Elsevier

Drug and Alcohol Dependence

Volume 146, 1 January 2015, Pages 75-80
Drug and Alcohol Dependence

Full length article
Post-exposure prophylaxis use and recurrent exposure to HIV among men who have sex with men who use crystal methamphetamine

https://doi.org/10.1016/j.drugalcdep.2014.11.010Get rights and content

Highlights

  • Few studies have investigated biomedical HIV prevention interventions for men who have sex with men who use crystal methamphetamine (CM).

  • This study investigated the use of CM by MSM who sought post-exposure prophylaxis (PEP).

  • MSM who use CM had higher risk exposures during the event that led to seeking PEP.

  • MSM who use CM also had greater recurrent exposure to HIV following PEP use.

  • HIV prevention interventions that address both recurrent HIV exposure and substance use may be particularly effective.

Abstract

Background

Men who have sex with men (MSM) who use crystal methamphetamine (CM) are at increased risk for HIV infection. Post-exposure prophylaxis (PEP) is a useful HIV prevention strategy if individuals are able to identify high-risk exposures and seek timely care, however to date there has been limited data on the use of PEP by CM users.

Methods

A: Retrospective cohort study of all PEP prescriptions (N = 1130 prescriptions among 788 MSM) at Fenway Community Health in Boston, MA was undertaken. Multivariable models were used to assess the association between CM use during exposure (7.4% used CM during exposure) and chronically (7.4% of MSM were chronic CM users) and individual-level and event-level outcomes among MSM who used PEP at least once.

Results

Compared to those who had not used CM, MSM PEP users who used CM more frequently returned for repeat PEP (aOR 5.13, 95% CI 2.82 to 9.34) and were significantly more likely to seroconvert over the follow-up period (aHR 3.61, 95% CI 1.51 to 8.60). MSM who used CM had increased odds of unprotected anal intercourse as the source of exposure (aOR 2.12, 95% CI 1.16 to 3.87) and knowing that their partner was HIV infected (aOR 2.27, 95% CI 1.42 to 3.64).

Conclusions

While MSM who use CM may have challenges accessing ART in general, these data highlight the fact that those who were able to access PEP subsequently remained at increased risk of HIV seroconversion. Counseling and/or substance use interventions during the PEP course should be considered for CM-using MSM.

Introduction

Crystal methamphetamine (CM) is a highly addictive psychostimulant that has been linked to high-risk sexual behavior and incident HIV infection among men who have sex with men (MSM; Gonzales et al., 2010, Koblin et al., 2006, Mayer et al., 2013). The use of CM is considerably more prevalent among MSM in the United States than in the general population, with the prevalence of use nearly 10 times greater (Colfax and Shoptaw, 2005, Mimiaga et al., 2012b). It has been well established that CM use is predictive of higher risk sexual encounters, including low rates of condom use, an increase in number of sexual partners, including anonymous partners, and prolonged sexual encounters spanning multiple days (Benotsch et al., 2012, Halkitis et al., 2001, Rajasingham et al., 2012).

Post-exposure prophylaxis (PEP) consists of a 28-day course of antiretroviral therapy (ART) given prophylactically within 72 h of a high-risk exposure (Smith et al., 2005). Although PEP efficacy in humans has never been tested in a randomized controlled trial, it has been shown to reduce the odds of HIV seroconversion in animal models (Tsai et al., 1995) and following health care workers’ needle stick exposures in a nested case control study (Cardo et al., 1997, Jain and Mayer, 2014). Although CM-using MSM might benefit from biomedical HIV prevention strategies such as PEP or pre-exposure prophylaxis (PrEP), concerns related to the ability of users to adhere to ART regimens have limited prescription of PEP for this subpopulation (Landovitz et al., 2012, O’Connor, 1999, Oldenburg et al., 2013). Furthermore, evidence suggests that MSM who use stimulants are significantly less likely to be aware of PEP as an HIV prevention strategy, which further limits its use among this group (Liu et al., 2008). A key component to the success of PEP is an individual's ability to identify high-risk exposures, know where to get treatment, and seek medical attention within 72 h, in addition to their ability to complete the prescribed regimen.

The purpose of the present study is two-fold. First, we sought to characterize the effect of event-level and chronic CM use and sexual risk behavior during the exposure that led to PEP, compared to individuals who accessed PEP but had not used CM. Event-level CM use may affect risk-taking behavior differentially compared to chronic use, and thus we attempt to understand the effect of CM use at the time of event independently of whether or not the individual is a chronic methamphetamine user. Second, we sought to assess the relationship between repeat PEP use and long-term outcomes following presentation for PEP in MSM with CM use compared to those who had not used CM. A better understanding of the context of risk prior to, and after, first PEP use and the trajectory of subsequent PEP use among MSM who use CM will help to inform the optimal deployment of biomedical HIV prevention strategies for this group of MSM.

