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Arch Sex Behav (2011) 40:267–272 DOI 10.1007/s10508-009-9566-7 ORIGINAL PAPER Methamphetamine Use, Attitudes About Condoms, and Sexual Risk Behavior Among HIV-Positive Men Who Have Sex with Men Nadine Nakamura ã Brent T. Mausbach Monica D. Ulibarri ã Shirley J. Semple ã Thomas L. Patterson ã Received: 11 March 2009 / Revised: 21 August 2009 / Accepted: 19 September 2009 / Published online: 24 October 2009 Ó The Author(s) 2009. This article is published with open access at Springerlink.com Ab
  ORIGINAL PAPER MethamphetamineUse,AttitudesAboutCondoms,andSexualRiskBehavior Among HIV-Positive Men Who Have Sex with Men Nadine Nakamura ã Brent T. Mausbach ã Monica D. Ulibarri ã Shirley J. Semple ã Thomas L. Patterson Received: 11 March 2009/Revised: 21 August 2009/Accepted: 19 September 2009/Published online: 24 October 2009 Ó The Author(s) 2009. This article is published with open access at Springerlink.com Abstract This study examined attitudes about condoms as amoderatoroftherelationshipbetweenmethamphetamineuseandsexual risk behavior in a sample of 297 HIV-positive, metham-phetamine-usingmenwhohavesexwithmen(MSM).Totestforamoderatingeffectofattitudestowardscondoms,aninteractiontermwasincludedinmultipleregressionanalysisalongwithage,income, negative condom attitudes, frequency of methamphet-amine use, and Beck depression score. A post hoc analysis wasconductedtodeterminetherelationsbetweenmethamphetamineuse and unprotected sex for persons with more vs. less negativeattitudes toward condoms. These analyses indicated that whenindividuals had more negative attitudes toward condoms, therelation between methamphetamine frequency and unprotectedsexwas significant,while amongparticipantswith less negativeattitudes toward condoms, no significant association was found.Addressing methamphetamine-using MSM’s attitudes aboutcondomscanserveasaformofharmreductionforthosewhoarenotyetreadyorwilling todiscontinue methamphetamine use. Keywords Methamphetamine Á Attitudes Á Condoms Á Sexual risk  Á Men who have sex with men Introduction According to the Centers for Disease Control and Prevention(2007), more than half a million men who have sex with men(MSM)havereceivedanAIDSdiagnosisintheUnitedStates.Whileonly5–7%ofmenintheUnitedStatesreportedhavinghad sex with other men, MSM made up more than two-thirds(71%)ofallmenlivingwithHIVin2005.In2005,thenumberofnewHIV/AIDScasesamongMSMwas11%morethanthenumberofnewcasesin2001.Whileitisnotclearwhetherthisincrease is due to increased HIV testing or to higher rates of infection, whatiscertain is thatHIV continues to bea serioushealth threat to MSM.TheriseofHIVamongMSMmaycorrespondwiththeriseinmethamphetamine use in this population (CDC,2007). Meth-amphetamineusehasbeenidentifiedinanumberofstudiesasapredictor of risky sexual behavior among MSM (Colfax &Shoptaw,2005; Halkitis, Parsons, & Stirratt,2001; Semple, Patterson,&Grant,2002).Methamphetamineusersoftenreportdecreased sexual inhibition, increased self-esteem, euphoria,and hypersexuality when under the influence (Halkitis et al.,2001). Methamphetamine use has also been associated with anumberofsexualriskfactors,includingenhancedsexualdrive,behavioraldisinhibition,increaseddesireforhighriskactivities,lowratesofcondomuse,highratesofsexuallytransmitteddis-ease, and multiple partners (Colfax & Shoptaw,2005). Meth-amphetaminenotonlyincreasesHIV-negativeusers’risk,butitalsohasserioushealthconsequencesforHIV-positiveusersbyincreasing neuropsychological deficits and decreasing medi-cation adherence (Colfax & Shoptaw,2005).Noteveryonewhousesmethamphetaminehasunprotectedsex(Crosby,Stall,Paul,&Barrett,1996).Recentstudieshavechallenged the ideas that methamphetamine use necessarilyleads to increased risky sexual behavior and that it thereforeshould be the primary focus of our HIV-prevention efforts N. Nakamura Á B. T. Mausbach Á M. D. Ulibarri Á S. J. Semple Á T. L. Patterson ( & )Department of Psychiatry (0680), University of California,San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0680, USAe-mail: tpatterson@ucsd.eduT. L. PattersonMIRECC, San Diego VA Medical Center, La Jolla, CA, USA  123 Arch Sex Behav (2011) 40:267–272DOI 10.1007/s10508-009-9566-7  (Grov,Parsons,& Bimbi,2008; Rawstorne, Digiusto, Worth,& Zablotska,2007). Rawstorne et al. (2007) examined data from two cohort studies of Australian MSM and found that,while there was an increase in methamphetamine use from26% in 2002 to 39% in 2005, the rate of unprotected anal sexwithcasualpartnerseitherdidnotchangeoractuallydecreasedduringthistime.Rawstorneetal.concludedthatsincethereisnoevidencethattheproportionofunsafesexisdirectlycausedby