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Instrument: India HIV-related stigma scales Scoring: Included in article. Reliability or validity: Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, Wrubel J, Ekstrand ML. HIV-related stigma: Adapting a theoretical framework for use in India. Social Science & Medicine 67 (2008) 1225–1235.

How do club drugs impact HIV prevention?

What are club drugs?

Club drugs are illegal drugs that are often, although not exclusively, used at dance clubs, raves and circuit parties. Drugs often referred to as club drugs include: MDMA (ecstasy), methamphetamine (crystal meth, speed), GHB (liquid X), Ketamine (special K) and less often, Viagra and amyl nitrites (poppers)¹. These drugs also are often used outside of clubs and parties. Raves are large parties featuring house or techno music and visual effects. Mostly younger people attend raves. Circuit parties are a series of large, predominantly gay parties lasting several days and nights in a row that are frequented mostly by younger and older middle-class white men. They occur annually in different cities.² Some of the physical and psychological effects of club drugs include: elevated mood, increased empathy, altered vision, sensations and emotions, increased alertness, decreased appetite, relaxation, increased physical energy and/or self-confidence. Many people use drugs recreationally with few or no immediate repercussions. Misuse of club drugs can lead to problems with toxicity (from the drugs themselves or from interactions with other drugs), with legal issues and sometimes with addiction. Persons using one or more club drugs during sex often report engaging in extremely high HIV risk behaviors.³ Club drugs can cause a variety of non-HIV-related health risks. This fact sheet will focus on sexual and drug-using HIV risk behaviors that can occur with club drug use.

Who uses club drugs?

Most of the research on club drugs has been with gay men, mainly because HIV prevalence and risk of infection are high among gay men. Use of club drugs varies by different populations and by geography.⁴ A survey of gay male circuit party attenders in San Francisco found that 80% used ecstasy, 66% ketamine, 43% methamphetamines, 29% GHB, 14% Viagra and 12% poppers during their most recent out-of-town weekend party. Half (53%) used four or more drugs.⁵ A study of rave attenders in Chicago found that 48.9% had used any club drugs, 29.8% used LSD, 27.7% ecstasy and 8.5% methamphetamine. Rave attenders used club drugs with other drugs such as marijuana (87%), alcohol (65.2%) and cocaine/crack (26.1%).⁶

What is the risk?

There are many negative physical and psychological side effects of club drugs. The reason club drugs present a potential HIV risk is because they can lower inhibitions, impair judgment, increase sexual endurance and encourage sexual risk-taking. With injected drugs, there is also a potential risk from sharing injection equipment. The risk for HIV occurs mainly when drug use occurs during sexual activity. For example, methamphetamine is often used to initiate, enhance and prolong sexual encounters, allowing individuals to have sexual intercourse with numerous partners. Poppers are used for receptive anal sex, to relax the anal sphincter. Speed is also dehydrating, which may make men and women more prone to tears in the anus, vagina or mouth, and therefore more prone to HIV/STD infections.^3,7 In one study, HIV- heterosexual methamphetamine users reported an average of 9.4 sex partners over two months. The number of unprotected sexual acts in two months averaged 21.5 for vaginal sex, 6.3 for anal sex and 41.7 for oral sex. Most users (86%) reported engaging in “marathon sex” while high on methamphetamine. Over one-third (37%) of users reported injecting, and of those, almost half had shared and/or borrowed needles.⁷ Unprotected sex with a partner whose HIV status is unknown is a high-risk activity. A survey of gay men found that 21% of HIV+ and 9% of HIV- men reported unprotected anal sex with a partner of unknown status at their most recent circuit party.⁵ A study of gay men at raves in New York City found that about one-third (34%) used ecstasy at least once a month. Men who used ecstasy were more likely to report recent unprotected anal intercourse than men who used other drugs, including alcohol.⁸

Why do people use club drugs?

For many people, straight or gay, drug use and sex are a natural occurrence at raves and circuit parties, and one of the appeals of these parties. These parties are popular social activities for some groups of youth and gay men, and there can be strong peer pressure to use drugs and be sexually active. While circuit parties and raves may not themselves cause drug use, they may attract persons who are more inclined to use drugs.¹⁰ People use club drugs for many reasons. Some people use club drugs to have fun, dance and loosen inhibitions. Others use them to escape their problems and to counter feelings of depression or anxiety. Parental drug use, childhood sexual abuse and depression are some of the factors that may lead to drug use.⁴

What’s being done?

