This article was downloaded by: [University Of Maryland] On: 17 October 2014, At: 02:25 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Substance Use and Sexual Risk Differences among Older Bisexual and Gay Men with HIV a
b
a
c
Mark Brennan-Ing , Kristen E. Porter , Liz Seidel & Stephen E. Karpiak a
ACRIA, ACRIA Center on HIV & Aging, and New York University College of Nursing
b
John E. McCormack School of Policy & Global Studies, University of Massachusetts
c
ACRIA, ACRIA Center on HIV & Aging, and Fordham University Graduate School of Social Service Published online: 04 Aug 2014.
To cite this article: Mark Brennan-Ing, Kristen E. Porter, Liz Seidel & Stephen E. Karpiak (2014) Substance Use and Sexual Risk Differences among Older Bisexual and Gay Men with HIV, Behavioral Medicine, 40:3, 108-115, DOI: 10.1080/08964289.2014.889069 To link to this article: http://dx.doi.org/10.1080/08964289.2014.889069
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
BEHAVIORAL MEDICINE, 40: 108–115, 2014 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2014.889069
Substance Use and Sexual Risk Differences among Older Bisexual and Gay Men with HIV Mark Brennan-Ing ACRIA, ACRIA Center on HIV & Aging, and New York University College of Nursing
Downloaded by [University Of Maryland] at 02:25 17 October 2014
Kristen E. Porter John E. McCormack School of Policy & Global Studies, University of Massachusetts
Liz Seidel ACRIA, ACRIA Center on HIV & Aging, and Fordham University Graduate School of Social Service
Stephen E. Karpiak ACRIA, ACRIA Center on HIV & Aging, and New York University College of Nursing
Bisexual and gay men are disproportionately affected by HIV/AIDS. Research typically combines these groups into the category of men who have sex with men, and little is known about between-group differences. HIV-positive populations are aging and have high rates of substance use compared to non-infected peers, while substance use among older adults has increased and is associated with unprotected intercourse. Among a sample of 239 HIVpositive bisexual and gay men aged 50 and older, bisexual men were more likely to report cigarette, cocaine, crack, and heroin use compared with gay men. However, bisexual men were less likely to use crystal meth, club drugs, poppers (nitrate inhalers), and erectile dysfunction (ED) medications compared to gay men. While bisexual men reported lower rates of unprotected sex, logistic regression analysis found that current use of poppers and ED drugs, which were higher among gay men, explained this difference. Implications for education and prevention programs are discussed.
Keywords: bisexual, gay, HIV/AIDS, MSM, older adults, substance use By 2015, half of those living with HIV in the US will be age 50 or older. Gay and bisexual men remain disproportionately affected by the virus since 60% of infections among men in this age group are attributed to male-to-male sexual contact.1,2 Of new HIV diagnoses, 17% are detected in people aged 50 and older, with substance use remaining a primary link to increased risk of HIV transmission.1,3,4 Substance use in the general population of older adults is understudied, but current evidence suggests that 5% of Correspondence should be addressed to Mark Brennan-Ing, PhD, Director for Research and Evaluation, ACRIA, 575 Eighth Avenue, Suite 502, New York, NY, 10018, USA. E-mail: [email protected]
those aged 50 and older have used illicit substances in the past year; a proportion expected to double by 2020.5 Substance use among bisexual and gay men, and those with HIV/AIDS, is typically higher than the general population, but such research among older adults with HIV is limited.6,7 This article examines differences between bisexual and gay older HIV-positive men regarding substance use and unprotected sexual intercourse. A content analysis of the medical literature found that only 18% of articles examined bisexual people as a discrete group.8 Failing to consider bisexual people as a distinct research population contributes to bi-invisibility, namely, the non-recognition of this unique
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OLDER BISEXUAL AND GAY MEN WITH HIV
sexual identity.9,10 Moreover this limited literature suggests that bisexual people report poorer mental health outcomes (i.e., mood and anxiety disorders) than do those with a monosexual orientation (ie, heterosexual or homosexual), and such disorders have the potential to impact substance use and sexual risk.8,11,12 Extant literature on HIV transmission and substance use typically combines gay and bisexual men into the category of men who have sex with men (MSM), reflecting the Center for Disease Control and Prevention’s (CDC) behaviorally-defined category of male-tomale sexual contact. However, bisexuality may be defined in terms of not only behavior, but also the social construct of identity or attraction to both sexes, regardless of sexual contact.13 Behavioral classifications may obscure differences arising from the complex interactions of biology, culture, and society which underlie bisexual and gay identities. Consequently, the detection of important group differences between bisexual and gay men in regards to the primary predictor of unprotected sex, namely substance use, could improve HIV-prevention efforts. The research on substance use and unprotected sex comparing bisexual and gay men discussed below has focused primarily on younger ages and frequently defines bisexuality by behavior rather than identity.
