HIV COUNSELOR PERSPECTIVES Volume 14 Number 3 July 2005

DRUGS, SEX, AND HIV TRANSMISSION The effect of substance use on sexual activity has been an engine driving the epidemic since its inception. Changes in sub- stance-use patterns, however, have changed the shape of this effect. The Research Update in this issue of PERSPECTIVES reviews some of these shifts—including sharp increases in the use of substances such as methamphetamine, Ecstasy, and drugs for erectile dysfunction, and new combinations of substances—and looks at how substances affect both the physiology and psy- chology of sexual behavior and HIV risk. The Implications for Counseling section focuses on those clients, in particular, whose shame and fatalism about sexual behavior, substance use, and HIV risk inhibit a belief that prevention is possible.

butyl, isobutyl, and amyl nitrites ing unprotected receptive anal inter- Research Update (poppers); marijuana; methamphet- course were 4.2 times more likely to The combination of sex and drugs amine; methylenedioxymetham- be HIV-infected than men who had may be the most potent force currently phetamine (MDMA, Ecstasy) and unprotected receptive anal intercourse propelling the HIV epidemic in the sildenafil citrate (Viagra).1-4 without ever using poppers.9 The United States. This combination does For example, in urban gay male researchers postulated that an HIV- not represent a new phenomenon, but communities, substances have a strong negative person with a history of pop- a review of the recent literature sexual association and are used specif- per use and unprotected receptive anal describes shifts in substance-use pat- ically to facilitate or enhance sex.3,5,6 sex had 5.5-fold increased odds of terns and in cultural and social con- Further, over the past 10 years, these becoming HIV-infected in the future. nections between substance use and associations have expressed them- Similarly, a 1998 San Francisco study sex. While this research has not estab- selves in new ways, including “party of 337 gay men examined associations lished the precise cause-and-effect and play,” the combination of drug between various substances and time relationship among substance use, use (party) and sex (play); circuit par- to HIV seroconversion. The data sexual behavior, and HIV serocon- ties, large weekend-long parties held showed that a continuing history of version, data on the physiological and sequentially in different cities and popper or amphetamine use strongly psychological effects of substance use often involving both sex and drug use; increased the chances of HIV sero- offer insights into this complex phe- internet chat rooms; and an epidemic conversion, but current use (with no nomenon. of methamphetamine use. The research encompasses multi- Drug Use and Seroconversion Data ple populations, but recent studies Inside PERSPECTIVES have tended to focus on men who Many studies have found positive 1 Research Update have sex with men. Researchers have associations between HIV serocon- found that the following substances version and non-injection substance 5 Implications for Counseling are associated with sexual behavior use, particularly methamphetamine, 7 Case Study 4,7-9 that has a high risk of HIV trans- cocaine, Viagra, and poppers. For 8 Test Yourself mission, particularly unprotected example, a 1992 study of 481 men who 8 Using PERSPECTIVES anal intercourse: alcohol; gamma have sex with men found that men hydroxybutyrate (GHB); ketamine; who always used poppers while hav-

