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Club Drugs and HIV: Possible New Strain Offers Wake-up Call Feb 23, 2004

People tiring of safe sex warnings just got a powerful reminder that HIV and AIDS have not yet been conquered.

Last Friday, the New York City Department of Health and Mental Hygiene announced that a local man had been diagnosed with a highly resistant strain of HIV. While people with HIV sometimes develop drug resistance over time, this man, who had not previously been treated for HIV, has not responded to three of the four classes of HIV drugs. He also appears to have developed AIDS unusually quickly after becoming infected with HIV. It's possible that there are genetic reasons for his drug resistance and for the rapid progression from HIV to AIDS, and those issues are still being studied.

Besides his genetic makeup, another possible reason for the man's fast-moving infection is his drug use. The unidentified man reported having sex with multiple partners while under the influence of the club drug methamphetamine, also known as crystal meth. It's theorized that amphetamines may suppress the immune system, allowing the virus to replicate more quickly in the body. Methamphetamine also contributes to unsafe sex practices that make the spread of HIV more likely. This highly addictive drug releases people from their inhibitions, leading otherwise sexually responsible men, women and teenagers to engage in risky sexual behavior.

At a press conference, New York City Health Commissioner Thomas R. Frieden, MD, MPH, said, "This case…is a wake-up call to men who have sex with men, particularly those who may use crystal methamphetamine."

Below, Perry Halkitis, PhD, a chair of the department of applied psychology at New York University, discusses the relationship between club drugs such as methamphetamine and HIV infection.

What is the state of the HIV epidemic today?
We've seen a worsening of the HIV epidemic in the last several years. Infection rates were stable during the 1990s, but in the last few years there's been a spike in new HIV transmissions across the population, especially among gay and bisexual men. In this population, there was a 14 percent increase in new HIV infections between 1999 and 2001.

What has lead to this increase?
First of all, there's a fatigue around HIV in the gay population and in the general population. People feel that the HIV epidemic is over, and they're more complacent about safer sex practices. They think there is a cure and, as a result, people are not being as safe or as responsible in their sexual behavior. Number two, prevention efforts haven't evolved as people have become sophisticated about HIV. So "use a condom every time" campaigns, which worked fine in the early 1980s and the mid-1980s, are no longer effective.

We're also seeing a complex interaction between sexual risk-taking and drug use in the gay population and also in the straight population. We're seeing this in particular with a subset of drugs known as "club drugs" because of their association with dance clubs and bars.

Are people still going to clubs to do these drugs?
Twenty years ago, these substances were used a lot in dance club situations. Our research shows very clearly that people do them at home, they do them with their friends, they do them in the park—they do them wherever they need to do them. Some people have suggested that maybe a better label for them would be "party drugs" because these are the drugs that people do to have wild and inhibited sex, to go dancing, or to do both of those things in combination.

Which drugs are contributing to increase HIV risk?
We're talking about methamphetamine, also known colloquially as "crystal." We're talking about MDMA, which is known commonly as "ecstasy." We're talking about ketamine, Rohypnol and we're still talking about cocaine, to some extent. Most importantly, we need to think about not just each of these drugs in isolation, but these drugs being used in combination with each other, and in combination with alcohol and prescription drugs such as Viagra.

Which drugs are the most worrisome and why?
Perhaps the most worrisome is methamphetamine. This is a psychostimulant and a form of speed. Crystal is a hypersexual drug. It's a hugely disinhibiting drug. We know, and it's been clearly documented, that people who are using this substance have sex without rational thinking, they have multiple partnerings, they just let go. They feel like they're on top of the world, so nothing is a problem and any logical thinking around safer sex practices gets wiped away. Methamphetamine is also a problem because it's a highly addictive drug from a psychological perspective, so people have a very difficult time coming off of it because the cravings are so intense.

Does the way methamphetamine is administered affect HIV risk?
Absolutely. When a person first starts using it, methamphetamine is usually snorted. Eventually chronic users begin to smoke it because it is a more effective way of ingesting the drug; it gives a better and a longer and a faster high. Eventually, people who are dependent on the substance become injectors of methamphetamine. They inject it in their veins or muscles because it creates a much quicker and more intense high. So transmission through injection and the sharing of needles and the sharing of works creates another route of HIV transmission that is linked to methamphetamine use.

Do we know how much club drug use is affecting HIV risk?
We know—anecdotally in New York City and from documentation on the West Coast—that when we look at gay men who have become HIV-positive, more often than not, in the last several years, these men report having used methamphetamine with sex. So while we're not able to put an exact number on it, you can bet that a large percentage of new seroconversions are among people who are drug users.

Does methamphetamine make oral sex riskier?
We know that the mouth produces saliva, which has protective factors that assist in the prevention of HIV. When people are high on methamphetamine, they have extremely dry mouths. Suppose an HIV–negative person is using methamphetamine and is having sex with an HIV–positive person. That is more dangerous than having sex with a person who is not high on methamphetamine.

What role does depression play in drug use?
We should never deny the fact that drugs make people feel good; that's why they do them, right? What we know, also, is that people often use drugs in our society to mask bad feelings. So people who are experiencing depression or loneliness or low levels of self-esteem, which can be addressed with therapy and with medications, are self-medicating by using these substances. The unfortunate cycle that develops is that people who are depressed, for example, go on crystal, use crystal, feel better while they're high and then crash and feel even worse than when they started. When we address HIV in the United States, I think it's incredibly important that we think about the link that exists between drug abuse, mental health and HIV. Addressing one of those issues in isolation doesn't seem to be sophisticated any more. We need to address all those three things together.

How does drug use affect people on HIV therapy?
What we know, from our work, is that adherence—taking your medications the way you're supposed to take them—is a problem across the board. If we believe the literature, people are supposed to be adherent 95 percent of the time. It's very hard for people to be adherent 95 percent of the time when they're high. When they're feeling good, the last thing they want to do is actually stop to remember to take their medications. Number two, we know that methamphetamine is an immunosuppressant. Methamphetamine that is sold on the street is not pure methamphetamine. It's been cut with talc, heroin and variety of other substances that have an effect on people's immune systems. Number three, and probably most alarming of all, is that some recent studies indicate that even if an individual is highly adherent to his or her medications, if they are using methamphetamine, replication of the virus in the brain is accelerated.

What is your advice to people who use methamphetamine?
To people who haven't started and who hear wonderful tales about this drug, don't start using it. This is not a wonderful drug. The price that you will pay in the long run is not worth it. To people who have started, I say look for help. Because what do we know about methamphetamine and its effects on people's lives? People become physically ill and they become socially ill. They lose their friends, they lose their family and they lose their jobs. Methamphetamine has often been referred to as the "Grim Reaper" because of horrible and devastating effects it has on people's lives.

How can people reduce their risk of HIV?
Clearly, one of the strategies is abstinence from both sex and intravenous drug use. For young adults and for adolescents, becoming totally informed and educated about HIV and its transmission is going to be a very important strategy, as well as considering delaying the onset of sex until an individual is at a point where he or she can make the right choices around sex. The consistent use of condoms, of course, is important with anonymous or casual partners. Even in the context of some relationships that are not monogamous, the use of condoms is actually a really good idea. Finally, the mixing of sex and drugs is not a good idea. A glass of wine is very different from two lines of methamphetamine. The combination of drugs and sex is where a lot of the risk is happening now and where a lot of the transmissions are actually occurring.

It's extremely important for individuals in our country to remain informed. The disease is constantly changing. There are new medications that are coming out that are effective. But people are not necessarily living their whole lives with HIV; people are still dying. So remaining informed about HIV and remaining informed about strategies for safer sex is important.