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Data are virtually nonexistent on substance use among HIV-positive older adults, where sexual identity is a variable. One study found men with HIV more likely to report both club drug and injectable drug use relative to HIV-negative men.21 In a combined sample of bisexual and gay men, HIV-positive individuals had higher rates of substance use compared to HIV-negative peers.24 In an examination of substance use in older adults with HIV compared to heterosexual men, heterosexual women, and the combined category of gay/bisexual men, gay/bisexual men had the highest rates of alcohol, popper, and marijuana use.25 Sexual Behavior and Sexual Identity Research on the likelihood of bisexual and gay men to engage in unprotected insertive intercourse is inconclusive. Some find bisexual men to have less frequent unprotected anal intercourse with casual partners compared to gay men,26 while others have found no differences in condom use during same-sex encounters.22,27 Other studies report that bisexual men engage in more transactional sex which may increase the risk of seroconversion.22,28 Substance Use and Sexual Risk
Substance Use Research on substance use comparing bisexual and gay men is very limited, yielding inconclusive results; and no studies were identified that have examined this issue in older populations. For example, among a group of mixedgender college students using a behavioral definition of bisexuality, the bisexual students had higher levels of substance use including binge drinking.14,15 One study found higher rates of substance use disorders among gay men compared to bisexual and heterosexual men,16 but this pattern has not been replicated.17 In terms of specific types of substances, bisexual people are more likely to smoke cigarettes and smoke a greater number of cigarettes compared with gay men.16,18 Some research suggests that marijuana dependence and use is higher among bisexual men, as well as those reporting male and female sexual partners, regardless of sexual identity.16,17 But others find lower marijuana use among men reporting being equally attracted to both sexes.19 Findings on alcohol use are also inconsistent. In studies of young men, gay men have been found to consume more alcohol compared with bisexual men.16,20 Sexual identity did not relate to alcohol use among gay and bisexual men ages 18 to 69 in France.19 Studies of “club drugs” (e.g., meth amphetamine, cocaine, crystal, ecstasy, ketamine) find that bisexual men are less likely to use these substances compared with gay peers,20,21 with one study reporting higher cocaine use in bisexual men.17 Research on injection drug use (IDU) is inconclusive.20–23
A few studies have examined substance use and sexual risk among older HIV-positive adults but did not differentiate between gay and bisexual men. One study found older adults with HIV who used club drugs were twice as likely to report irregular condom use.29 In another, 60% of HIV-positive older gay/bisexual men reported using drugs/alcohol during sex and half reported inconsistent condom use.30 The use of nitrate inhalers (ie, poppers) as a sexual stimulant, used predominantly by gay and bisexual men, has received scant attention in the literature.31 However, popper use has been attributed to greater sexual-risk behaviors that results in HIV-seroconversion compared with other substances,32 especially among older men.33,34 Poppers reduce inhibitions, which promotes unprotected sex; as well as enlarge blood vessels, making it easier for the HIV virus to enter the bloodstream.31 Purpose and Rationale Substance use is associated with an increase in unprotected intercourse and HIV transmission in sexual minority men. Yet, gay and bisexual men are typically grouped together in studies of substance use and unprotected sex, though the available evidence, albeit incomplete, supports the view that bisexual men and gay men are unique populations. There are little data addressing the issues of substance use and sexual risk among older adults in general, and among older adults with HIV in particular. Since older
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BRENNAN-ING ET AL.