2 PERSPECTIVES: DRUGS, SEX, AND HIV TRANSMISSION history) of these substances did not.10 men who have sex with men found of another, and this combination may The study found, however, that cocaine that 40 percent used more than one increase HIV-related risk. users were more likely than non-users drug at a time.3 In this sample, pri- Alcohol. Alcohol, ingested in liq- to seroconvert; in fact, an analysis of marily of men of color, alcohol, mar- uid form, depresses the central nerv- risk factors found that current cocaine ijuana, and poppers were the most ous system and slows brain func- use, in itself, was almost equal to popular substances. However, less tioning, respiration, and blood engaging in unprotected anal inter- than 5 percent of the men reported circulation.17 Although often used in course in predicting seroconversion. using any drug, besides alcohol and the context of sexual activity and seen Finally, a 2004 San Francisco study marijuana, more than twice a week. as an aphrodisiac, alcohol can impair of more than 9,000 male HIV anti- A New York study of 450 men who erection and ejaculatory ability and body testing clients found that men have sex with men found that of the decrease sexual arousal in men. In who have sex with men who had 65 percent who used methamphet- sexual situations, people who are used either amphetamines or Via- amine, many used that drug in com- using other substances, especially gra had a significantly increased risk bination with other substances.14 stimulants, often use alcohol as well. of HIV infection.11 Further, men who Almost 56 percent of the metham- Methamphetamine. Methampheta- have sex with men who used both phetamine users also used alcohol, mine—ingested, injected into the methamphetamine and Viagra in the 50 percent used Viagra, 44 percent bloodstream, snorted, smoked, or prior year were almost four times used ecstasy, and 41 percent used inserted anally—is a synthetic stim- more likely to seroconvert than those poppers. Black men were less likely ulant, similar to amphetamine, that who used neither substance. The to use methamphetamine than White, increases central nervous system study linked seroconversion with Latino, or Asian American men. activity. Methamphetamine use is non-White ethnicity, especially among Studies have also found significant epidemic in the western United States African Americans. Likewise, a recent regional differences in patterns of among men who have sex with men San Francisco study of almost 3,000 drug use. For example, a large inter- in urban settings and is increasing men who have sex with men found net study of almost 3,000 gay and among men who have sex with men that amphetamine-using men were bisexual men found that metham- in New York City.14 three times more likely than non-users phetamine use is much more com- Methamphetamine, particularly to have recently seroconverted.12 mon in the western United States than the form called “crystal meth,” which in other parts of the country.15 Alter- is the powdered, smokable form of Patterns of Substance Use nately, the same study found that men the drug, can lead to hypersexual- There has been a great deal of from the northern and south-central ity.17 Users report greatly increased research about prevalence and pat- areas of the country were more likely sex drive, increased sexual pleasure, terns of substance use among gay and to report drinking until drunk than multiple orgasms, and delays in bisexual men. Many studies have men on the West Coast. There were, orgasm, which allows them to have found that men who have sex with however, no significant regional dif- sex for longer periods.5,8,17 Metham- men use a wider range of substances ferences in popper or cocaine use. phetamine’s euphoric effects may than do heterosexual men, although also block pain, which can facilitate it is not clear if lifetime use is higher Physiological Effects: A Brief Survey rougher sexual activity or mask the among men who have sex with men A survey of some of the physio- than among heterosexual men.3,6 One logical effects of substances associ- study comparing heterosexual and ated with HIV transmission sheds gay men living in San Francisco in the some light on the complex physio- A San Francisco 1990s found the prevalence of mari- logical interactions among substance study of 3,000 juana, poppers, Ecstasy, and metham- use, sexual activity, and HIV trans- phetamine to be higher in gay men.6 mission. Overall, researchers have men who have sex Interestingly, research has found that found that substances can lower with men found that most gay men do not use any single immune responses, for example, substance frequently enough to con- CD4+ cell production and CD8 cell amphetamine-using stitute chronic use or abuse.6,13 activity, making it easier to contract men were three times Consistent with these findings, HIV.1,16 Further, drugs and alcohol researchers have found that men who can impair judgment, undermining more likely than have sex with men, in particular, tend sexual negotiation and follow non-users to have to use more than one substance, either through on risk reduction. Finally, in combination or sequentially.2,6 For people may use one substance to recently seroconverted. example, a study of 456 HIV-positive counteract the less desirable effects PERSPECTIVES: DRUGS, SEX, AND HIV TRANSMISSION 3 pain or irritation resulting from injury to sensitive areas such as the penis, Relation of HIV Incidence to Amphetamine and the vagina, or the lining of the rec- Viagra Use: Results of Two Studies tum. Dehydration, caused by drug- induced increases in respiration and club activities such as dancing and sex, also increase the opportunity for 8 7.7 tearing and other injury during sex- 7 ual activity. Further, methamphetamine can 6 6.3 cause erectile dysfunction, sometimes 5 called “crystal dick.” This inability to Users of both substances produce an erection in combination 4 4.1 with an urgent sexual drive leads Amphetamine Users otal Sample 3 iagra Users some men who are using the drug to T V Non-Users engage in receptive anal sex, creating Incidence (%) 3.0