Section snippets

Study sample

Data for this study were derived from a retrospective longitudinal review of all PEP users at Fenway Community Health in Boston, MA between July 1, 1997 and August 1, 2013. Full methods for the study have been previously reported (Jain et al., 2014). Briefly, patients with a prescription for a one month course of an antiretroviral medication combination in their electronic medical record during this time period who were HIV-uninfected were screened for study eligibility. Inclusion criteria

Descriptive statistics

Of 788 MSM who sought PEP between July 1, 1997 and August 1, 2013, 58 (7.4%) had a documented chronic CM use disorder at the time of their first PEP prescription. Among the 788 MSM who sought PEP, there were 1,130 PEP prescriptions during the observation period (range 1 to 15 prescriptions per patient). Of these, CM was used during 84 (7.4%) of exposures that led to seeking PEP. Median follow-up time was 1.9 years (IQR 1.1 to 4.6 years) among MSM with a CM use disorder and 1.0 (IQR 0.1 to 3.1

Discussion

The results of this study indicate that a substantial proportion of Boston MSM who sought PEP following a high-risk exposure had used CM, and that these individuals knew where and how to seek treatment within 72 h of the exposure. MSM who used CM were more likely to return for repeat PEP than those who did not use this stimulant, suggesting high levels of recurrent risk, as well as the ability to identify risky exposures and access care quickly following exposure. However, despite repeat PEP

Role of the funding source

The sponsors did not have a role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.

Contributors

CEO designed the study, collected data, carried out statistical analyses, and drafted the manuscript. SJ designed the study, collected data, interpreted results, and drafted and critically reviewed the manuscript. KHM designed the study, interpreted results, critically reviewed the manuscript, and provided study oversight. MJM designed the study, interpreted results, critically reviewed the manuscript, and provided study oversight. All authors have read and approved the final version of the

Conflicts of interest

None to declare.

References (25)

  • S. Shoptaw et al.

    Outcomes using two tailored behavioral treatments for substance abuse in urban gay and bisexual men

    J. Subst. Abuse Treat.

    (2008)
  • E.G. Benotsch et al.

    Attitudes toward methamphetamine use and HIV risk behavior in men who have sex with men

    Am. J. Addict.

    (2012)
  • K. Buchacz et al.

    Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco

    AIDS

    (2005)
  • D.M. Cardo et al.

    A case-control study of HIV seroconversion in health care workers after percutaneous exposure and the Centers for Disease Control and Prevention Needlestick Surveillance Group

    N. Engl. J. Med.

    (1997)
  • A.W. Carrico et al.

    Community-based harm reduction substance abuse treatment with methamphetamine-using men who have sex with men

    J. Urban Health

    (2014)
  • G. Colfax et al.

    The methamphetamine epidemic: implications for HIV prevention and treatment

    Curr. HIV/AIDS Rep.

    (2005)
  • R. Gonzales et al.

    The methamphetamine problem in the United States

    Annu. Rev. Public Health

    (2010)
  • R.M. Grant et al.

    Preexposure chemoprophylaxis for HIV prevention in men who have sex with men

    N. Engl. J. Med.

    (2010)
  • P.N. Halkitis et al.

    A double epidemic: crystal methamphetamine drug use in relation to HIV transmission

    J. Homosex.

    (2001)
  • S. Jain et al.

    Practical guidance for nonoccupational postexposure prophylaxis to prevent HIV infection

    AIDS

    (2014)
  • S. Jain et al.

    Longitudinal trends in HIV non-occupational post-exposure prophylaxis (NPEP) use at a Boston Community Health Center between 1997 and 2013

    J. Acquir. Immune Defic. Syndr.

    (2014)
  • B.A. Koblin et al.

    Risk factors for HIV infection among men who have sex with men

    AIDS

    (2006)
  • Cited by (15)

    • Ice parties among young men who have sex with men in Thailand: Pleasures, secrecy and risks

      2018, International Journal of Drug Policy
      Citation Excerpt :

      While there is scarce research on practices surrounding ice use in Thailand, similar to ya ba, ice produces similar euphoric effects and risks that may include prolonged and unprotected sexual intercourse with multiple partners (Chomchai & Chomchai, 2015). Meth use among MSM have been found to be significantly associated with polydrug use, increased libido and increased pain threshold (thus facilitating receptive anal intercourse), as well as decreased condom use and increased number of anonymous sex partners (Oldenburg, Jain, Mayer, & Mimiaga, 2015; Sewell et al., 2017; Wei, Lim, Guadamuz, & Koe, 2012; Xu et al., 2014). Therefore, risk contexts surrounding ice use and the online and offline spaces where these risks transpire are particularly important, yet they have not been extensively studied among Thai YMSM.

    View all citing articles on Scopus
    View full text