A drug treatment program for gay methamphetamine users in Los Angeles, CA, sought to reduce drug use and HIV-related sexual risk behaviors. Treatment options included: 1) cognitive behavioral therapy, a 90-minute group session delivered three times a week; 2) contingency management, a behavioral intervention that offered increasingly valuable vouchers for abstinence from drug use; and 3) cognitive behavioral therapy culturally tailored to gay issues. All men reduced their drug use, and those using contingency management reduced drug use longer. The highest reduction in sexual risk-taking occurred in men who used the culturally tailored program.¹¹ DanceSafe promotes health and safety within the rave and nightclub community, with local chapters throughout the US and Canada. DanceSafe trains volunteers to be health educators and drug abuse prevention counselors at raves and nightclubs. They use a harm reduction approach and primarily target non-addicted, recreational drug users. DanceSafe offers information on drugs, safer sex and staying healthy, and in some venues offers pill testing to make sure drugs do not contain harmful substitutes.¹² Twelve Step programs such as Crystal Meth Anonymous (CMA), Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) are for people for whom drug use has become a problem. Twelve Step advocates abstinence from crystal meth, alcohol and other illicit drugs. Twelve Step meetings occur in many cities across the US.¹³ The PROTECT project at the South Florida Regional Prevention Center aims to reduce club-drug use among young gay men. PROTECT trains police officers, teachers and other community stakeholders on club drugs, particularly ecstasy. They also developed a web site with a chat room monitored by peer counselors.¹⁴ Stepping Stone, in San Diego, CA, is a residential drug treatment facility for gay men and lesbians. Most of their clients are poly drug users and most are dually diagnosed with psychiatric disorders. They address sexual behaviors and mental health issues in the context of drug abuse treatment. Stepping Stone sponsors a harm reduction social marketing campaign to increase awareness of the dangers of club drugs and alcohol.15

What needs to be done?

Several organizations are currently addressing the negative effects of club drugs at raves and parties across the country. More education is needed about the toxicity of club drugs, poly drug use and the connection between drug use and unsafe sex. Referrals for mental health counseling should also be made available at these venues. The gay community needs to address the very real pressures in some sub-communities to party and be highly sexually active, and ask the question “is drug use worth the risks men are taking?”³ It is not enough to attempt to reduce drug use and abuse at circuit parties without also addressing the powerful sexual motivations to using drugs.^3,9 When prescribing Viagra, physicians should counsel men on safer sex and the harmful effects of combining Viagra with methamphetamines, poppers and ecstasy. Physicians should inquire about club drug use among their HIV+ patients and counsel them on the danger of combining them with HIV treatment drugs.¹⁶ Physicians should be aware that club drug use can affect adherence to HIV drugs.

Says who?

1. Freese TE, Miotto K et al. The effects and consequences of selected club drugs. Journal of Substance Abuse Treatment. 2002;23:151-156. 2. Swanson J, Cooper A. Dangerous liaison: club drug use and HIV/AIDS. IAPAC Monthly. 2002;8:1-15. 3. Halkitis PN, Parsons JT, Stirratt MJ. A double epidemic: crystal methamphetamine drug use in relation to HIV transmission among gay men. Journal of Homosexuality. 2001;41:17-35. 4. Stall R, Paul JP, Greenwood G et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 2001;96:1589-1601. 5. Colfax GN, Mansergh G, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison. Journal of Acquired Immune Deficiency Syndromes. 2001;28:373-379. 6. Fendrich M, Wislar JS, Johnson TP et al. A contextual profile of club drug use among adults in Chicago. Addiction. 2003;98:1693-1703. 7. Semple SJ, Patterson TL, Grant I. The context of sexual risk behavior among heterosexual methamphetamine users. Addictive Behavior. 2004;29:807-810. 8. Klitzman RL, Pope HG, Hudson JI. MDMA (“ecstacy”) abuse and high-risk sexual behaviors among 169 gay and bisexual men. American Journal of Psychiatry. 2000;157:1162-1164.10. Adlaf EM, Smart RG. Party subculture or dens of doom? An epidemiological study of rave attendance and drug use patterns among adolescent students. Journal of Psychoactive Drugs. 1997;29:193-198. 11. Shoptaw S, Reback CJ. Drug and sex risk behavior reductions with behavioral treatments for methamphetamine dependence among gay/bisexual men. Presented at the National HIV Prevention Conference, Atlanta, GA. 2003. Abstract #T3-D1004. 12. www.dancesafe.org 13. www.crystalmeth.org, www.na.org, www.aa.org 14. Rothaus S. Workshop targets young gays with a penchant for club drugs. Miami Herald. July 16, 2003. 15. Johnson SB. Stepping Stone: a catalyst for change. Presented at Methamphetamine Use and Gay Men Meeting. Sacramento, CA. April 24, 2003. 16. Romanelli F, Smith KS, Pomeroy C. Use of club drugs by HIV-seropositive and HIV-seronegative gay and bisexual men. Topics in HIV Medicine. 2003;11:25-32.