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HIV-positive adults are sexually active and are known to engage in unprotected intercourse, this lack of evidence hinders the development of informed secondary prevention efforts. The purpose of this article is to examine differences in substance use and sexual risk behavior among older HIV-positive self-identified bisexual and gay men. This study tested the following hypotheses: (1) There will be significant differences between older bisexual and gay men regarding lifetime and current use of alcohol and other substances; (2) alcohol and substance use correlates of unprotected intercourse will differ between bisexual and gay men; and (3) bisexual and gay men will differ in the odds of unprotected intercourse after controlling for socio-demographics and substance use.
Substance Use Respondents were asked if they had ever used any of the following substances and if they had used them in the past 3 months (ie, current use); cigarettes, alcohol, crystal meth, cocaine, crack cocaine, heroin, marijuana, ecstasy, GHB, ketamine, LSD/PCP, poppers, pain killers, or ED medications. The number of drugs used currently was calculated by summing responses to the above, exclusive of cigarettes and ED medications, but inclusive of alcohol. For logistic regression analyses, current drug use was collapsed into categories of (1) crystal meth, (2) marijuana, (3) crack or cocaine, (4) club drugs (ie, Ecstasy, GHB, ketamine), (5) heroin, (6) alcohol, (7) pain killers, (8) ED medications, and (9) poppers. Sexual Activity
METHODS Sample and Procedures The comprehensive research effort, Research on Older Adults with HIV (ROAH), was conducted in 2005–2006 in New York City.35 A convenience sample of 1,000 older HIV positive adults completed a self-administered survey, of which 914 were non-duplicative and usable. Eligibility criteria included being HIV-positive, 50 years or older, cognitively-intact, and sufficient English-language skills to complete the survey instrument. The selfadministered survey instrument and protocol were approved by the Copernicus Group Independent Review Board. Data were collected at community sites throughout New York City. Surveys took 1.5 to 2 hours to complete. Participants provided written informed consent before completing the survey, and received a $25 gift card. The 239 individuals who self-identified as male and either bisexual or gay were utilized for the analyses reported in this article. Measures Socio-demographics and Health Sexual identity was determined from an item that asked, “Do you consider yourself to be; (1) heterosexual or straight, (2) gay or lesbian, (3) bisexual, (4) queer, or (5) questioning.” Other single items assessed age, race, ethnicity, gender, education, employment, income adequacy, living alone, diagnosis of AIDS, use of anti-retroviral medications, and years since HIV diagnosis. How one was infected with HIV was a multiple-response question; possible answers were (1) anal intercourse, (2) vaginal intercourse, (3) sharing needles, and (4) other. The presence of comorbidities was self-reported from a list of 24 illnesses experienced other than HIV during the past year (yes/no) and summed for the number of comorbidities.