2 otal Sample 2.5 T what are sometimes called “instant HIV 2.3 2.1 bottoms.” Men may also combine 1 methamphetamine with drugs such 1.3 Amphetamine Users People who used while having sex as Viagra to maintain an erection.5,8,17 0 Drugs for Erectile Dysfunction. Viagra and Amphetamine Amphetamine Use Drugs for erectile dysfunction such Use among Repeat Testers11 among Testers12 as Viagra, tadalafil (Cialis), and var- denafil (Levitra) are legal and easily procured prescription medications reduces their sexual desire and abil- the smooth muscles around a person’s which come in the form of ingestible ity to achieve orgasm. blood vessels and the anal sphincter tablets. They promote erection and Ecstasy. Usually ingested in pill and provide a quick rush of eupho- subsequent erections after ejacula- form, Ecstasy increases serotonin lev- ria. These inhalants have long been tion by increasing blood flow to the els in the brain, producing a sensual called “the gay drug” because the penis, counteracting the erectile dys- and sexual euphoria.1,17 Users report relaxing effect on the anal sphincter function caused by some substances, overall a more sensual than sexual can facilitate receptive anal sex.17 Pop- notably methamphetamine.4 Erectile experience, and a decrease in ability pers dilate blood vessels in the anus, dysfunction drugs may also facilitate to have erections and orgasms. increasing the likelihood of HIV trans- insertive anal sex, which requires a Ecstasy, along with GHB and pop- mission.9 They also lower blood pres- harder erection than vaginal or oral pers, is considered a “club drug,” used sure, making it dangerous to combine sex. Use of these drugs can result in in combination with dancing and par- them with other substances such as rare circumstances in priapism, the tying because of its tendency to Viagra that also reduce blood pres- painful enlargement of the penis enhance appreciation of music, lights, sure.7 The combination of nitrates and for more than four hours. and other sensory stimulation of club Viagra can lead to dizziness, fainting, Cocaine. Cocaine is most often environments. heart attack, or stroke.18 snorted, injected, or smoked. It is a GHB. Usually ingested as a fluid, stimulant of the cental and periph- GHB is known as “liquid ecstasy.”17 Drug and HIV Treatment Interactions eral nervous system, constricting It enhances the levels of the brain HIV antiviral medications inter- blood vessels and elevating mood.17 chemical dopamine, depressing the act with substances in ways that may In some forms, cocaine can increase activity of the central nervous system. influence sexual activity in people arousal, but it can also decrease sex- It produces euphoria and is also used with HIV. For example, protease ual functioning. In particular, “crack” as an aphrodisiac. In larger quantities, inhibitors appear to raise levels of cocaine, a form that is usually GHB can cause unconsciousness, and Ecstasy and methamphetamine in smoked, has been linked to hyper- in this context it has been linked to the bloodstream, greatly exaggerat- sexuality, but this may be an inaccu- date rape. GHB is often used along ing the effects of these drugs.8,16 rate perception, based primarily on with other club drugs such as ecstasy Conversely, substance use may lead increased sexual activity among crack to counteract their stimulating effects.1 to increased viral load in people on users who may trade sex for money Poppers. Studies have shown that antiviral medications either by alter- or drugs.17 In fact, studies have found poppers—volatile liquid nitrites ing the metabolism and efficacy of these that crack users report that the drug whose vapors are inhaled—relax both medications or by decreasing treat-