Other internet resources:

www.tweaker.org www.crystalrecovery.com www.freevibe.com www.crystalneon.org

Prepared by Mike Pendo*, Pamela DeCarlo** *San Francisco Department of Public health, **CAPSJuly 2004. Fact Sheet #55E Special thanks to the following reviewers of this Fact Sheet: Michael Thomas Angelo, Grant Colfax, Viva Delgado, Paul Galatowitsch, Rob Guzman, Perry Halkitis, Manuel Laureano-Vega, Gary Leigh, Phil Reichert, Frank Romanelli, Mike Siever, Steve Shoptaw, Steven Tierney, Dan Wohlfeiler. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2004, University of CA.

What are the HIV prevention needs of crack cocaine users?

Prepared by Margaret R. Weeks PhD, Institute for Community Research and Pamela DeCarlo, CAPS Fact Sheet 66, December 2009

Is crack cocaine an issue?

Yes. Although many people think of it as a drug of the 80s, crack cocaine is still around. HIV prevention has traditionally focused on injecting drug use and other stimulants like methamphetamine. But many people use more than one drug and may be using these drugs in different ways, for example, smoking crack and injecting heroin. Crack use alone and crack use combined with other drugs present real risks for HIV transmission and acquisition. Crack cocaine is a powerfully addictive stimulant drug. Crack is a rock crystal, which can be smoked or dissolved and injected. It is relatively cheap and readily available on the street in mainly low-income urban areas. Crack is highly addictive and the effects of the drug are short-lived (about 5 minutes), making it necessary to use more to maintain a high. Recent studies of crack users show high rates of HIV infection. In Harlem, New York, 23.9% of users and sellers of crack were HIV+¹; in Los Angeles, California, 24% of older low-income MSM were HIV+²; and 22.4% of female street sex workers in Miami, Florida were HIV+³.

Who uses crack?

While crack use may vary geographically by race, age and sexual orientation, most crack use is concentrated in inner city communities that are impoverished and disadvantaged and have limited access to many services. These are the same neighborhoods with high rates of unemployment, homelessness, violence, substance abuse, HIV, sexually transmitted diseases (STDs) and other risks. However, some crack users do not fit these characteristics and are still at very high risk of health related consequences of crack use.

How does crack affect HIV transmission risk?

Risk of HIV and other sexually transmitted diseases can vary by level of crack use and addiction. Crack’s short-lived high and addictiveness can create a compulsive cycle in which users quickly exhaust their resources and turn to other ways to get the drug, including exchanging sex for money or drugs (such as a “hit” of crack)⁴. Trading sex in these circumstances often creates extremely risky situations that may include high numbers of partners, sex while under the influence and drug-related violence. This environment makes it hard to engage in safer behaviors and contributes to inconsistent condom use.^5,6 In one study, HIV infection was associated with intensive, daily crack smoking among women engaged in survival sex.^5,7 Crack use is also associated with very high rates of other STDs, including syphilis, gonorrhea, and chlamydia. Lesions and abrasions associated with these infections increase opportunities for infection with HIV, especially during repeated or protracted sex, common among crack users.⁸ Crack is often smoked in make-shift pipes that use a glass pipette (tube) or a broken car antenna as a mouthpiece. These crack pipes can lead to cuts and burns on the lips, which are associated with HIV transmission.⁹ It is not known if this is due to sharing pipes between users or sexual transmission during oral sex. Some research shows possible risk of pneumonia and tuberculosis transmission through sharing of crack pipes as well.¹⁰

How does crack affect HIV+ persons?