methamphetamine use, other variables that are correlatedwith both methamphetamine use and unsafe sex should befurtherexplored.Thus,itisimportanttoidentifyforwhomandunderwhatcircumstancesmethamphetamineuseisassociatedwith risky sexual behaviors. Identifying these factors couldprovideinterventiontargetsthatmayaidinreducingthespreadof HIV and other sexually transmitted infections.Attitudes and beliefs about condom use and social normsappeartosignificantlyinfluencewhethersubstance-usingMSMuse condoms (Crosby et al.,1996). For example, positive atti-tudestowardscondomscanactuallyprotectagainstriskysexualbehavior (Benotsch, Kalichman, & Cage,2002). However,attitudesaboutcondomshavenotbeenexaminedasamoderatorin previous research with methamphetamine-using MSM.An earlier study of methamphetamine-using, HIV-positiveMSM revealed that participants had high rates of depression,andthatthemajoritywasusingmethamphetaminetoself-medi-cate(Sempleetal.,2002).Sincedepressionmayaffecttherela-tionshipbetweencondomattitudesandsexualriskbehavior,wecontrolled for depression in our analyses.Inthepresentstudy,weexaminedattitudesaboutcondomsas a factor that may modify the relationship between level of methamphetamineuseandsexualriskbehaviorinasampleof HIV-positive MSM. Specifically, we hypothesized that therelationship between methamphetamine use and sexual risk behavior would be stronger among individuals with attitudestowards condoms that were more negative. Method ParticipantsThese analyses used baseline data from a sample of 297 menwho were enrolled in an eight-session, theory-based, one-on-one behavioral intervention designed to reduce sexual risk behaviors of HIV-positive, methamphetamine-using MSM.Eligible participants were HIV-positive MSM who were atleast 18 years old and who reported using methamphetamineatleast twiceinthe pasttwomonths.Because thestudy’s aimwas to reduce sexual risk behaviors, participants also had toreporthavinghadunprotectedanalororalsexwithatleastoneHIV-negative or serostatus-unknown male partner during thesame period, whereas men who used condoms 100 percent of thetimewithallHIV-negativeorserostatus-unknownpartnersor who had only HIV-positive partners over the previous twomonthswereexcluded.Inaddition,thosewhoendorsedactivesuicidal or psychotic symptoms, or who had been HIV-posi-tivefor lessthantwomonthswere alsoexcluded.Findingsonthe efficacy of the intervention have been published (Maus-bach, Semple, Strathdee, Zians, & Patterson,2007).Participants were recruited into the intervention study in SanDiego, California through multiple strategies, including large-scaleposterandmediacampaigns,streetoutreachinsocialenvi-ronmentsthatwereknowntohavehighconcentrationsofmeth-amphetamineusersandMSM(e.g.,gayclubs),andreferralsfromsocial service providers (e.g., HIV health clinics) or from menalready enrolled in the study. The study was advertised as auniversity-sponsored program for HIV-positive methamphet-amineuserswhowantedtolearnmoreaboutsafersexpractices.ProcedureParticipants underwent a 60-min, face-to-face, paper-and-pen-cil baseline interview that covered a range of topics, includingbackgroundcharacteristics,depressivesymptoms,useofmeth-amphetamine,condomattitudes,andsexualriskpractices.Par-ticipants were paid $30 for completing their baseline assess-ment and the first session of the counseling intervention. DataforthepresentanalyseswerecollectedbetweenNovember2000and October 2004.Measures  Background Characteristics Each participant was asked about his age, ethnicity, educa-tion, sexual orientation, employment status, and income.  Depressive Symptoms Depressed mood was assessed using the Beck DepressionInventory (BDI), which consists of 21 items, each having fourgradedstatementsabouthowthesubjecthasbeenfeelingduringthe past week (Beck,1967,1976). The statements within each questionareordered(0–3)toshowincreasingdepressivesymp-toms. Summary scores are calculated (range, 0–63). Frequency of Methamphetamine Use This was measured by self-report of the number of days onwhich methamphetamine was used during the past 30 days.  