4 PERSPECTIVES: DRUGS, SEX, AND HIV TRANSMISSION ment regimen adherence. One longi- making it easier to have sex with- heterosexually identified metham- tudinal study compared HIV viral load out an emotional connection.21 phetamine users found that most par- in HIV-positive methamphetamine In a small qualitative study of ticipants were in the contemplation users with viral load in nonusers.19 methamphetamine users, HIV-nega- stage and preparation stage (also Subjects who had positive urine tests tive users reported using the drug to known as the “ready for action” for methamphetamine at the time of cope with emotional pain and bore- stage) with regard to protecting them- the study had increased plasma virus dom, and to rationalize sexual risk selves from HIV transmission. That loads only if they were receiving triple behavior.5 Even men who admitted is, they were aware a problem existed combination antiviral treatment. Those there is a risk of HIV transmission but were ambivalent about change, who were untreated or receiving mono- tended to transfer the responsibility or they were preparing for changes or dual-drug therapies did not have for safer behavior onto their partners they might make in the future.23 elevated viral loads, nor did those who rather than taking it on themselves, The researchers suggest that focus- did not use methamphetamine. The especially when high on metham- ing on condom use skills, encourag- researchers theorized that this occurred phetamine.5 Former methampheta- ing positive social norms favoring HIV because methamphetamine may, in mine users in another study also stated prevention behaviors, and raising fact, affect both metabolism of the that they had felt less responsible about awareness of the risks for other sexu- antiviral treatments and adherence to HIV transmission to other people while ally transmitted diseases are ways that these regimens. they were using. In a follow-up to this counselors can help people move from study, researchers found that although the contemplation to the preparation Psychological Effects of Substances condom use did not increase substan- stage.23 Finally, the researchers found The recent research on the psy- tially over the year after drug treat- that participants in the contemplation chological effects of substance use on ment, participants’ sense of responsi- stage used more methamphetamine HIV-related sexual behavior derives bility about HIV transmission did.22 than those in the preparation stage, primarily from relatively small qual- Finally, methamphetamine use may indicating that reduction in drug use itative studies of methamphetamine lead to sexual compulsivity that extends and movement toward HIV-related users. These studies have found that to a loss of control over sexuality, as risk reduction may in some way be drug use and dependence is often well as lapses in judgment and ability linked to each other. As another associated with denial and the desire to negotiate safer sexual practices. In a researcher puts it, “What remains to for escape. For example, ethnographic qualitative study of 34 HIV-positive be demonstrated is whether or not sex- studies of substance users, especially men who have sex with men who were ual risk reduction follows from alter- those who use methamphetamine, also former methamphetamine users, ations in the sex-drug-using” behav- have found that both HIV-positive participants said that when they were iors or whether sexual behaviors must and HIV-negative men who have sex using, they engaged in behaviors that change in order to reduce drug use.20 with men use drugs, at least partially, they would not have ordinarily agreed to reduce their anxiety about either to if they had not been using. These Conclusion contracting or transmitting HIV.5,20,21 behaviors included unprotected recep- Although it seems clear that there In a large circuit party study, tive anal intercourse.22 is a relationship between drug use and researchers asked 1,169 men who have HIV-related sexual activities, much sex with men why they attend the par- The Stages of Change remains unknown about the causal ties. Participants responded that they The HIV counseling session is by links between these two behaviors. attended the parties: to be wild and definition limited: counselors are More research is necessary, especially uninhibited (68 percent), to party and rarely able to directly address sub- about motivations for using drugs use drugs (58 percent), to have sex (43 stance dependence and its psycho- with sex; the reasons for the rise of percent), and to forget about HIV and logical underpinnings. However, social phenomena such as circuit par- AIDS (14 percent).2 Most of the par- counselors may be able to help clients ties, party and play, and metham- ticipants were HIV-negative, and understand the effects of substance phetamine use; the implications of the predominant substances of choice use on sexual activity and HIV trans- these phenomena for health and well- were alcohol, Ecstasy, and ketamine. mission by applying the Stages of being; and the ways HIV prevention A smaller study of 25 HIV-posi- Change model to both substance- might be applied in these contexts. tive men who have sex with men related and sexual behaviors. The Even without clear answers to some described motivations for using model describes readiness to change of these questions, recognizing the methamphetamine, including mak- a behavior in terms of five stages: pre- complexity of the drug-sex interac- ing sex more pleasurable, facilitating contemplation, contemplation, prepa- tion for individual clients can aid sexual expression, making it easier ration, action, and maintenance.23 counselors in implementing client- to approach sexual partners, and One study of 212 HIV-negative centered prevention counseling. PERSPECTIVES: DRUGS, SEX, AND HIV TRANSMISSION 5