Respondents answered a series of gender-specific questions regarding their sexual behaviors in the past 90 days. Respondents were asked to report the number of times they had engaged in each type of sexual activity (ie, oral, anal or vaginal intercourse; insertive or receptive; protected or unprotected) by partner type (ie, main or non-main) and by serostatus (ie, HIV-negative, HIV-positive, or unknown status). A summary dichotomous dependent variable that identified participants who had at least one instance of unprotected anal/vaginal sex regardless of the partner’s serostatus was created based on these data. Design and Analysis The present study used a cross-sectional, correlational design to examine differences in substance use and unprotected sexual intercourse among older self-identified gay and bisexual men with HIV. Univariate statistics were calculated on all study variables prior to bivariate analysis. To examine significant differences in socio-demographics, health status, substance use, and unprotected sex differences between gay and bisexual men, bivariate analyses were conducted using ANOVA and chi-square analysis for continuous and categorical variables, respectively. To address the second hypothesis on differences in patterns of association of substance use and unprotected sex, Pearson correlations were calculated for the total group and each group individually. To address the third hypothesis, hierarchical logistic regression analyses were performed on the binary dependent measure of any unprotected anal/vaginal sex (yes/no). The first block contained socio-demographic and health covariates that differed significantly between the two groups as controls, and the second block added bisexual identity. The third block added the number of substances currently used, and the final block tested the effects of different classes of substances used on the odds of unprotected intercourse. Categorical variables (eg, bisexual identity) were dummy-coded prior to analyses. Only covariates that
OLDER BISEXUAL AND GAY MEN WITH HIV TABLE 1 Sociodemographic and Health Characteristics Total
Downloaded by [University Of Maryland] at 02:25 17 October 2014
Variable Race/Ethnicity*** Non-Hispanic White Non-Hispanic Black Hispanic/Latino Education** Less than high school High school graduate Some college College graduate/post-grad Employment Working (Full or part time) Not working Disabled Other Income Adequacy Not enough money Just manage Enough, a little extra Money not a problem Lives alone (yes) How infected with HIV*** Anal intercourse Vaginal intercourse Sharing needles Multiple/Other/Not known Diagnosed with AIDS (yes) Anti-retroviral therapy (yes)* Age Year since HIV diagnosis Number of comorbidities Self-rating of health Number of substances (3 mo.)
Bisexual
Gay
N
%
N
%
N
%
77 75 74
34.1 33.2 32.7
5 27 22
9.3 50.0 40.7
72 48 52
41.9 27.9 30.2
16 43 66 112
6.8 18.1 27.8 47.3
8 14 17 17
14.3 25.0 30.4 30.4
8 29 49 95
4.4 16.0 27.1 52.5
34 54 130 9
15.0 23.8 57.3 4.0
9 14 30 0
17.0 26.4 56.6 0.0
25 40 100 9
14.4 23.0 57.5 5.2
37 127 49 23 197
15.7 53.8 20.8 9.7 82.4
11 30 8 7 48
19.6 53.6 14.3 12.5 82.8
26 97 41 16 149
14.4 53.9 22.8 8.9 82.3
173 7 9 50 145 214 M 56.4 14.2 3.2 6.9 1.7
72.4 2.9 3.8 20.9 61.4 89.5 SD 5.5 5.0 2.2 1.7 1.5
27 6 7 18 31 48 M 55.8 13.4 3.1 7.0 1.4
46.6 10.3 12.1 31.0 55.4 82.8 SD 5.4 5.4 2.2 1.6 1.6
146 1 2 32 114 166 M 56.6 14.5 3.2 6.9 1.8
80.7 .6 1.1 17.7 63.3 91.7 SD 5.5 4.9 2.2 1.8 1.5
Notes. N D 239 (Bisexual, n D 58, Gay, n D 181). *p < .05, ** p < .01, ***p < .001.
were significantly related to either bisexual identity or unprotected intercourse were retained in the regression model. Potential multicollinearity of covariates was examined (ie, r 0.7), and no potential problems were identified. Listwise deletion of missing values was used.
RESULTS Comparison of Older HIV-Positive Bisexual and Gay Men The average age of the sample was 56.4 years (see Table 1). Bisexual men were more likely to be ethnic/racial minorities (91%) as compared with gay men (58%). Gay men reported higher levels of educational attainment compared with bisexual men. However, these groups did not differ significantly with respect to employment, income
111
adequacy, or living alone. Gay men were more likely to report contracting HIV through anal intercourse (81%) versus 47% of bisexual men, but there were no significant differences in years since HIV diagnosis (14.2) or the likelihood of an AIDS diagnosis (61%). However gay men were more likely to report being on anti-retroviral therapy compared to bisexual men (92% and 83%, respectively). The two groups did not differ significantly with regard to the number of comorbid conditions in addition to HIV (3.2), self-ratings of health (6.9), or the number of substances used in the past 3 months (1.7).
