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.9 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.
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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.
9. Task Force on Crystal, Syphilis and HIV. Confronting crystal methamphetamine use in New York City. Public policy recommendations. Gay Men’s Health Crisis, New York, NY. July 2004.
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.
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:
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.
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