Factors associated with sex in the context of methamphetamine use in different sexual venues among HIV-positive men who have sex with men

Methamphetamine use among men who have sex with men (MSM) has been associated with high rates of sexually transmitted infections, low rates of condom use, high rates of unprotected anal sex, prolonged sexual activity, multiple partners, and casual partners [1‐4]. In recent years, researchers have studied the complex array of factors that affect HIV risk behaviors in this population. We reported findings from a behavioral intervention among HIV-positive, methamphetamine-using MSM that demonstrated that it was possible to reduce high-risk sexual behaviors among this population, even in the context of ongoing methamphetamine use [5]. To date, however, little research has focused on sexual venues and the risk behaviors of HIV-positive, methamphetamine-using MSM. Enhanced understanding of the interplay between individual behavior and social context could lead to more effective behavioral interventions and sexual harm reduction initiatives [6].

Several studies have revealed that sexual risk behaviors of HIV-negative MSM vary according to sexual venue. Coates and colleagues reported that MSM who met their partners in sex clubs and bathhouses had significantly more unprotected anal intercourse and used more drugs and alcohol than did men who did not attend these venues [7]. In two studies involving Latino MSM, Diaz and colleagues found an association between public sex environments and higher levels of unprotected anal sex and illicit drug use [8, 9]. Ekstrand and colleagues found an association between high-risk sexual behaviors and attendance at commercial sex venues [10]. In a large-scale study of MSM, Binson and colleagues reported significant associations between demographic characteristics, attendance at sexual venues, and risky sexual behaviors [11].

Parsons and Halkitis compared the sexual risk behaviors, drug use behaviors, and psychosocial characteristics of HIV-positive MSM who attended commercial and public sex environments with those who did not [12]. MSM who frequented non-commercial, public sex environments were more "sexually compulsive" and engaged in more sexual risk-behavior as compared to men who did not. MSM who frequented commercial sex environments reported higher levels of depression and were more likely to use amphetamines, ecstasy, hallucinogens, and poppers. To date, the Parsons and Halkitis paper appears to be the only published study of sexual venues among HIV-positive MSM. Given the close relationships between high-risk sex, methamphetamine use, and sexual venues, we designed this study to help inform the development of behavioral interventions and harm reduction initiatives in social-sexual environments. Three research questions were addressed: 1) What type of sexual venues are most frequently used by HIV-positive methamphetamine-using MSM when they have sex and are "high" on methamphetamine?; (2) What types and levels of sexual- and drug-risk behavior are associated with different types of venues where sexual activity and methamphetamine use are combined?; and (3) Are demographic characteristics, substance-use variables, and psychosocial factors associated with specific patterns of attendance at venues where sexual activity is combined with methamphetamine use?

The main finding of this research was the tendency for HIV-positive, methamphetamine-using MSM to have sexual encounters in more than one type of venue. Although a large majority of the men had had sex in a private venue, only one-third of the sample restricted itself to this type of venue. The majority of participants had had sex in private settings as well as in either a commercial or a public venue. This finding complements previous work that has described situations where MSM meet in commercial venues, such as bars or clubs, and later have sex in a public venue such as a park, beach, or alley [21]. Future studies should examine how sexual transactions evolve and how locations for sexual activity are decided upon. Individual characteristics and attitudes are likely to be pivotal; however, social, legal, and political environments are also likely to have a strong influence on individuals' decisions and actions [6].

About one-third of the sample had had at least one sexual encounter in a public place during the previous two months. This finding has implications for HIV-prevention efforts, given that MSM in the public-venues group had the highest levels of both sexual risk behavior and drug use behavior. Higher levels of sexual risk behavior in public venues may be associated with the limited opportunities available to outreach workers in public settings to provide HIV prevention messages and endorse safer sex norms, particularly when risk activities occur late at night [1, 22]. One model of harm reduction for MSM that was tested in San Francisco involved late-night trips in a van to high-risk neighborhoods; workers distributed condoms and lubricant, exchanged needles, and provided harm-reduction information and HIV/STI testing to anyone who was out in public at that hour and was interested in receiving these items or services [23]. A similar outreach model could be tested in a number of types of public venue, including parks, public restroom areas, and beaches.

