human Services,

2011). Since the epidemic began, injection drug use has directly and indirectly accounted

for more than one-third (36%) of AIDS cases in the United States (CDC, 2007).

Noninjection drugs (such as “crack” cocaine) also contribute to the spread of the

epidemic when users trade sex for drugs or money, or when they engage in risky sexual

behavior that they might not engage in when sober (CDC, 2007). By assessing the data

from the SIR, I was able to analyze the results for the participants who indicated

having sex with known drug users. The results from this analysis will be beneficial in

contributing to public health departments raising awareness about the diseases that are

common among drug users that may also be transmitted to their partners.

Exchanging Sex For Drugs/Money

Since the beginning of the AIDS epidemic and through the use of epidemiological

data in the United States, researchers have demonstrated that MSM accounted for 61% of

new HIV infections in 2009 and 79% of the infections among all newly infected men

(CDC, 2012). In the same year, among all MSM, black/African American MSM

accounted for 10,800 (37%) new HIV infections (2012). Exchange sex (i.e. sex in

exchange or money, drugs, or other needs) has also been associated with increased risk

for acquisition of HIV and sexually transmitted diseases (STDs) among both HIV-

positive and HIV negative youth (Edwards, Iritani, & Hallfors, 2006 & Roy, Haley, &

Leclerc, 2000). The youth who had a history of exchange sex were more likely to be

HIV-positive than youth with no history of exchange sex (Edwards, Iritani, & Hallfors,

2006).

The exchange of sexual activities for money, drugs, or other goods, a form of

sexual exploitation, has been associated with other risky sexual behaviors, such as earlier

sexual debut (Pederson & Hegna, 2003; Svedin & Priebe, 2007), a greater number of

sexual partners (Edwards, Iritani, & Hallfors, 2006; Pedersen & Hegna, 2003; Svedin &

Priebe, 2007), and involvement in casual sex (Lavoie, Thibodeau, Gagne’, & Hebert,

2010). These behaviors are known to increase the risk of HIV and other STIs; indeed,

youth who had engaged in trading sex were found to be more likely than those who had

not to report a history of HIV/STI diagnosis (Edwards et al.; Greene, Ennett, & Ringwalt,

1999; Roy et al., 2000).

Through the process of exchange sex or “sex trading,” MSM are exposed to

sexual risk behaviors or drug use that could put them at risk for contracting HIV

(Newman & Rhodes, 2004). With each additional encounter is another opportunity for

the spread of disease that contributes to the elevation of HIV rates (Newman & Rhodes,

2004). Among MSM, those who engage in sex trading have been found to be more

likely to participate in unprotected sex with non-sex trading male (Rietmeijer et al., 1998;

Elwood et al., 1997; Estcourt et al., 2000) and female (Elwood et al., 1997) partners than

their non-sex trading counterparts which would lead to increased risk for HIV

transmission in non-sex trading encounters. This behavior increases their own risk for

contracting HIV and also may infect their non-sex trading male and female partners

(Newman & Rhodes, 2004). Very little research has addressed the factors associated

with sex trading among MSM (Newman, Rhodes, 2004), that presents a gap in the

literature.

This information was of importance to my study because exchange sex was listed

as one of the possible risk factors on the SIR designed to collect information about the

MSM under study. Under the topic of Sexual Preferences, the participants had the

opportunity during the interview to answer a question as to whether he has exchanged

drugs/money for sex by indicating Yes or No as appropriate.

Club Drugs

Club drugs refer to a wide variety of dangerous drugs. While club drug use among

MSM has been examined in various areas of the country, its prevalence and associated

HIV risk behaviors within the South Atlantic Region, namely Georgia (Atlanta) had

remained virtually unexplored. Being that there was unexplored territory, there was a

critical gap in the ability to target MSM populations for the opportunity to provide

information on the prevention of STIs including HIV/AIDS prevention and intervention

efforts. Upon fulfilling this gap, this information will be very important to Public Health

and to all those affected.