meet people. Gus said he now uses Implications for Counseling crystal habitually, “because it’s more intense and easier to just have sex The primary prevention goal of to reduce risk are actually thinking without an emotional connection.” HIV counseling is to enhance or clar- about—contemplating—HIV risk Karla reframed Gus’s words by say- ify people’s perception of their HIV and even HIV prevention. As diffi- ing, “You didn’t get what you wanted risk and to support their capacity to cult as shame and fatalism are, they out of dating, so you found a way to prevent infection in the future. To may offer an opportunity for HIV have sex without having to worry achieve this goal, counselors explore prevention counseling. about getting disappointed when an areas where HIV is a concern—pri- When shame and fatalism are dom- ongoing relationship did not develop.” marily sex and drug use—and then inant themes in a session, motivating In this way, Karla highlighted an build motivation for prevention by a client to prevent HIV in the future example of Gus’s ability to create what acknowledging past successes. This requires a counselor’s concerted effort he once perceived as a life-enhanc- kind of empowerment, however, can to convey a neutral stance and uncon- ing change. At the same time, Karla be particularly difficult to achieve with ditional positive regard. Three tools helped reveal discrepancies in Gus’s clients whose shame and fatalism can help counselors intervene most thinking. By reflecting back to Gus his about sex, drugs, and HIV inhibit their effectively: uncovering past successes; deeper feelings of disappointment belief that prevention is possible. giving specific and authentic praise; Karla sought to spark Gus’s thinking and negotiating realistic, incremental by distinguishing between his fatal- Challenges of Shame and Fatalism change. The following hypothetical ism about risk behavior and his fatal- Mixing drugs with sex can physio- scenarios aid in discussing these tools. ism about not finding someone to date. logically and psychologically facilitate Karla’s goal was to help Gus con- HIV transmission. Cultural forces may Uncovering Past Successes ceive of change in the future by bring- also influence a client’s motivation to Feeling both a motivation to change ing to light his capacity to change in prevent HIV. For example, drug use is and a belief in the possibility of suc- the past. From Gus’s perspective, often stigmatized—particularly when cess facilitates behavior change. To having sex without worrying about it is combined with survival sex and help a client achieve these attitudes disappointment was a demonstra- pleasure-seeking sex—potentially con- in the face of the client’s shame and tion of his capacity to meet his needs. tributing to a client’s internalized fatalism, counselors may have to look Unfortunately, this change has also shame and doubts about the value of beyond HIV prevention to discover increased Gus’s HIV risk. This means his or her health. ways in which the client has demon- that looking at the change from Gus’s Additionally, since most people strated a capacity to change in the past. perspective is only one step to moti- know the “safest” forms of prevention For example, with a client who sees vate him toward HIV prevention. but have difficulty practicing them, no need to change behavior “because Getting to the other steps, however, clients may frame having sex that is contracting HIV is inevitable,” a coun- can be challenging if a counselor is not risk-free as “failure.” Faced with selor may explore the context of the impeded by his or her judgments all of these issues, some people give client’s sex life and drug use to uncover about a client’s behavior. up completely on prevention, ashamed how the client has increased his or her of past behaviors and fatalistic about satisfaction with these activities, inde- Specific and Authentic Praise the inevitability of future ones. pendently of reducing the HIV risk Fatalistic clients are often ambiva- Broaching behavior change under related to them. The counselor thereby lent; they have thought about change these conditions is especially tricky helps the client think differently about but feel that it is impossible. For a per- because the shame of not using pro- his or her ability to create change by son who is in the contemplation stage, tection reinforces existing shame, con- highlighting a past shift from feeling tributing to HIV risk. In the words unable to make a life-enhancing change of one client, “I should be using a to being able to make one, from a sense A Counselor’s Perspective condom every single time, but I don’t. of futility to a sense of possibility. I’m probably positive. That’s my pun- “Karla,” a counselor working with “Change doesn’t happen ishment for what I’ve done.” “Gus,” a gay man who has anony- Counselors may find consolation mous unprotected anal sex, took this in the absence of hope.” in the fact that shame and fatalism approach by asking: “How did you Reverend Yvette Flunder, are often signs of contemplation. first figure out sex parties would be Client’s who are ashamed of past something you’d like?” Gus had tried Executive Director, unprotected sex because of its HIV dating without much success and The Ark of Refuge, San Francisco risk or who assume that they will fail started using methamphetamine to

6 PERSPECTIVES: DRUGS, SEX, AND HIV TRANSMISSION the main intervention is to explore pros to build rapport—the ability to a loss and quickly responded to and cons. Contemplative clients need empathize—can lead them to iden- Kathy’s story by saying, “I’m so glad to voice their ambivalence—which may tify with a client’s despair. In an you came in for a test.” also mean voicing hopelessness and attempt to find something to praise, Because Carlos noticed his neu- resignation—without having the dis- counselors often look for any attempt tral stance was off kilter, he made a comfort of their experience taken away of the client’s to practice HIV pre- process comment and followed it by a counselor’s inauthentic praise. vention, which is the precise thing with an open-ended question: “That Stigma and internalized shame about which the client feels hopeless. didn’t sound quite right. How do you often make clients particularly sensi- One of the easiest routes out of this feel once the horniness wears off?” tive to negative judgment. One of the trap is for the counselor to continue Eventually, Carlos learned that Kathy easiest ways to lose rapport with clients exploring the client’s experience with had recently disconnected her tele- who are vigilant in this way is to offer open-ended questions. Eventually, phone, which in turn meant she had nonspecific praise in the hope that any because all people exhibit strength and fewer tricks, less crack, and less praise is better than none. Coming resilience, the client will reveal some- unprotected sex. After hearing this, across as phony, however, can under- thing that deserves to be acknowledged Carlos offered specific praise that mine a counselor’s credibility and through specific and authentic praise. authentically highlighted Kathy’s devalue moments of authentic praise, An example of this process is the ability to change, hoping that this leading clients to suspect that judg- experience of a counselor, “Carlos.” would build Kathy’s confidence ments are interfering with the coun- Carlos worked with “Kathy,” who about effecting future changes. selor’s ability to be honest. had unprotected sex with HIV-pos- Authentic positive regard is par- itive men but did not care in the Negotiating an Incremental Step ticularly challenging to express in the moment because being high on crack If, through specific and authentic face of a client’s shame and fatalism. made her feel “horny.” Like many praise, counselors can help clients The very skill that counselors rely on beginning counselors, Carlos felt at remember other times in their lives