Negative Condom Attitudes Participants’ negative attitudes on this topic were calculatedby summing responses to the following questions: (1) ‘‘I be-lievethatusingcondomsinterfereswithsexualpleasure,’’(2) 268 Arch Sex Behav (2011) 40:267–272  123  ‘‘Ibelievethatstoppingtoputonacondomruinsthemoment,’’(3) ‘‘I believe that using condoms makes me less sexuallydesirable,’’ (4) ‘‘Using condoms during sex ruins the mood,’’(5) ‘‘Using a condom will feel unnatural,’’ and (6) ‘‘My part-ner(s) will not be sexually satisfied if we use a condom’’(Mausbach,Semple,Strathdee,&Patterson,2009).Responsestoitemsonthisscalerangedfrom1 = ‘‘StronglyDisagree’’to4 = ‘‘StronglyAgree.’’Ahighscoreindicatedmorenegativeattitudes about condom use, while a low score indicated lessnegativeattitudesaboutcondomuse.Alphareliabilityforthisscale with our sample was .85. Sexual Risk Behavior  Sexualriskbehaviorwasdefinedasunprotectedanalsexwithan opposite- or same-sex partner. Three categories of partnertype were assessed: steady (e.g., spouse, boyfriend); casual(e.g., one-night stand); and anonymous (e.g., someone in thepark). For each partner type, participants were asked howmany times during the past two months they had engaged inreceptive analsex and insertive analsex. For eachtype ofsexact,participantswereaskedhowmanyofthosetimestheyhadused a condom. A summary variable was created to representtotal number of unprotected anal sex acts during the previoustwo months.Data AnalysisTo determine the moderating effect of negative condom atti-tudes on the relations between methamphetamine frequencyandunprotectedsex,amultiple linearregressionapproachwasused (Baron & Kenny,1986). Prior to the analyses, all inde-pendent variables were centered at their means, as is recom-mendedintheliterature(Kraemer&Blasey,2004).Thefollow-ingvariableswereenteredaspossiblepredictorsofunprotectedsex:age,income,BDIscore,methamphetaminefrequency,neg-ative condom attitudes, and the interaction between metham-phetamine frequency and negative condom attitudes (seeTable1).Posthocanalyseswereconductedtodeterminethenatureof the interaction. In these tests, we created a variable for highcondom attitudes (i.e., centered negative condom attitudesminus 1 SD ) and one for low condom attitudes (i.e., centerednegativecondomattitudesplus1 SD ).Eachofthesevariableswas then multiplied by the (centered) methamphetamine fre-quency variable to create an interaction term. We then con-ducted two additional regression analyses, each of whichincludedthemaineffectformethamphetaminefrequency,oneof the condom attitude variables (i.e., high condom attitudesor low condom attitudes), and the interaction of the metham-phetamine frequency and condom attitudes variable, therebyproducing the slope for the high and low condom attitudeconditions. Greater details on how to conduct such post hocanalyses as these can be found in Holmbeck (2002). Results Sample DescriptionThis study used data from 297 participants who had com-pleted baseline assessment in the intervention study. Partici-pantsrangedinagefrom20to61 years,withameanof36.89( SD = 7.27).Allparticipantsreportedhavingsexwithamalepartner in the previoustwomonthsandwerethus categorizedasMSM,withthemajority(79.1%)identifyingashomosexualorgay,20.1%identifyingasbisexual,andlessthan1%as‘‘notsure.’’ The majority of participants was White (56.6%), fol-lowed by African American (21.5%), Latino (13.1%), NativeAmerican (4%), Other (4%), and Asian (.7%). Most partici-pants had some college education or more (59.9%), while27.9%hadonlyahighschooldegree,and12.1%hadlessthanahigh school degree. The majority of participants (50.5%) hadan annual income of less than $10,000, while 27.6% earnedbetween $10,000 and $19,999, and 21.9% earned more than$20,000. In the past 30 days, the mean days of metham-phetamine use was 10.43 ( SD = 8.96). In the same period,the mean number of unprotected anal sex acts was 13.30( SD = 17.09), with a range of 0–83. The Negative CondomAttitudes Scale had a range from 6 to 24, with a mean scoreof14.50( SD = 4.47).BDIscoresforthissamplerangedfrom Table 1 Hierarchical linear regression predicting unprotected sex from measure of age, income, depression, frequency of methamphetamine use,negative condom attitudes, and frequency of methamphetamine use times negative condom attitudes (  N  = 281)Model Variable B SE  Beta t p Adjusted R 2 Step 1 Age .023 .138 .010 \ 1 ns .025Income 2.151 .713 .178 3.01 .003Step 2 Depression score .055 .098 .033 \ 1 ns .150Frequency of meth use .302 .107 .160 2.81 .005Condom attitudes 1.227 .215 .321 5.70 .000Step 3 Meth use 9 Condom attitudes .049 .022 .120 2.16 .031 .161Arch Sex Behav (2011) 40:267–272 269  123  0to62,withameanscoreof15.32( SD = 10.07),whichfallsinto the mild to moderate range of depressive symptoms.Correlation AnalysesPearson correlation coefficients were used to examine back-ground characteristics as correlates of negative condom atti-tudes,unprotectedsex,andfrequencyofmethamphetamineuse.None of the background characteristics were significantly cor-related with negative