Patterson et al. (2009) gathered information from a 9-month training program

with Volunteers of America: Kentucky STOP (Stop The Spread of HIV Through

Outreach and Prevention), which was supervised by CDC. Volunteers of America is the

largest provider of HIV case coordination services and is located in Kentucky

(Volunteers of America, 2013). Volunteers with the STOP program provide HIV/AIDS

prevention, testing, and outreach (Volunteers of America, 2013). The members in the

STOP program are MSM as well and one of their duties is to provide outreach services to

venues which are frequented by other MSM. Some of these places include recreational

parks, coffee shops, bars, and any areas where MSM host parties. The data were collected

between March and September of 2004 in order to identify the extent of club drug use

and associated risk behaviors among the local MSM community. In order to receive an

invite to participate in the program, one had to identify himself as MSM and also had to

be sober. To remain in compliance with regular outreach activities, no demographic or

identifiable information was required of the participants. The outreach workers decided

that by maintaining a level of anonymity, the participants would more likely give more

candid responses (Volunteers of America, 2013). According to the researchers, drugs

and alcohol use did in fact increase the participants’ HIV risk. This study is similar to

what I will be conducting. My research is designed to study the association between

recreational (club) drugs and MSM’s sexual risk behavior which increases their risk of

acquiring HIV and other STIs.

My study drew from secondary data that was generated from the administration of

a questionnaire completed by MSM in the Metro Atlanta Area who participated in an

interview with local health departments after testing positive for syphilis. The

questionnaire (SIR) was used to obtain information on the sexual risk behavior of the

MSM (Gwinnett Board of Health, n.d.). Because I used secondary data from the SIR

questionnaire, I did not have to send out invitations for participation. The information had

already been collected and was stored in a secure location. The participants were

contacted as a means to provide testing and treatment opportunities for themselves as

well as their partners in an attempt to stop the spread of disease. Other information

collected from the interview was used to gain more information about the participant’s

sexual behaviors and drugs of choice (Gwinnett Board of Health, n.d.). Being sober was

not a requirement at the time of information collection either. The information could have

come from anyone who had a positive syphilis test at that time.

Club drugs have become increasingly available in New York City and other urban

areas of the United States (Stall et al., 2001; Klitzman et al., 2002). In the United States,

8.3% of adults and adolescents reported using illicit drugs in the last month, and 2.8%

met criteria for a drug use disorder in the past year (SAMHSA, 2007). The authors of

the last decade of research has suggested drug use, particularly methamphetamine, has

been growing among MSM (Parsons, Halkitis, & Bimbi, 2006), with use as much as 10

times higher than in the general population (Colfax & Shoptaw, 2005).

Methamphetamine increases the release and blocks the reuptake of brain chemical (or

neurotransmitter) dopamine, leading to high levels of the chemical in the brain—a

common mechanism of action for most drugs of abuse (NIDA, 2010). Dopamine is

involved in reward and the experience of pleasure and methamphetamine has the ability

to release dopamine rapidly in reward regions of the brain that produces the intense

euphoria, or “rush,” that many users feel after snorting, smoking, or injecting the drug

(NIDA, 2010). Transmission of HIV and hepatitis B and C can be consequences of

methamphetamine abuse. The intoxicating effects of methamphetamine, regardless of

how it is taken, can alter judgment and inhibition and can lead people to engage in unsafe

behaviors, including risky sexual behavior (NIDA, 2010). Long-term consequences of

methamphetamine use include weight loss, depression, and impaired cognitive

performance (Mayer, Colfax, & Guzman, 2006). The use of a “trail mix,” the

combination of two or more drugs to achieve desired effects (Halkitis et al., 2003;

Parsons et al., 2006), is popular in the gay dance scene. As a result of using multiple

drugs, users risk experiencing enhanced negative psychophysiological effects.