References 9. Seage GR, Mayer KH, Horsburgh CR, et al. 16. Urbina A, Jones K. Crystal methampheta- The relation between nitrite inhalants, unpro- mine, its analogues, and HIV infection: Med- 1. Romanelli F, Smith KM, Pomeroy C. Use of tected receptive anal intercourse, and the risk of ical and psychiatric aspects of a new epidemic. club drugs by HIV-seropositive and HIV- human immunodeficiency virus infection. Amer- Clinical Infectious Diseases. 2004; 38(6): 890–894. seronegative gay and bisexual men. Interna- ican Journal of Epidemiology. 1992; 135(1): 1–11. tional AIDS Society—USA: Topics in HIV Medi- 17. Peugh J, Belenko S. Alcohol, drugs and sex- ual function: A review. Journal of Psychoactive cine. 2003; 11(1): 25–32. 10. Chesney MA, Barrett DC, Stall R. Histories of substance sue and risk behavior: Precursors Drugs. 2001; 33(3): 223–232. 2. Mattison AM, Ross MW, Wolfson T, et al. Cir- to HIV seroconversion in homosexual men. 18. Patient summary of information about Via- cuit party attendance, club drug use, and unsafe American Journal of Public Health. 1998; 88(1): . Journal of Substance Abuse. gra (sildenafil citrate) tablets. Viagra. 2002; sex in gay men 2001; 113–116. 13(1–2): 119–126. http://www.viagra.com/pi/prodInfo.html. 11. Loeb L, Kellogg TA, Nelson K, et al. Recre- 3. Purcell DW, Parsons JT, Halkitis PN. Sub- 19. Ellis RJ, Childers ME, Cherner M, et al. ational use of Viagra is independently associ- stance use and sexual transmission risk behav- Increased human immunodeficiency virus loads ated with HIV seroconversion, San Francisco. ior of HIV-positive men who have sex with men. in active methamphetamine users are explained Presentation from the XIV International AIDS Journal of Substance Abuse. 2001; 13(1–2): 185–200. by reduced effectiveness of antiretroviral ther- Conference, Barcelona, Spain, July 2002. apy. Journal of Infectious Diseases. 2003; 188(12): 4. Loeb L. Viagra: The science and politics of 1820–1826. drugs, sex, and risk. FOCUS: A Guide to AIDS 12. Buchacz K, McFarland W, Kellogg TA, et al. Research and Counseling. 2004; 19(6): 5–7. Amphetamine use is associated with increased 20. Ostrow DG. The role of drugs in the sexual HIV incidence among men who have sex with lives of men who have sex with men: Contin- 5. Reback CJ. The social construction of a gay AIDS men (MSM) in San Francisco. . In press. uing barriers to researching this question. AIDS drug: Methamphetamine use among gay and and Behavior. bisexual males in Los Angeles. University of Cal- 13. Colfax G, Vittinghoff E, Jusnik MJ, et al. 2000; 4(2): 205–219. ifornia at Los Angeles Integrated Substance Abuse Substance use and sexual risk: A participant- 21. Semple SJ, Patterson TL, Grant I. Motiva- Programs. 2004; http://www.uclaisap.org/doc and episode-level analysis among a cohort of tions associated with methamphetamine use uments/final-report_cjr_1-15-04.pdf. men who have sex with men. American Journal among HIV+ men who have sex with men. of Epidemiology. 2004; 159(10): 1002–1012. Journal of Substance Abuse Treatment 6. Stall R, Purcell DW. Intertwining epidemics: . 2002; 22(3): A review of research on substance use among 14. Halkitis PN, Green KA, Mourges P. Longi- 149–156. men who have sex with men and its connec- tudinal investigation of methamphetamine use 22. Reback CJ, Larkins S, Shoptaw S. Changes tion to the AIDS epidemic. AIDS and Behavior. among gay and bisexual men in New York City: in the meaning of sexual risk behaviors among 2000; 4(2): 181–192. Findings from Project BUMPS. Journal of Urban gay and bisexual male methamphetamine Health. 7. Poppers still a major factor in HIV risk. AIDS 2005; 82(1 Supp. 1): 18–25. abusers before and after drug treatment. AIDS Alert. and Behavior. 2004; 8(1): 87–98. 2004; 19(6): 62–64. 15. Hirshfield S, Remien RH, Humberstone M, 8. Halkitis PN, Parsons JT, Stirratt MJ. A dou- et al. Substance use and high-risk sex among 23. Semple SJ, Patterson TL, Grant I. Determi- ble epidemic: Crystal methamphetamine drug men who have sex with men: A national online nants of condom use stage of change among use in relation to HIV transmission among gay study in the USA. AIDS Care. 2004; 16(8): heterosexually-identified methamphetamine men. Journal of Homosexuality. 2001; 41(2): 17–35. 1036–1047. users. AIDS and Behavior. 2004; 8(4): 391–400.