Sexual Identity, Substance Use, and Unprotected Sex There were myriad statistically significant differences in lifetime and current substance use between older HIV-positive bisexual and gay men (see Table 2). Bisexual men were twice as likely to be current smokers compared to gay men (60% and 30%, respectively). Lifetime (90%) and current alcohol use (53%) was not related to sexual identity. Gay men were more likely than bisexual men to have ever used crystal meth (14% and 3%, respectively), but there were no significant differences in the proportion currently using this substance (4%). Lifetime use of both cocaine (62%) and crack (41%) did not differ significantly between the two groups, however bisexual men were twice as likely to report the current use of these substances (24% and 24%, respectively) compared with gay men (12% and 12%, respectively). Bisexual men were also significantly more likely to have ever used heroin (38%) or to currently be using this drug (7%) as compared with gay men (16% and 1%, respectively). While gay men were significantly more likely to report ever using marijuana (83%) as compared to bisexual men (71%), there were no significant differences in current use (28% overall). Lifetime and current use of club drugs, such as Ecstasy, GHB, and ketamine ranged from 5% to 15%. Only with respect to lifetime use of ketamine did bisexual and gay men differ (2% and 11%, respectively). Nearly half (45%) had used a hallucinogen like LSD or PCP, but current use was infrequent (1%) and did not differ by sexual orientation. Gay men were significantly more likely to report lifetime or current use of poppers (81% and 26%, respectively) compared with bisexual men (45% and 7%, respectively). A similar pattern was observed with pain killers, with gay men more likely than bisexual men to report lifetime (75% and 55%, respectively) and current use (36% and 21%, respectively). While older HIVpositive gay men were more likely to report having used ED medications (53%) than bisexual men (31%), current use did not differ significantly between the two groups (29%). Lastly, bisexual men were less likely (12%) to have reported unprotected intercourse in the past 3 months compared with gay men (22%), but this was not significant at the p < .05 level.
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BRENNAN-ING ET AL. TABLE 2 Patterns of Alcohol, Substance Use, and Unprotected Sex among Older HIV-positive Bisexual and Gay Men Total
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Substance Cigarettes – Lifetime Cigarettes – 3 months*** Alcohol – Lifetime Alcohol – 3 months Crystal Meth – Lifetime* Crystal Meth – 3 months Cocaine – Lifetime Cocaine – 3 months* Crack – Lifetime Crack – 3 months* Heroin – Lifetime*** Heroin – 3 months** Marijuana – Lifetime* Marijuana – 3 months Ecstasy – Lifetime Ecstasy – 3 months GHB – Lifetime GHB – 3 months Ketamine – Lifetime* Ketamine – 3 months LSD/PCP – Lifetime LSD/PCP – 3 months Poppers – Lifetime*** Poppers – 3 months** Pain Killers – Lifetime** Pain Killers – 3 months* ED medications – Lifetime** ED medications – 3 months Any Unprotected Anal/Vaginal IntercourseCCC
Bisexual
Gay
N
%
N
%
N
%
185 86 215 122 27 9 148 35 97 34 50 6 190 65 37 0 11 1 21 1 105 1 171 50 168 75 114 68 47
77.4 36.8 90.0 53.0 11.3 3.8 61.9 15.0 40.6 14.6 20.9 2.5 80.2 28.0 15.5 0.4 4.6 0.4 8.8 0.4 44.5 0.4 71.8 21.4 70.3 32.2 47.9 28.9 19.7
49 33 50 24 2 0 33 13 29 13 22 4 41 12 6 0 2 0 1 0 22 0 26 4 32 12 18 14 7
84.5 60.0 86.2 44.4 3.4 0 56.9 23.6 50.0 24.1 37.9 7.1 70.7 21.4 10.3 0 3.4 0 1.7 0 38.6 0 44.8 6.9 55.2 21.4 31.0 24.1 12.1
136 53 165 98 25 9 115 22 68 21 28 2 149 53 31 1 9 1 20 1 83 1 145 46 136 63 96 54 40
75.1 29.6 91.2 55.7 13.8 5.0 63.5 12.4 37.6 11.7 15.5 1.1 83.2 30.1 17.1 0.6 5.0 0.6 11.0 0.6 46.4 0.6 80.6 26.1 75.1 35.6 53.3 30.5 22.1
Notes. N D 239 (Bisexual, n D 58; Gay, n D 181). CCCp < .10, * p < .05, **p < .01, ***p < .001.