One who uses drugs will be the best person to give information as to why he or

she uses. Russell et al. (2008) provided a report on risk factors for methamphetamine

(MA) use in youth. More than 40 electronic databases, websites, and key

journals/meetings abstracts were searched and included studies that compared children

and adolescents who used methamphetamine to those who did not. Among low-risk

youth, a history of engaging in a variety of risky behaviors was significantly associated

with MA use. A history of psychiatric disorder was a risk factor for MA for both low and

high-risk youth. Family environment was also associated with MA use. Many of the

included studies were cross sectional making it difficult to assess causation. Future

research should use prospective study designs so that temporal associations between risk

factors and MA use can be established. In terms of sexual behavior, researchers of two

cross sectional studies independently reported significant association between having

ever previously engaged in sexual intercourse and methamphetamine. The findings are

important to my research study as theoretical based risk and protective factors affect

youth and contribute to or safe guard against substance abuse (NePIP, n.d.).

In an attempt to determine the pattern of club drug use and the relative influence

of club drug use on sexual risk taking Jerome et al., (2009) conducted a study with

participants drawn from the Project BUMPS; a large scale (n=450), longitudinal, mixed

method investigations of club drugs use among gay and bisexual men in New York City

conducted from 2000 to 2004. The participants were divided into two groups, the

seroconverted and the seronegative. Five specific club drugs were the subject of focus

(methamphetamine, MDMA, ketamine, GHB, and powdered cocaine) and the data was

collected in four waves (baseline, months 4, 8, and 12) using both quantitative measures

and qualitative interviews. Both groups indicated having used, on average, four of the

five club drugs, with 44% (n=7) of the seroconverted men and 38% (n=6) of the

seronegative men reporting having used all five club drugs (Jerome, Halkitis, &

Siconolfi, 2009).

The previous research was designed to test associations between MSM, the use of

the aforementioned drugs, and sexual risk factors. A few of the drugs studied are identical

to those which were used in my study but with some variances. Additional drugs that I

used to further test such associations and fill the literature gap were nitrates/poppers, and

Viagra to determine if their usage had any effect on the sexual risk behaviors of MSM.

Earlier criticisms of the purported link between Viagra use and STDs including HIV

infection were mostly based on the fact that other drugs were also taken with the Viagra

and that it was the use of the other drugs and not the Viagra that was more responsible for

the association of Viagra use and STD/HIV incidence (Sugar, 2006). Even though there

are numerous possible drug combinations, given all of the various club drugs that are

available, there are two primary patterns of drug combinations: those for sexual

performance and those considered “party drugs.” The sexual performance combination is

methamphetamine, Viagra, and poppers (Semple, Strathdee, Zians, & Patterson, 2009).

Sexual Effects Of Noninjection Drugs

Injection drug use comes with many risks. The use of non-injection drugs (i.e.

methamphetamines) has been associated with unprotected anal sex with persons of

unknown HIV status among MSM (Semple, Patterson, & Grant, 2003; Koblin, Chesney,

& Husnik, 2003; Chu, McFarland, & Gibson, 2003). Methamphetamines have become

one of the most commonly used recreation drugs among MSM in the West Coast region

(Koblin et al., 2003). In some studies of MSM recently infected with HIV researchers

reported significant associations of unsafe sexual activity with methamphetamine use

prior to the time of HIV diagnosis (Brewer, Golden, & Handsfield, 2004; Taylor,

Aynalem, Smith, Montoya, & Kerndt, 2007). The sexual experiences under the influence

of methamphetamines were described as having increased intensity, prolonged

performance, and orgasm, which were all due to the pleasurable effects of the

methamphetamine. Methamphetamine users reported variable use of condoms, and HIV

negative methamphetamine users were less likely to report use of condoms than were

HIV positive men (Reback, 1997). HIV positive methamphetamine users in this cohort

were likely to report having more sexual partners with whom they participated in

unprotected receptive anal sex than were non-users (Shoptaw, Reback, & Freese, 2002).