PERSPECTIVES: DRUGS, SEX, AND HIV TRANSMISSION 7

Case Study Cisco, a 27-year-old gay man who uses methamphetamine and alcohol, has had unprotected anal sex several times with men he met on the internet. “I’ve always used drugs,” he says, “but crystal is new to me. It makes it easier to say yes to the ads that say ’no condoms.’ I know I shouldn’t, but . . .” Cisco’s last test was a year ago, and he has come in today for a rapid test.

Counseling Intervention says, “I should be doing something more than testing During informed consent, Cisco’s counselor, Tanya, but I don’t think I can. Anything I say I’ll do now, I notices he looks away when she takes out the data col- know I won’t think about when I’m high again.” lection form (the Client Information Form, in Cali- Tanya responds, “I appreciate your ability to say fornia). She comments, “It looks like you recognize what’s true for you. I want to be honest, too. I talk to this part of the session.” a lot of gay men who are struggling with situations Cisco responds, “I don’t really remember how many like yours. Tell me, if you were in my position, what partners I’ve had. And that form says I should remem- would you do or say that would be most helpful to ber, which just makes me feel worse.” Tanya puts the someone in your situation?” form down, commenting: “You know what works best Tanya’s intervention focuses on helping Cisco think for you. I’ll fill the form out later. What do you mean differently about the inevitability of his situation. Cisco that remembering makes you ‘feel worse’?” is contemplative, although he seems to be moving between Tanya’s intervention seems to run counter to HIV pre- thinking about change and not thinking about change. vention, since the data collection form is useful as a coun- “People should be talking more about HIV and seling tool, a source of epidemiological data, and a record meth,” Cisco responds, which prompts Tanya to explore for reimbursement. But because she is applauding Cisco’s how such discussions would impact his HIV risk. By ability to speak to and prevent what makes him feel bad, engaging Cisco in a conversation about other people Tanya’s intervention invites Cisco to discuss HIV-related in similar situations, Tanya asks him to imagine beyond risk and his recent practice of not using condoms. the inevitability of his own situation, gaining some After receiving an HIV-negative test result, Cisco distance from his own sense of futility.

when they were able to make suc- some of the men he was used to see- of Change. In response, Karla non- cessful changes, the next step is to ing at a sex party were gone: “I figure judgmentally reframed Gus’s past “fail- encourage them to prevent HIV in they’re HIV-positive now, and that’s ures” and highlighted new motivations the future. A useful way of bringing why they’re not partying anymore.” for him to engage in prevention. up the topic is to simply listen for Karla summarized and reflected After more discussion, Gus and highlight HIV prevention steps Gus’s words, “It sounds like you think expressed an interest in talking with a client has already tried. With clients the only thing that would help other other meth-using peers, outside of who are fatalistic, however, the lim- guys gain more control would be to a sex party. Karla was able to refer ited role of the counselor may limit become HIV-positive. Is that the same Gus to a support group. the intervention to planting the seed for you?” When Gus agreed, Karla for referrals. questioned him about his possible Conclusion For instance, Karla learned that motivations for preventing HIV: “I There is no sure-fire prescription the little things Gus used to do to nur- know you’ve been successful in nur- for how to deal with a client’s fatal- ture himself during a speed run— turing yourself in the past, and now ism and shame about sex, drugs, and drink water and keep food in the even those steps feel out of reach. HIV prevention. However, counselors refrigerator in preparation for his Short of getting HIV yourself, what usually can begin by reflecting to post-high crash—had slowly fallen would help you feel more in control?” clients—through specific and authen- away. Gus reported, “I feel like I’m Rather than try to solve Gus’s prob- tic praise—their capacities to effect completely out of control and there’s lem by offering options from a harm change. This approach, combined nothing I can do about it.” reduction menu, Karla realized that with a tolerance for client ambiva- Karla delved further into the con- Gus’s challenge ran deeper than sim- lence and despair, can help clients text of Gus’s HIV risk: “Was there a ply figuring out how to use speed more and counselors discover realistic, specific incident that brought you safely or how to engage in safer sex. incremental change that reduces the here?” Gus had recently noticed that Gus was recycling to an earlier Stage chance of HIV infection in the future.