Associations of Substance Use and Unprotected Intercourse
pain killers was not related to unprotected intercourse in either group.
Neither past nor current use of alcohol was correlated with unprotected sex in either older bisexual or gay men with HIV. Lifetime and current use of crystal meth or cocaine were significantly related to unprotected sex among gay men, but not bisexual men. Lifetime crack use was related to unprotected sex in both groups, but current crack use was only significantly related to unprotected sex among gay men. Lifetime and current use of Ecstasy was related to unprotected sex in gay men but not bisexual men. This observation was the same for the other “club” drugs GHB and ketamine. Heroin use was not related to unprotected sex, nor was lifetime use of LSD or PCP. Current use of LSD/PCP trended toward a significant correlation with unprotected sex among gay men only. With regard to marijuana and poppers, only current use was associated with unprotected intercourse for both bisexual and gay men. While lifetime use of ED medications was not related to unprotected sex, current use was significantly associated with unprotected intercourse only among gay men. Use of
Logistic Regression on Unprotected Anal/Vaginal Intercourse The first block of socio-demographic control factors that differed between bisexual and gay older men with HIV explained 8% of the variance in unprotected intercourse; however, none of the covariates was significant. In the second block, bisexual identity was added, and found to reduce the odds of unprotected intercourse by 65% (see Table 3), and increase the explained variance to 11%. In the third block, the number of substances used, including alcohol, was entered. Bisexual identity was no longer significant, but there was a 50% increased odds of unprotected intercourse for every substance used. The final block tested the current use of different classes of drugs on the odds of unprotected sex. Alcohol, LSD/PCP, heroin, and pain killers were not examined due to their nonsignificant or tenuous relationships to the dependent variable. Current use of ED medications increased the odds of unprotected intercourse by 2.5,
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OLDER BISEXUAL AND GAY MEN WITH HIV
while current use of poppers resulted in a 2.7 greater odds of unprotected sex. When controlling for the specific use of ED medications and poppers, current use of crystal meth, marijuana, crack/cocaine, and club drugs did not significantly increase the odds of unprotected intercourse.