According to Taylor et al., (2007), there is a correlation between the use of

methamphetamine and the indulgence of risky sexual behaviors that present the possible

acquisition of HIV and other STIs. Methamphetamine is a drug of choice for MSM (on

this West Coast region) and is known for its ability to make sexual experiences more

pleasurable and enhanced for its users (Taylor et al., 2007). There is no information

available from this study (Taylor et al., 2007) as to the effect of the other drugs that were

also used or the impact that they had on sexual performances.

Summary and Conclusion

In conclusion, testing and treatment of STIs can be an effective tool in preventing

the spread of HIV (CDC, 2010). CDC estimates that 1.2 million people in the United

States are living with HIV (CDC, 2012) and an estimated 50,000 people are newly

infected annually. In 2006 MSM comprised approximately 53% of all new HIV

infections, 12% were injection-drug users (IDU), and 4% were both MSM and IDU (Hall,

Song, Rhodes, et al., 2008). In order to determine some of the factors which contribute to

the spread of HIV/AIDS and possibly other STIs there is a need to study the associations

between club drug use and unprotected sex.

According to researchers, club drugs, including cocaine, methamphetamine,

methylenedioxymethampetamine (MDMA, commonly known as “ecstasy”), gamma

hydroxyl-butyric acid (GHB), and ketamine, are often used in combination with each

other, are a frequent feature of gay-oriented night clubs, bars, and circuit parties; and are

commonly used as an enhancement to sexual encounters for MSM (Halkitits & Parson,

2002). There is a complex association between its (club drugs) use and HIV and it

involves many different facets of social, physical, and psychological health (Drumright,

Patterson, & Strathdee, 2006). I examined the associations between club drug use among

MSM in the Metro Atlanta area (Fulton and Dekalb Counties) and the effects that they

had on the sexual risk behaviors of MSM. The drugs under study were cocaine,

nitrates/poppers, ecstasy, methamphetamine, and Viagra.

Another goal was to determine the magnitude of the association of the above

referenced drugs in comparison to other drugs (heroin, crack) or with no drug use at all in

terms of the effects that they had on sexual risk behaviors of MSM. The results from this

study would help determine which drugs contribute to MSM participating in risky sexual

behaviors that place them at increased risk for contracting HIV/AIDS and other STIs.

Club drug use was the independent variable while sexual behavior/sexual risk taking

served as the dependent variables. Injection drug use and a history of imprisonment and

previous STIs were covariates in the analysis.

Following this comprehensive literature review is Chapter 3, which includes a

detailed description of the data and the analysis proposed to achieve the goals of this

research project.

Chapter 3: Research Method

Introduction

This research was a secondary data analysis that tested the effects that club drugs

have on MSMs’ risky sexual behavior. This chapter will include a review of the methods

and procedures used in this research. The major sections will include the research design

and rationale, sampling and procedures, and instrumentation and operationalization.

Research Design and Rationale

This ecological study was based on an analysis of secondary data collected from

Fulton and Dekalb County Health Departments in the Metropolitan Atlanta Area as a

result of the collaborative effort among federal and local government agencies. The goal

was to determine if there is an association between club drug use (cocaine,

nitrates/poppers, ecstasy, methamphetamine, and Viagra) among MSM who test positive

for syphilis in Metro Atlanta (Fulton & Dekalb Counties) and engaging in risky sexual

behaviors. I further sought to determine if type of drug use (i.e., club drugs, injection

drugs, heroine or crack cocaine, or no drug use) predict engaging in unprotected sex

among MSM who test positive for syphilis in the Metro Atlanta area (Fulton and Dekalb

counties). It is risky sexual behaviors that can potentially make MSM susceptible to

contracting syphilis, HIV, and other sexually transmitted diseases.