We noted that MSM who used public sex venues had higher levels of methamphetamine use, alcohol use and intoxication, and use of other illicit drugs, including crack cocaine and heroin. Previous research indicates that drunkenness and heavy drug use are not well tolerated in commercial settings such as bathhouses and sex clubs [24]. Methamphetamine-using MSM who arrive at commercial establishments severely intoxicated may be turned away or feel unwelcome there. Further, as did other researchers [12, 25, 26], we found that MSM in the commercial-but-no-public-venues group were more likely to use "club drugs." Although we did not ascertain whether these drugs were used in the venue, it is plausible to assume that stimulant drugs mix well with the general "party" atmosphere in sex clubs and bars.

Higher depression scores, greater experiences of social stigma, and higher sexual compulsivity scores reported by the public-venues group may be markers for internalized homophobia. Some of these men could be avoiding public, gay-oriented establishments in favor of venues where sex tends to be anonymous. Their greater perception of social stigma could reflect shame or discomfort about their sexual orientation [27]. Higher levels of sexual compulsivity reported by the same group is consistent with this hypothesis and with the findings of other researchers. Parsons and Halkitis [12] proposed that using public sex venues requires little planning and may be a convenient outlet for expressing compulsive behavior. If, as our data would suggest, the typical man who has unprotected sex with other men in public venues is depressed, not connected to the gay community, stigmatized, and highly compulsive, then condom-promotion efforts in gay-identified establishments are unlikely to reach this subgroup. The challenge for harm reduction interventions is to develop safer sex programs that promote individual behavior change while addressing stigma, discrimination, and mental health issues within the constraints of social and political environments.

Our findings indicate that the mean number of unprotected sex acts and unprotected anal sex acts in the past two months was highest among MSM who reported going to commercial but no public venues and among those who went to public venues. This should be interpreted with caution, because we did not ask participants whether they engaged in unprotected sex when "high" on methamphetamine in these venues. However, other studies have reported an association between having sex in a commercial venue and increased high-risk, unprotected sex [28, 29].

Several studies have shown that commercial venues (e.g., bars, bathhouses) are appropriate settings for conducting HIV prevention education campaigns [12]. By contrast, conducting HIV prevention outreach in public settings is more controversial. Previous studies suggest that sexual behavior in public parks is highly secretive and occurs most often in secluded areas [30]. While these circumstances are challenging, a first step would be to implement discreet and appropriately placed condom vending machines and educational posters in public spaces that these men are known to frequent.

Our findings have several limitations. Although the sample was relatively large, our reliance on volunteers potentially limits generalizability. Data for sexual risk and drug use behaviors were self-reported, which might have resulted in underreporting. In the absence of prospective, longitudinal data, we cannot draw any conclusions regarding causal relationships between HIV risk behaviors and participants' use of sexual venues. Also, this research did not assess the extent to which participants had sex in these and other venues when not "high" on methamphetamine. Finally, this research used a two-month assessment window, which limits the reporting of activities. Some men might have been placed in a different sexual venue category if a longer recall period had been considered.

These analyses enhance our understanding of the relationship between the use of different sexual venues and HIV risk behaviors in a sample of HIV-positive, MSM who had sex when they were "high" on methamphetamine. From a prevention perspective, ways must be found to promote safer sex in public venues. Structural interventions (such as condom machines) and social marketing campaigns are avenues that should be formally evaluated. Altering the "built environment" to discourage sex in public venues (e.g., removing doors in restrooms) may have the unintended consequence of driving men further underground and thus making them even less accessible to safer sex messages. Community interventions that promote acceptance of MSM lifestyles and address depressive symptoms and social stigma may be the best long-term option for reducing the need that some men feel to seek sex in public spaces. Further investigation should seek to enhance our understanding of the cultures that develop around venues where some HIV-positive men engage in sex in the context of methampethamine use. Research is also warranted into factors that are potentially modifiable (e.g., living arrangements, sexual compulsivity) to determine if attendance at risky sexual venues and concomitant HIV risk behaviors can be reduced by ameliorating these factors.