Prevalence and Correlates of Methamphetamine Use Among Older Men Who Have Sex with Men in San Francisco

Abstract:

Methamphetamine use is associated with morbidity and mortality, yet remains under-researched among older men who have sex with men (MSM). We used the 2017 National HIV Behavioral Surveillance Survey to identify the correlates of methamphetamine use among MSM ages 50 and older in San Francisco. Those who were HIV-positive (aOR = 30.18; 95%CI = 1.41-645.26), diagnosed with syphilis (aOR = 34.36; 95%CI = 3.26-361.76), used ecstasy (aOR = 18.84; 95%CI = 2.26-157.20), or poppers (aOR = 44.51; 95%CI = 5.28-374.99) had significantly greater odds of methamphetamine use. Interventions for older methamphetamine using MSM should address polysubstance use and sexual health.

Key Words:

methamphetamine, HIV, men who have sex with men, sexually transmitted infections, substance use, aging

Methamphetamine is an illicit stimulant used worldwide (Buxton and Dove, 2008; Degenhardt et al., 2010) that has been associated with serious negative health consequences, including methamphetamine-induced psychosis, paranoia, depression, seizures, cardiac arrhythmia, myocardial infarction, strokes, and death (Buxton and Dove, 2008; Degenhardt et al., 2010; Passaro et al., 2019).

Methamphetamine use among HIV-negative and HIV-positive men who have sex with men (MSM) is up to thirteen and thirty-four times more prevalent, respectively, than in the general U.S. adult population (Centers for Disease Control and Prevention [CDC], 2016; Substance Abuse Menatal Health Services Administration [SAMHSA], 2017). Among MSM, methamphetamine use is associated with sexual risk behaviors and HIV seroconversion (Drumright, Patterson, and Strathdee, 2006; Vosburgh et al., 2012). Moreover, methamphetamine use is associated with lower pre-exposure prophylaxis (PrEP) and anti-retroviral adherence (ART) adherence (Carrico et al., 2011; Hojilla et al., 2018; Zepf et al., 2020).

Few studies have examined the prevalence of methamphetamine use or associated characteristics specifically among older MSM (Ostrow et al., 2009; Plankey et al., 2007; Shoptaw and Reback, 2007). One study among older HIV-positive MSM observed a lifetime prevalence of methamphetamine use at 11.3 percent and use in the past three months at 3.8 percent (Brennan-Ing et al., 2014).

Another study of club-drug users observed that 62 percent of older MSM had used methamphetamine in the past four months (Halkitis, Green, and Mourgues, 2005). Qualitative interviews suggest older MSM may be more likely to use methamphetamine for sexual reasons and less likely for social reasons, compared to younger MSM (Halkitis, Fischgrund, and Parsons, 2005).

One study among older, lower-income MSM showed that methamphetamine use during sex was associated with condomless sex, sex in public venues, having an HIV-positive partner, exchanging goods for sex, and greater numbers of partners (Ober et al., 2009). Older MSM also may face unique challenges due to homophobia and ageism within the MSM community. These chronic stressors have been associated with substance use and may simultaneously prevent engagement in programs that teach coping skills and harm reduction (Halkitis et al., 2015; Lyons et al., 2010). The limited number of studies calls attention to the need to further examine the characteristics of older MSM methamphetamine users, understand their needs, and inform interventions.

To address these gaps in the literature, we assessed the prevalence of methamphetamine use among older MSM in the San Francisco implementation of the National HIV Behavioral Surveillance Survey (NHBS) of persons at high risk for HIV infection or transmission. We describe the prevalence of methamphetamine use among MSM ages 50 and older and examine demographic, behavioral, and social characteristics associated with methamphetamine use in NHBS.