Using secondary data from the State of Georgia’s reporting system, also known as

SENDSS, I was able to obtain the information necessary to meet the needs of this

ecological study. This type of study was chosen because my goal was to determine if the

participant is an MSM who has engaged in recreational drug use and if there is a possible

linkage between the drug use and the participant engaging in risky sexual behavior that

could result in them contracting an STI, such as syphilis, or some other sexually

transmitted infection. Using a correlational research design for this analysis allowed me

to gather information that might show a correlation between drug use and risky sexual

behaviors.

A correlational research design is useful to researchers who are interested in

determining to what degree two variables are related; however, correlational research

“does not ‘prove’ associations; rather it indicates an association between two or more

variables” (Creswell, 2008). A correlational research design served to evaluate the nature

and degree of association between two naturally occurring variables (ETR Associates,

2013). It contains two pieces of information: (a) a number, which summarizes the degree

to which the two variables are linearly associated, and (b) a sign, which summarizes the

nature or direction of the association (ETR Associates, 2013). The time constraints

associated with correlational research is that data is only collected one time as their focus

is not based on future or past performance of the participants (Creswell, 2008).

Methodology

Population

Information was collected originally from approximately 500 individuals (MSM)

who had reactive serology laboratory results for syphilis reported by a provider or

laboratory to local and state health departments (CDC, 2003). They may or may not have

been HIV positive and could possibly have had other STIs. The participants were

recruited based on their positive lab results through information that was acquired

through a process known as case reporting. Some of the purposes and uses of syphilis

surveillance using case reporting data at local, state, and national levels are to monitor

rates and trends of infections and to identify persons at risk for syphilis and the affected

communities in which they live (CDC, 2003). They were also chosen because they were

residents of Fulton County, which ranked Number 6 in the state with high syphilis rates

or Dekalb County, which ranked Number 19 (CDC, 2010). All persons with positive lab

results for syphilis were sought for interviews with high regards to those with primary or

secondary diagnosis. The purpose of the original interview was to gather information

from index patients about partners they have had within a defined period of time (CDC,

2008). In addition to eliciting as many partner names as possible, the interviewer

attempted to obtain enough information about the partners so that they can be located and

notified of their possible exposure (CDC, 2008).

Sampling and Sampling Procedures

A minimum of 153 participants of this secondary study were chosen from data

that were reported to Fulton and Dekalb Counties via case reporting. The criteria for

selecting the participants were that they were MSM and had a reactive serology for either

primary or secondary syphilis. This sample size was conducive to representing the

targeted population and the participants met the requirements for this study. My sample

size was calculated by using G*Power 3.1 software using a priori power analysis (Faul et

al., 2009). The effect size was set to 0.15, the alpha to 0.05, and the power to 0.95. With

an alpha of 0.05, essentially the value means that the result could be expected to occur by

chance at least 5 times out of every 100 times the statistical analysis is run (Trochim &

Donnelly, 2007). A power of 0.95 would mean a 5% chance of failing to detect an effect

that is there or a 95% chance of correctly rejecting the null hypothesis when it is false

(Trochim & Donnelly, 2007). Based on the information given and the possibility of

seven predictors, the total minimum sample size was 153.

Data Collection Process

The information that was used in this study contains archival data. The original

data for this study were collected from community providers or laboratories that report

positive serology results as mandated by district health protocols. In order to gain more

information about the participants and their risky behaviors, interviews were performed

whether via telephone or in person. The responses were recorded by the interviewers

(Communicable Disease Specialists, CDS) on a SIR, which is located in Appendix A.

Program managers at the state level were contacted in order to gain access to the data set

to begin the information collection process. They provided permission slips indicating

that use of the SIR was approved by them (Appendix B).

Since I used secondary data (archival), no data were collected specifically for this

study. The information was initially collected during original and secondary interviews of

MSM who tested positive for syphilis infections as a part of standard procedures for

diagnosis and treatment (CDC, 2008). The participants who had positive

results were contacted by a CDS based on information that they listed on information

sheets during the time that they were tested. If they were notified as being a contact to a

case of syphilis, they were contacted based on information that was given by the original

patient (OP). The CDS explained to each person the relevance of the visit or call and

explained the importance of the interview to encourage participation and to ensure that

their information would be confidential and protected. Those who wanted to participate

went on to answer the questions in a private setting where it was just them and the CDS.