Crack use affects HIV+ persons on many levels: biological, social and behavioral. On a biological level, crack use can accelerate HIV disease progression.¹¹ One study found that persistent crack users were over three times as likely to die from AIDS-related causes as non-users.¹² On a social level, most crack users who are HIV+ live in disadvantaged and impoverished communities, which present a variety of barriers to health. Crack users with HIV are less likely than HIV+ non-users to have access to basic medical services and more likely never to have been in HIV primary care.¹³ They are less likely to have a regular healthcare provider and to initiate medical care and treatment.¹⁴ On a behavioral level, crack users have low rates of adherence to HIV therapy once they have begun treatment.¹⁵ And HIV+ crack users are more likely than HIV+ non-users to continue to engage in high risk sexual behaviors with HIV- or unknown status partners after learning their HIV status.¹³

What’s being done?

The Risk Avoidance Partnership (RAP) Project in Hartford, Connecticut, trained active drug injectors and crack users to deliver an HIV, hepatitis, and STD prevention intervention to hard-to-reach drug users both inside and outside of their networks. The Peer Health Advocates (PHAs) received training in risk reduction and health promotion, communication skills and the importance of health advocacy. Crack users in RAP helped to design special “crack kits” they distributed to encourage use of rubber tips on crack pipes; kits also included male and female condoms and “dental dams” (flat latex sheets for use when performing oral sex on women). Study participants reported significant risk reduction.¹⁶ Using a harm reduction model, a needle exchange program in Ottawa, Canada distributes safety kits to crack users to reduce the risk of cuts and burns and potential transmission from sharing crack pipes and to decrease needle sharing. The kits include glass stems, rubber mouthpieces, brass screens, chopsticks, lip balm and chewing gum. Recipients reported less injecting and less sharing of pipes.^10,17 JEWEL (Jewelry Education for Women Empowering their Lives) was an economic empowerment and HIV prevention project for crack-using women involved in prostitution in Baltimore, Maryland. The JEWEL intervention used six 2-hour sessions that taught HIV prevention and the making, marketing and selling of jewelry. Women participants significantly reduced trading drugs or money for sex, the number of sex trade partners, and daily crack use.¹⁸ Two separate intervention trials compared a standard National Institute on Drug Abuse HIV prevention intervention to woman-focused, culturally-specific interventions for female African-American crack cocaine users. The two interventions were grounded in motivation and empowerment theories and addressed the reality of the daily lives of women and the violence and poverty of their inner-city neighborhoods. Women in the culturally-specific interventions reported more reductions in sexual risk behaviors¹⁹ as well as improvements in employment and housing status.²⁰

What still needs to be done?

While there is still no medical treatment for crack or cocaine abuse and dependence, several behavioral treatments have demonstrated efficacy for helping people to initiate abstinence and to prevent relapse to cocaine use. These include contingency management, cognitive behavioral therapy, and motivational interviewing.²¹ Currently available treatment for crack dependence tends to be limited to 12-step programs, which have little evidence of efficacy. Further development and testing of efficacious behavioral and medical treatments are needed to help crack users overcome the intense cravings associated with crack addiction. Federal sentencing laws currently give far harsher penalties for crack cocaine than for powdered cocaine.²² Using a 100-to-1 ratio, a person who sells a small amount of crack receives the same sentencing as a person who sells 100 times that amount of powder cocaine, resulting in prisons packed with low-level, predominantly African American offenders. In 2008, over 80% of offenders sentenced for crack-related federal crimes were Black and 10% were White. Activists and legislators are working to change the legislation, and to make it retroactive for those currently incarcerated.²³ Stronger public policy around sentencing guidelines are needed. Substance use is complicated and HIV prevention has tended to simplify efforts into either reducing needle sharing and needle use, or reducing sexual risk. However, many IDUs also use crack, and often smoke crack when they’ve stopped injecting. Programs for IDUs should address poly-drug use, including crack use, and sexual risk reduction in the context of complex psychological and social needs and pressures associated with addiction. Crack users face a variety of barriers to remaining healthy, and programs need to take a more holistic approach to prevention.²⁴ Crack users often need basic services such as childcare, safe shelter, food security, basic necessities and substance abuse treatment before they can think about HIV prevention.²⁵ Interventions should not simply focus on drug and sex risks, but should address these basic survival needs as well as education, employment, housing and job training.

Says who?