condom attitudes. Lower negative con-domattitudeswereassociatedwithlowerlevelsofunprotectedsex ( r  = .35, p \ .0001). Higher number of days of metham-phetamineusewasassociatedwithhigherlevelsofunprotectedsex ( r  = .18, p \ .01). Higher depression scores were associ-ated with a higher number of days of methamphetamine use( r  = .22, p \ .0001) and lower income ( r  =- .15, p \ .01).Higher income was associated with more unprotected sex( r  = .17, p \ .01). No correlation was high enough to causeconcern about multicollinearity in the regression analysis.Regression AnalysisA multiple regression analysis was conducted. The outcomeof interest, total unprotected sex, was regressed on negativecondomattitudes,withbackgroundcharacteristics,frequencyof methamphetamine use, and Beck depression scores in-cluded in the regression equation. Variables that were signif-icantinthecorrelationanalyseswereincludedascovariatesinthe regression. Age was included as an independent variable,even though it was not significantly correlated with any of the other variables,because ofthe strongassociationbetweenyounger age and sexual risk behavior in population-basedstudies of MSM (Xia et al.,2006). Missing data for the BDI( n = 16)reducedthenumberofparticipantsintheregressionequation to 281. Missing participants did not significantlydiffer from included participants on any of the demographic,predictor, or outcome variables.Independentvariableswereenteredinthreeseparatesteps.In the first step, age and income were entered as a block. As ablock, these two variables accounted for three percent of thevariance in the dependent variable. Income was the only sig-nificantvariable.Thedirectionofthebetacoefficientindicatedthathigherincomewasassociatedwithmoreunprotectedsex.Insteptwo,negativecondomattitudes,frequencyofmeth-amphetamineuse,andBeckdepressionscoreswereenteredasablock.Together,thesevariablesaccountedforanadditional14%of variance (  p \ .05). Negative condom attitudes accounted for10% of the variance of the outcome (  p \ .001), while frequen-cy of methamphetamine use accounted for 2% (  p \ .01). Anexamination of the individual test statistics indicated that meth-amphetamine frequency was positively associated with unpro-tected sex, as were negative condom attitudes. Therefore, moremethamphetamine use was associated with more unprotectedsex, and lower scores on negative condom attitudes were asso-ciated with less unprotected sex. In the final step (three) of theregression,theinteractionterm(frequencyofmethamphetamineusetimesnegativecondomattitudes)wasentered.Thistermwassignificant,suggestinga potentialmoderator effect.As described above, we conducted post hoc analyses todeterminetherelationsbetweenmethamphetamineuseandun-protected sex for persons with more vs. less negative attitudestoward condoms. These analyses indicated that when individ-uals had more negative attitudes toward condoms, the relationbetweenmethamphetaminefrequencyandunprotectedsexwassignificant ( t  = 3.81; p = .001). That is, greater methamphet-amineusewasassociatedwithgreaterfrequencyofunprotectedsex. However, among participants with less negative attitudestowardcondoms,nosignificantassociationwasfoundbetweenmethamphetamine frequency and unprotected sex ( t  = 1.00).This moderating effect is plotted in Fig.1. Discussion This study investigated the relationship between methamphet-amineuse,attitudesaboutcondoms,andunprotectedanalsexinasample of HIV-positive, methamphetamine-using MSM. Foryearsnow,evidencehasshownthatmethamphetamineuseispos-itivelyassociatedwithgreaterlevelsofunprotectedsex(Colfax&Shoptaw,2005; Halkitis et al.,2001; Semple et al.,2002). Recently, Rawstorne et al. (2007) encouraged researchers to ex-plore other variables that are correlated with both methamphet-amineuseandunprotectedanalsexinordertodeepenourunder-standing of the relationship between these behaviors. So far, thisstudy is the only one of which we are aware that has soughtto identify factors that could moderate the relationship betweenunprotectedanalsexandmethamphetamineuse.Toevaluatethedirect and independent effects of methamphetamine use andcondom attitudes in relation to unprotected anal sex, we used anadditive, multivariate regression model. In that model, morenegativecondomattitudesandhigherlevelsofmethamphetamine    #  o   f   U  n  p  r  o   t  e  c   t  e   d   S  e  x   A  c   t  s Methamphetamine Intensity Fig. 1 Relationship between unprotected sex and methamphetamineintensity for low and high negative condom attitudes270 Arch Sex Behav (2011) 40:267–272  123
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