Methods

Study Design

Data originated from the 2017 NHBS MSM cycle in San Francisco. NHBS is a CDC-led collaboration of twenty-one health jurisdictions in the United States that samples MSM, injection drug users, and high-risk heterosexuals on a three-year cycle (Gallagher et al., 2007). NHBS uses time-location sampling to obtain quasi-probability samples of MSM (MacKellar et al., 2007). Eligibility criteria were: age ≥ 18 years; resident of the San Francisco Metropolitan Statistical Area; and self-identify as male who has ever had sex with another man. Participants completed an interviewer-administered electronic survey on tablet computers and then were tested for HIV. The survey measured demographics, sexual behavior, substance use, and self-reported sexually transmitted infections (STI). Men received $50 for their participation. NHBS is conducted anonymously. This study received IRB approval from the University of California, San Francisco. All participants gave informed consent.

Data Analysis

For the current analysis, we restricted the sample to participants ages 50 and older. We first identified potential correlates of methamphetamine use in bivariable analyses using Fisher’s exact and Wilcoxon rank-sum tests. Variables chosen were factors previously shown or hypothesized to be associated with methamphetamine use among MSM (Carrico et al., 2012; Fisher et al., 2011). In our multivariable logistic regression analysis, we employed a commonly used approach to ensure that the variables included and retained significantly contributed to our model (Bursac et al., 2008; Hosmer and Lemeshow, 2000). Analyses were conducted in STATA version 15 (College Station, Texas).

Results

This study included 147 older MSM. Demographic, behavioral, and clinical characteristics are summarized in Table 1 (see below). The overall mean age was 59 years (standard deviation [SD]=7). The majority were white (72 percent); 7 percent identifying as African American, 11 percent as Latino/Hispanic, and 10 percent as other racial and ethnic groups (Asian and Pacific Islander, Native American, Native Hawaiian or Pacific Islander, or Multiracial). Sixty-six percent completed college, 30 percent were retired, 20 percent were unemployed and 39 percent were employed full-time. One-third were living with HIV.

Table 1: Sample Characteristics of Older Men who have sex with men (50 years old  or older) from the San Francisco National HIV Behavioral Surveillance study, 2017

*Fisher’s Exact or Wilcoxon Ranksum tests.
†PrEP use among HIV negative or antiretroviral therapy use among people living with HIV.

The prevalence of methamphetamine use in the past twelve months was 10 percent. In bivariate comparisons, a greater proportion of men who used methamphetamine reported being diagnosed with syphilis, had ever injected drugs, and indicated pain killer, heroin, powder cocaine, crack cocaine, ecstasy, and popper use, compared to men who did not use methamphetamine.

The multivariable logistic model is summarized in Table 2 (see below). Older MSM who were living with HIV (compared to those without HIV), were diagnosed with syphilis (compared to those not diagnosed with syphilis), used ecstasy (compared to those who did not use ecstasy), and used poppers (compared to those who did not use poppers) had significantly greater odds of methamphetamine use, adjusting for age, race/ethnicity, and employment status.

Table 2. Multivariable Logistic Regression Model for Methamphetamine Use in Past 12 months Among Older MSM in San Francisco

†PrEP use among HIV negative or antiretroviral therapy use among people living with HIV.

Discussion

We saw that one in ten older MSM in the San Francisco Bay Area used methamphetamine in the preceding year, which is a higher ratio relative to the general older adult population, for whom it is estimated that past-year use of any illicit substance, including methamphetamine, at around 3.1 percent (Colliver et al., 2006). This finding highlights a public health issue that is often overlooked, under-identified, and stigmatized among older adults: illicit substance use (Kuerbis et al., 2014; Patterson and Jeste, 1999). These findings challenge assumptions that illicit substance use, including methamphetamine and polysubstance use, is limited to younger populations.

We also observed higher methamphetamine use among older MSM living with HIV. Studies have observed methamphetamine use initiation among MSM occurring after HIV diagnosis, further supporting this hypothesis (Halkitis, Levy, and Solomon, 2016). Older MSM living with HIV may also use methamphetamine to cope with HIV-related stressors (Halkitis et al., 2016). This finding is of particular importance as people living with HIV are aging in the United States—nearly one in two Americans living with HIV are ages 50 or older, the majority of whom are MSM (Mitsch et al., 2018).