Some people refused to participate because they did not want to answer the questions.

Though the preference was for them to participate, it was their right to refuse.

The information was then stored in a State Electronic Notifiable Disease

Surveillance System (SENDSS), a web-based reporting system designed to collect

information pertaining to notifiable diseases in Georgia (Public Health Preparedness,

n.d.). The ability to use SENDSS makes reporting more efficient and timely. It allows

public health agencies to track data and follow-up with affected individuals (SENDSS,

n.d.). It is also used to identify outbreaks and examine disease trends across the state

(SENDSS, n.d.). Reporting is done at the users’ convenience and is structured to guide

the user through the information needed for each disease, such as pertinent laboratory

information, making it a user friendly system (Public Health Preparedness, n.d.). Anyone

who has a computer with internet capabilities and has been approved can log on to

SENDSS. At the main login screen, click on the Register Here button. Once a potential

user has provided the Georgia Division of Public Health with some general information,

he or she will be assigned a temporary password and will be notified via email. When full

use is granted, user IDs are established so that potential users can only view records that

are part of their hospital system, county, or district.

The dataset was obtained from the State of Georgia Division of Public Health’s

STD division in order to be used in this research. I contacted them verbally and followed

up with a written letter seeking permission to use their data. A copy of the approval letter

is placed in Appendix C.

Instrumentation and Operationalization of Constructs

The initial process for collecting information for this study was recorded on paper

and then transferred to a Sexually Transmitted Disease Management Information System

(STDMIS) database. First released in 2004, the Performance Measures for the system

included timeliness of P&S syphilis interviews, timeliness of treatment for contacts to

P&S syphilis cases, associates and suspects tested, associates and suspects treated, and

timeliness of gonorrhea interviews (CDC, 2011). The information was reviewed by the

CDS who initially conducted the interview and then was reviewed again by a supervisor

before the case could be considered to be complete and closed. SENDSS is the online

database established as a repository for this information and is available for use statewide

(GDPH, n.d.). This database was appropriate for the current study because it contained

information relevant to each MSM who has tested positive for syphilis. The information

stored here is encrypted with Verisign certification. Each public health official and

healthcare provider who has access to this system is given a password to a set of web

pages and web-based tools. New users will be permitted to use the system after they have

registered on the SENDSS site. The information being reported here includes lab

confirmed as well as clinical diagnoses, which are reportable according to the specified

time interval as outlined on the Georgia Notifiable Disease Report Form. Permission was

sought and granted from officials at the State Division of Public Health to analyze these

data that were originally obtained from health districts in order to stage, diagnose, and

treat syphilis cases. The database for this project was extracted from SENDSS and

recreated using a form of secondary data analysis.

This information from SENDSS is appropriate to the current study because this is

the database that the labs and providers use to report positive serology to the health

departments and the state office before any follow-up work can be done. After the

investigations have begun, additional information is collected on SIRs. The dataset

included MSM participants from the original data and also included demographic

information that allowed respondents to answer questions about the areas in which they

live, housing type, sexual orientation, alcohol and drug usage, and sexual behavior risks.

Appendix A contains the SIR used to collect the information. The questions were

multiple choice questions where the participants could check the box that was applicable

to them or that best described their living situation. There was no published information

on the reliability of the SIR; however, it remains the single source of information

collection during the process of interviewing MSM who have tested positive for syphilis

in Georgia (Gwinnett County Board of Health, n.d.).