1. Davis WR, Johnson BD, Randolph D , et al. Risks for HIV infection among users and sellers of crack, powder cocaine and heroin in central Harlem: Implications for interventions. AIDS Care. 2006;18:158-165. 2. Ober A, Shoptaw S, Wang PC, et al. Factors associated with event-level stimulant use during sex in a sample of older, low-income men who have sex with men in Los Angeles. Drug & Alcohol Dependence. 2009;102:123-129. 3. Inciardi JA, Surratt HL, Kurtz SP. HIV, HBV, and HCV infections among drug-involved, inner-city, street sex workers in Miami, Florida. AIDS and Behavior.2006;10:139-147. 4. Edwards JM, Halpern CT, Wechsberg W. Correlates of exchanging sex for drugs or money among women who use crack cocaine. AIDS Education and Prevention. 2006;18:420-429. 5. Sharpe TT. Behind the eight-ball: Sex for crack cocaine exchange and poor Black women. Taylor and Francis, New York. 2005 6. Sterk CE, Elifson KW, Theall KP. Individual action and community context: The health intervention project. American Journal of Preventive Medicine.2007;32:S177-S181. 7. Shannon K, Bright V, Gibson K, et al. Sexual and drug-related vulnerabilities for HIV infection among women engaged in survival sex work in Vancouver, Canada.Canadian Journal of Public Health. 2007;98:465-469. 8. Miller M, Liao Y, Wagner M, et al. HIV, the clustering of sexually transmitted infections, and sex risk among African American women who use drugs. Sexually Transmitted Diseases. 2008;35:696-702. 9. Theall KP, Sterk CE, Elifson KW, et al. Factors associated with positive HIV serostatus among women who use drugs: continued evidence for expanding factors of influence. Public Health Reports. 2003;118:415-424. 10. Johnson J, Malchy L, Mulvogue T, et al. Lessons learned from the SCORE project: A document to support outreach and education related to safer crack use. June 2008. 11. Baum MK, Rafie C, Lai S, et al. Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users. Journal of AIDS. 2009;50:93-99. 12. Cook JA, Burke-Miller JK, Cohen MH, et al. Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women. AIDS. 2008; 22:1355-1363. 13. Metsch LR, Bell C, Pereyra M, et al. Hospitalized HIV-infected patients in the era of highly active antiretroviral therapy. American Journal of Public Health. 2009;99:1045-1049. 14. Cunningham CO, Sohler NL, Berg KM, et al. Type of substance use and access to HIV-related health care. AIDS Patient Care and STDs. 2006; 20:399-407. 15. Moss AR, Hahn JA, Perry S, et al. Adherence to highly active antiretroviral therapy in the homeless population in San Francisco: a prospective study.Clinical Infectious Diseases. 2004;39:1190-1198. 16. Weeks MR, Li J, Dickson-Gomez J, et al. Outcomes of a peer HIV prevention program with injection drug and crack users: the Risk Avoidance Partnership.Substance Use & Misuse. 2009;44:253-281. 17. Leonard L, DeRubeis E, Pelude L, et al. “I inject less as I have easier access to pipes” Injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed. Int’l Journal of Drug Policy. 2008; 19:255-264. 18. Sherman SG, German D, Cheng Y, et al. The evaluation of the JEWEL projects: An innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution. AIDS Care.2006;18:1-11. 19. Sterk CE, Theall KP, Elifson KW, et al. HIV risk reduction among African-American women who inject drugs: a randomized controlled trial. AIDS and Behavior. 2003;7:73-86. 20. Wechsberg WM, Lam WK, Zule WA, et al. Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers. American Journal of Public Health. 2004;94:1165-1173. 21. National Institute on Drug Abuse. Research Report Series. Cocaine: Abuse and Addiction. May 2009. 22. Sentencing. Stiff sentence for HIV+ crack user affirmed on appeal. AIDS Policy & Law. 2007;22:8. 23. Emery T. Will crack-cocaine sentencing reform help current cons? Time Magazine. August 7, 2009. 24. Schlabig Williams J. Researchers adapt HIV risk prevention program for African-American women. NIDA Notes. April 2004. 25. MacMaster SA. Social service delivery preferences among African American women who use crack cocaine: What women say they need before they can be open to HIV prevention services? Journal of HIV/AIDS & Social Services.2006;5:161-179.

Special thanks to the following reviewers of this Fact Sheet: Susan Boyd, Michael Campsmith, Judith Cook, Tom Donohoe, Waleska Maldonado, Lisa Metsch, Kate Shannon, Steve Shoptaw, Claire Sterk, Bill Stewart, Tanya Telfair Sharpe. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©December 2009, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].