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TABLE 3 Correlates of Unprotected Anal/Vaginal Intercourse among HIVC Bisexual and Gay Men
Alcohol – Lifetime Alcohol – 3 Months Crystal meth – Lifetime Crystal meth – 3 months Cocaine – Lifetime Cocaine – 3 months Crack – Lifetime Crack – 3 months Ecstasy – Lifetime Ecstasy – 3 months Heroin – Lifetime Heroin – 3 months GHB – Lifetime GHB – 3 months Ketamine – Lifetime Ketamine – 3 months LSD/PCP – Lifetime LSD/PCP – 3 months Marijuana – Lifetime Marijuana – 3 months Poppers – Lifetime Poppers – 3 months ED medications – Lifetime ED medications – 3 months Pain killers – Lifetime Pain killers – 3 months
Total
Bisexual
Gay
r
r
R
.03 .07 .22*** .18** .13* .13* .21*** .14* .20* .13* .03 .06 .19** .13* .22*** .13* .09 .13* .12 .23*** .08 .23*** .12 .22*** ¡.03 .01
¡.01 ¡.03 ¡.07 ... .00 ¡.18 .27* .01 .05 ... .04 .16 ¡.07 ... ¡.05 ... ¡.08 ... .12 .29* ¡.02 .32* .10 .16 .02 ¡.01
.03 .07 .25*** .18** .16* .25*** .22** .22** .22** .14CC .07 .07 .25** .14CC .24*** .14CC .12 .14CC .10 .21** .06 .20** .10 .23** ¡.07 ¡.01
Notes. N D 239 (Bisexual, n D 58; Gay, n D 181). CCp
Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Substance Use and Sexual Risk Differences among Older Bisexual and Gay Men with HIV a
b
a
c
Mark Brennan-Ing , Kristen E. Porter , Liz Seidel & Stephen E. Karpiak a
ACRIA, ACRIA Center on HIV & Aging, and New York University College of Nursing
b
John E. McCormack School of Policy & Global Studies, University of Massachusetts
c
ACRIA, ACRIA Center on HIV & Aging, and Fordham University Graduate School of Social Service Published online: 04 Aug 2014.
To cite this article: Mark Brennan-Ing, Kristen E. Porter, Liz Seidel & Stephen E. Karpiak (2014) Substance Use and Sexual Risk Differences among Older Bisexual and Gay Men with HIV, Behavioral Medicine, 40:3, 108-115, DOI: 10.1080/08964289.2014.889069 To link to this article: http://dx.doi.org/10.1080/08964289.2014.889069
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
BEHAVIORAL MEDICINE, 40: 108–115, 2014 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2014.889069
Substance Use and Sexual Risk Differences among Older Bisexual and Gay Men with HIV Mark Brennan-Ing ACRIA, ACRIA Center on HIV & Aging, and New York University College of Nursing
Downloaded by [University Of Maryland] at 02:25 17 October 2014
Kristen E. Porter John E. McCormack School of Policy & Global Studies, University of Massachusetts
Liz Seidel ACRIA, ACRIA Center on HIV & Aging, and Fordham University Graduate School of Social Service
Stephen E. Karpiak ACRIA, ACRIA Center on HIV & Aging, and New York University College of Nursing
Bisexual and gay men are disproportionately affected by HIV/AIDS. Research typically combines these groups into the category of men who have sex with men, and little is known about between-group differences. HIV-positive populations are aging and have high rates of substance use compared to non-infected peers, while substance use among older adults has increased and is associated with unprotected intercourse. Among a sample of 239 HIVpositive bisexual and gay men aged 50 and older, bisexual men were more likely to report cigarette, cocaine, crack, and heroin use compared with gay men. However, bisexual men were less likely to use crystal meth, club drugs, poppers (nitrate inhalers), and erectile dysfunction (ED) medications compared to gay men. While bisexual men reported lower rates of unprotected sex, logistic regression analysis found that current use of poppers and ED drugs, which were higher among gay men, explained this difference. Implications for education and prevention programs are discussed.