Social History

To further capture information about the participant, the SIR was used. Its social

history section captured demographic information about each participant in terms of their

marital status, primary language, country of birth, current and past addresses, education,

and contact information. The collection of such information served as identifiers when it

comes to searching for previous STI history. The current address allowed for the

collection of information that would help to insure that the morbidity was claimed for the

correct county. This information contributed to providing each county’s rankings based

on the number of positive lab results, and they were categorized accordingly. One

challenge that comes with interviewing is finding a homeless individual who has no

home address (UNC, n.d.). Sometimes the only information known is what soup kitchen

he or she frequents, or finding a prostitute based only on what streets he or she works

(UNC, n.d.). This social history was not used in my study; it was for information only.

Sexual Behavior

Information was also captured on the participants’ sexual behaviors. At a

minimum, data should be analyzed by demographic and risk behavior characteristics,

including gender of sex partners (CDC, 2003). This information was collected to

determine if the patient had engaged in sexual activities with a male, female, anonymous

partners, had sex while intoxicated and/or high on drugs, had sex with a person known to

her/him to be an IDU, exchanged drugs/money for sex and (female only), or had sex with

a person who is known to be an MSM. Each response was indicated with Y-Yes, N-No,

R-Refused, or D-Did Not Ask. This information was included in my study.

Social Behavior

This section of the SIR captures information about the types of environments or

social networks frequented by MSM. Network analysis is defined as the study of how

people connect in social structures and of its implications (Potterat, 1998). When the

questions were presented about the partners they have had within the past 12 months,

participants were permitted to choose between males, females, transgenders, and also the

numbers of each. In this same section, information could also be gathered about the

places they met their partners as well as the places in which they had sex. The CDS

would note as to whether it was a club, grocery store, or a home and indicate specifically

the name. It is especially important to understand the role these venues have in the spread

of HIV and STIs so that interventions can be tailored and/or marketed to those who

frequent these venues (Aynalem et al, 2006). This information was not used in my study

but for information only.

Drug Use Behavior

Information captured here is indicative of the engagement of drug use within the

past 3 months as well as the past 12 months. First, a general question was asked about

whether or not the participant engaged in injection drug use. The choices included

circling Y-Yes, N-No, R-Refused, and D-Did Not Ask. The drugs of choice of injection

or non-injection drugs included cocaine, heroin, crack, nitrates/poppers, ecstasy,

methamphetamines, erectile dysfunction medications (e.g. Viagra) or none (Supplemental

Interview Record, n.d.). Any admission of drug use would be recorded by placing a check

mark in the blank beside the drug that was used by the participant. An empty blank was

provided just in case they used a drug that was not listed on the questionnaire and wanted

to list it.

Other Risk Factors

Other information that is relevant to this study included the collection of

information in regards to incarceration and will be included in the study as covariates.

The participant was asked if he had been incarcerated? If a yes response was given, the

next step would be to ask if the incarceration was within a 6 month or 12 month time

frame. Answers in these sections include a choice of circling Y-Yes, N-No, R-Refused,

and D-Did Not Ask. Also included in this section was information on a previous STI

history. The possible responses included placing an “X” on Y-Yes, N-No, R-Refused, or

D-Did Not Ask.

There were several variables used to collect information, but they were not used

in this research. The information used was captured during the interview of the MSM by

the CDS. Most often, the public health clinic provides a safe and convenient setting in

which to interview and counsel patients compared to a field setting (CDC, n.d.). In the

initial collection process the participants’ names were used to accurately record their

information. A lot system requires that case management records be maintained in a

single folder (CDC, n.d.). The goal of the lot system is to assure that all obtainable

information regarding the continuing management of cases contained in a lot is readily

available to all responsible workers (CDC, n.d.).

Data Analysis Plan

The original database for this study was created using the SIR and then deposited

into SENDSS. The dataset included information about MSM who had tested positive for

primary or secondary syphilis and were sometimes co-infected with HIV. Also included

was information about their social history, sexual behavior, drug use behavior, and other

risk factors. Permission was granted from public health officials in the STD/HIV unit to

analyze this data. The dataset contained no identifying information that could be linked

with other data in the files.