Arts Social Sciences Centre for Social Research in Health Methamphetamine use among men who have sex with men in Australia: A literature review Max Hopwood, Elena Cama, Carla Treloar December 2016 Acknowledgements The authors thank Professor Gary Dowsett (Australian Research Centre in Sex, Health and Society, La Trobe University) and Professor Peter Aggleton (Centre for Social Research in Health, UNSW Australia). Centre for Social Research in Health UNSW Sydney NSW 2052 Australia T +61 (2) 9385 6776 F +61 (2) 9385 6455 E [email protected] W csrh.arts.unsw.edu.au © UNSW Sydney 2016 Suggested citation Hopwood, M., Cama, E., & Treloar, C. (2016). Methamphetamine use among men who have sex with men in Australia: A literature review. Sydney: Centre for Social Research in Health, UNSW Australia. http://doi.org/10.4225/53/58d4418d0a14b Contents Executive summary 1 1 Introduction 5 2 Method 7 2.1 Research questions 7 2.2 Context 7 2.3 Search strategy 7 2.4 Search method and results 8 3 Findings 10 3.1 Increasing methamphetamine use 10 3.2 Risk associations 13 3.3 Sex-based sociality 16 3.4 Individual-level interventions 18 4 Recommendations 22 5 References 24 Appendix A: Table of select publications 31 Appendix B: Further review of studies 35 Appendix C: Further recommendations for health promotion 44 Centre for Social Research in Health I Methamphetamine use among men who have sex with men in Australia: A literature review Executive Summary This review aimed to investigate methamphetamine use among men who have sex with men (MSM) in Australia and other developed regions to help build an understanding of the contexts where high-risk sex and drug use practices occur. This information can be used to inform the development of treatment and prevention interventions specifically for MSM. Peer-reviewed journal articles, technical reports and editorials regarding meth/ amphetamine epidemiology, methamphetamine use, sexual risk practice, prevention and treatment were located in searches of Medline, PsycINFO, The Cochrane Library and Google Scholar databases. The literature search was conducted to answer four research questions, and a literature review identified four main themes across the topic areas, namely: increasing methamphetamine use; risk associations; sex-based sociality; and, individual- level interventions. Within each theme there were several sub-themes. The review findings are organized around these themes and sub-themes in order to answer the research questions. Main Findings Increasing methamphetamine use Despite some fluctuation in rates and some variation within affected groups, nationally we are seeing over the longer term, increasing rates of methamphetamine use among both young people and MSM in the major metropolitan communities. However, among all MSM who have responded to the Perth Gay Community Periodic Surveys (GCPS), crystal use has remained stable during 2008 to 2016. MSM report higher rates of methamphetamine use when compared with the broader Australian population. Crystal methamphetamine is the drug most commonly injected, particularly among HIV-positive MSM. HIV-positive men remain considerably more likely than HIV-negative men to report any injecting drug use. Over the past decade, methamphetamine has increased in purity and decreased in cost. Risk associations The health risks associated with methamphetamine use are related to factors such as the frequency of use, the drug form (i.e., powder, base, or crystal) and the mode of drug administration, with the greatest risk being the regular injection of crystal. Crystal injection is associated with an elevated risk of dependence, mental health problems (e.g., depression, psychosis), heart problems, overdose, increased blood–borne virus Centre for Social Research in Health 1 Methamphetamine use among men who have sex with men in Australia: A literature review Executive Summary (BBV) infections and death. Crystal injection among MSM, in particular HIV-positive men, is associated with increased risk behaviors for acquiring HIV, hepatitis C (HCV) and other sexually transmissible infections (STIs), such as the sharing of injecting equipment and participation in condomless, adventurous sexual practices. There is evidence to suggest that the relationship between methamphetamine use and risk behavior is complex and that it is hard to establish direct causality. Several authors of large studies have suggested that methamphetamine attracts a hyper- sexual, risk-taking group of men who engage in unprotected sexual behaviors regardless of their methamphetamine use. Most research into methamphetamine use, to date, has employed quantitative methods. This has contributed to a particular view of methamphetamine as a dangerous drug that leads to risky behavior and poor health