Findings also corroborate links between methamphetamine use and HIV acquisition and transmission risk from broader samples of MSM, highlighting similar concern for older MSM. HIV diagnosis among older MSM have remained stable over the past decade (Mitsch et al., 2018), and it is estimated that one in fifty-nine MSM ages 50 or older will be diagnosed with HIV over a ten-year period (versus 1 in 2,527 among heterosexual men ages 50 or older) (Hess et al., 2017). Systematic reviews support the hypothesis that methamphetamine use is associated with HIV seroconversion through sexual transmission (Drumright, Patterson, and Strathdee, 2006; Vosburgh et al., 2012).

Our finding on the association between methamphetamine use and syphilis diagnosis is consistent with other studies of MSM (Shoptaw and Reback, 2007; Wong et al., 2005). Because syphilis is a risk factor for HIV-seroconversion, and may increase HIV viral load among those living with HIV, regular STI screening and treatment among older MSM who use methamphetamine are recommended (Bolan, 2012). Older MSM may also have weaker immune systems due to age that make them more susceptible to both syphilis and HIV.

Studies also have found high reported prevalence of substances in addition to methamphetamine use among MSM. Certain classes of substances that enhance sexual episodes (i.e., for “chemsex”) or night life (i.e., “club drugs”), like poppers and ecstasy, are often used together (Drumright, Patterson and Strathdee, 2006; Maxwell, Shahmanesh, and Gafos, 2019). The higher proportion of poppers use among methamphetamine users relative to non-users in our sample is concerning as their combined use has been attributed to HIV seroconversion in longitudinal studies (Ostrow et al., 2009; Plankey et al., 2007). Targeted and comprehensive HIV prevention interventions, including PrEP and post-exposure prophylaxis programs, are thus needed for polysubstance-using older MSM.

Our study has limitations. The measures for methamphetamine use and other risk behaviors were by self-report. As an interviewer-administered survey, social desirability may have resulted in underreporting. Recall bias also may have affected reporting. The cross-sectional design precludes assessing the temporal sequence of some associations (e.g., whether methamphetamine use occurred before people had been diagnosed with HIV, or vice versa). Given the small sample of older MSM, measures are imprecise (i.e., confidence intervals are wide), and our findings should be interpreted with caution. Lastly, the sampling approach includes only MSM who attend venues known to be frequented by MSM. MSM who never attend such venues are excluded, limiting generalizability.

Despite limitations, our study provides insights on the prevalence and correlates of methamphetamine use in a rare community-recruited sample of older MSM. This population’s needs are often overlooked given assumptions that older adults do not engage in substance use. The high prevalence of methamphetamine use among older MSM and associated sexually transmitted infections and polysubstance use speak to the critical need to develop and target sexual health and substance use interventions for older MSM methamphetamine users.   

Glenn-Milo Santos, PhD, is an associate professor in Community Health Systems at the University of California at San Francisco (UCSF), and a senior research scientist at the San Francisco Department of Public Health. Desmond Miller is a program coordinator at the San Francisco Department of Public Health. Jennifer Jain, PhD, is a postdoctoral scholar in Psychiatry at the UCSF School of Medicine. Akua Gyamerah, Dr.PH, MPH, is a postdoctoral scholar in Medicine at the UCSF School of Medicine. Erin Wilson, is a senior research scientist at the Center for Public Health Research in the San Francisco Department of Public Health, and an adjunct assistant professor at UCSF in the department of Epidemiology and Biostatistics. Willi McFarland, MD, PhD, MPH is a professor of Epidemiology and Biostatistics at UCSF, and a director of HIV Epidemiology Section at the San Francisco Department of Public Health. Henry F. Raymond, DrPH, MPH, is an associate professor in the Department of Biostatistics and Epidemiology at Rutgers School of Public Health.

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