8 PERSPECTIVES: DRUGS, SEX, AND HIV TRANSMISSION

6. True or False: A counselor’s skill 4. How do you approach the process Test Yourself in empathy may backfire if the coun- of referring clients to substance use selor identifies too strongly with a resources? Review Questions client’s despair. 1. True or False: The causal con- 5. Have you observed clients in dif- nections among substance use, sex- 7. Which of the following effects ferent stages of change regarding sub- ual behavior, and HIV infection are may not result from combining HIV stance use and HIV prevention? How well understood. antiviral medications and recreational has this situation helped or compli- drugs: a) an increase in the dura- cated these sessions? 2. According to the research, men tion and effect of the recreational who have sex with men tend to: a) use drug; b) an increase in viral load; c) 6. How have a client’s shame about a wide variety of substances but only a decrease in antiviral medication past behavior and fatalism about future one at a time; b) use one substance adherence; d) a decrease in viral load. risk affected that client’s ability to only to the point of chronic abuse, engage in HIV prevention discussions? especially if the substance is metham- 8. True or False: Counselors should How have they affected your own abil- phetamine, Ecstasy, or cocaine; c) use not explore a client’s past actions ities to engage in these discussions? a wide variety of substances, usually because the session should focus on more than one at a time either sequen- “where the client is.” Answers tially or in combination; d) tend not 1. False. While research has found associations to use substances. among these behaviors, it has not identified the Discussion Questions precise relationships that connect them. 3. True or False: Studies have shown 1. How does introducing the topic of 2. c. an association between the recreational drug and alcohol use affect your coun- 3. True. use of Viagra and HIV transmission. seling sessions? How do your own 4. False. Poppers can increase the risk of HIV attitudes influence these discussions? transmission by dilating blood vessels in the 4. True or False: Poppers are a harm- anus, and they can also be fatal when combined less drug whose main side effect is 2. In what ways have you observed with other substances that lower blood pressure. dizziness. drug and alcohol use affecting a 5. b. client’s sexual decision making? 6. True. 5. Which drug has not been shown to decrease sexual functioning? a) 3. In what ways does knowledge 7. d. methamphetamine; b) poppers; c) about the effects of substance use help 8. False. Clients may better reduce future HIV alcohol; d) cocaine. clients in making prevention decisions? risk by identifying past successes and strengths.

Using PERSPECTIVES HIV Counselor PERSPECTIVES Volume 14 Number 3 July 2005

PERSPECTIVES is Editor: Robert Marks an educational Researcher/Writers: Bryan Kutner; Beth Wrightson, LCSW resource for HIV test counselors and other Clinical Consultants: Barbara Adler, MFT; Frank Salerno, MSW health professionals. Production: Lisa Roth Each issue explores Circulation/Administrative Support: Jennifer Jones a single topic. Proofreading: Suzy Brady; Jennifer Jones Executive Director: A Research Update James W. Dilley, MD reviews recent research PERSPECTIVES depends on input from HIV test counselors and other Manager of Publications: related to the topic. health professionals. For this issue, PERSPECTIVES acknowledges the Robert Marks Implications for contributions of Michael Discepola, MA; Abel Gonzalez, MS; Clark Designer: Saul Rosenfield Counseling applies Marshall; and Nicolas Shoen, PhD. the research to the For subscription information, contact: counseling session. PERSPECTIVES is funded in part through a grant from the California UCSF AIDS Health Project, Box 0884, Also included are a Department of Health Services, Office of AIDS. PERSPECTIVES is San Francisco, CA 94143–0884 Case Study and ques- published four times a year and is distributed to HIV counseling and test- (415) 502–4930 tions for review and ing sites in California. PERSPECTIVES is also available by subscription. email: [email protected] discussion. © 2005 UC Regents: All rights reserved. ISSN 1532–026X Printed on recycled paper. searchable archive FREE DID YOU KNOW?

You can access a FREE searchable archive of back issues of this publication online! Visit http://www.ucsf-ahp.org/HTML2/archivesearch.html.

You can also receive this and other AHP journals FREE, at the moment of publication, by becoming an e-subscriber. Visit http://ucsf-ahp.org/epubs_ registration.php for more information and to register!

ABOUT UCSF AIDS Health Project Publications The AIDS Health Project produces periodicals and books that blend research and practice to help front-line mental health and health care providers deliver the highest quality HIV-related counseling and mental health care. For more information about this program, visit http://ucsf-ahp.org/ HTML2/services_providers_publications.html.