outcomes. While there is robust quantitative evidence to support such a view, research using a variety of methods is needed to progress our understanding of methamphetamine use and risk behavior. Further research using qualitative methods could help explain the risk associations identified in quantitative research, and qualitative methods would assist in shining a light upon factors, such as the meanings ascribed to methamphetamine use and risk practice among MSM. Sex-based sociality Sex-based sociality is a theme identified in MSM-related research and is used as a framework to describe the sexual construction of social life among MSM. This framework focuses attention on how men in contemporary, urban, gay communities socialise, often in groups and in places where sexual expression and activity have a central role. The concept of sex-based sociality assists in drawing together drug use, sexual practice, BBV risk and MSM socialising through its focus on the inter-connected nature of MSM’s lives and their drug- and sex-related risk practices. The research literature usually characterizes drug use as an individual practice. Yet among MSM, drug use is often a collective practice, and is commonly connected to sex-based sociality. Sex and drug use among MSM need to be understood as socially mediated, co-occurring risk practices for BBVs, STIs and other negative health outcomes, requiring simultaneous sex-drugs interventions focused upon groups rather than individuals. Methamphetamine, in particular crystal, is said to have an ‘elective affinity’ with urban gay sexual socializing (i.e., sex-based sociality) as it heightens a sense of sexual intimacy, disinhibition, and social connectedness, while enhancing sexual endurance. Among MSM, crystal use is one of a number of ways of increasing the range and intensity of sexual experience. Centre for Social Research in Health 2 Methamphetamine use among men who have sex with men in Australia: A literature review Executive Summary Qualitative research is needed to construct a broader and more sophisticated understanding of MSM’s social-sexual contexts, their personal values, the meanings of drug use and the ways that MSM use drugs and socialize for sex, than is currently available from the research literature. Individual-level interventions Randomised controlled trials (RCTs) of interventions to prevent and to treat methamphetamine use have been limited to a focus upon individual-level, behavioral and cognitive interventions such as cognitive behavioral therapy (CBT), contingency management (CM), motivational interviewing (MI), and combinations of these. The results of such interventions have been mixed. Currently, there are a limited number of studies of interventions for the treatment and prevention of methamphetamine use. In addition to too few studies, poly-drug use, which is common, has hampered the development of effective methamphetamine- focused treatment and prevention interventions. Online harm reduction resources and health services for MSM who use illicit drugs exist, but there is little evidence that they have been rigorously evaluated. Culturally appropriate interventions to reduce sex and drug risk practices among MSM are missing from the literature, and are urgently needed. Recommendations for future action To view MSM’s drug use as a collective practice rather than seeing it as solely a practice of individuals. To acknowledge that methamphetamine use among MSM has perceived benefits. To conduct research into MSM from Perth and Western Australia who use methamphetamine. To conduct research to develop specific, detailed information about methamphetamine use among MSM and to inform ongoing support to prevent BBV transmission, STIs and other harms among MSM. To build a concurrent stream of work in knowledge translation to assist in developing new HIV, HCV and other STI prevention strategies and to support the relevant workforces. To encourage researchers and policy-makers to adopt a frame of critical thinking about methamphetamine-related research and policy, in order to avoid ‘problem inflation’. To consider online sexual meeting community websites to disseminate harm reduction interventions. To implement a HCV awareness campaign for MSM to highlight the risk of both HCV sexual transmission and transmission via the sharing of any injecting and/or smoking equipment. Centre for Social Research in Health 3 Methamphetamine use among men who have sex with men in Australia: A literature review Executive Summary To support the use of qualitative research to better understand the dynamics that underpin sex and drug use risk practice within sex-based sociality among Australian MSM. To explore interventions that move beyond the individual-level. 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