Keywords: bisexual, gay, HIV/AIDS, MSM, older adults, substance use By 2015, half of those living with HIV in the US will be age 50 or older. Gay and bisexual men remain disproportionately affected by the virus since 60% of infections among men in this age group are attributed to male-to-male sexual contact.1,2 Of new HIV diagnoses, 17% are detected in people aged 50 and older, with substance use remaining a primary link to increased risk of HIV transmission.1,3,4 Substance use in the general population of older adults is understudied, but current evidence suggests that 5% of Correspondence should be addressed to Mark Brennan-Ing, PhD, Director for Research and Evaluation, ACRIA, 575 Eighth Avenue, Suite 502, New York, NY, 10018, USA. E-mail: [email protected]
those aged 50 and older have used illicit substances in the past year; a proportion expected to double by 2020.5 Substance use among bisexual and gay men, and those with HIV/AIDS, is typically higher than the general population, but such research among older adults with HIV is limited.6,7 This article examines differences between bisexual and gay older HIV-positive men regarding substance use and unprotected sexual intercourse. A content analysis of the medical literature found that only 18% of articles examined bisexual people as a discrete group.8 Failing to consider bisexual people as a distinct research population contributes to bi-invisibility, namely, the non-recognition of this unique
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OLDER BISEXUAL AND GAY MEN WITH HIV
sexual identity.9,10 Moreover this limited literature suggests that bisexual people report poorer mental health outcomes (i.e., mood and anxiety disorders) than do those with a monosexual orientation (ie, heterosexual or homosexual), and such disorders have the potential to impact substance use and sexual risk.8,11,12 Extant literature on HIV transmission and substance use typically combines gay and bisexual men into the category of men who have sex with men (MSM), reflecting the Center for Disease Control and Prevention’s (CDC) behaviorally-defined category of male-tomale sexual contact. However, bisexuality may be defined in terms of not only behavior, but also the social construct of identity or attraction to both sexes, regardless of sexual contact.13 Behavioral classifications may obscure differences arising from the complex interactions of biology, culture, and society which underlie bisexual and gay identities. Consequently, the detection of important group differences between bisexual and gay men in regards to the primary predictor of unprotected sex, namely substance use, could improve HIV-prevention efforts. The research on substance use and unprotected sex comparing bisexual and gay men discussed below has focused primarily on younger ages and frequently defines bisexuality by behavior rather than identity.
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Data are virtually nonexistent on substance use among HIV-positive older adults, where sexual identity is a variable. One study found men with HIV more likely to report both club drug and injectable drug use relative to HIV-negative men.21 In a combined sample of bisexual and gay men, HIV-positive individuals had higher rates of substance use compared to HIV-negative peers.24 In an examination of substance use in older adults with HIV compared to heterosexual men, heterosexual women, and the combined category of gay/bisexual men, gay/bisexual men had the highest rates of alcohol, popper, and marijuana use.25 Sexual Behavior and Sexual Identity Research on the likelihood of bisexual and gay men to engage in unprotected insertive intercourse is inconclusive. Some find bisexual men to have less frequent unprotected anal intercourse with casual partners compared to gay men,26 while others have found no differences in condom use during same-sex encounters.22,27 Other studies report that bisexual men engage in more transactional sex which may increase the risk of seroconversion.22,28 Substance Use and Sexual Risk
Substance Use Research on substance use comparing bisexual and gay men is very limited, yielding inconclusive results; and no studies were identified that have examined this issue in older populations. For example, among a group of mixedgender college students using a behavioral definition of bisexuality, the bisexual students had higher levels of substance use including binge drinking.14,15 One study found higher rates of substance use disorders among gay men compared to bisexual and heterosexual men,16 but this pattern has not been replicated.17 In terms of specific types of substances, bisexual people are more likely to smoke cigarettes and smoke a greater number of cigarettes compared with gay men.16,18 Some research suggests that marijuana dependence and use is higher among bisexual men, as well as those reporting male and female sexual partners, regardless of sexual identity.16,17 But others find lower marijuana use among men reporting being equally attracted to both sexes.19 Findings on alcohol use are also inconsistent. In studies of young men, gay men have been found to consume more alcohol compared with bisexual men.16,20 Sexual identity did not relate to alcohol use among gay and bisexual men ages 18 to 69 in France.19 Studies of “club drugs” (e.g., meth amphetamine, cocaine, crystal, ecstasy, ketamine) find that bisexual men are less likely to use these substances compared with gay peers,20,21 with one study reporting higher cocaine use in bisexual men.17 Research on injection drug use (IDU) is inconclusive.20–23
A few studies have examined substance use and sexual risk among older HIV-positive adults but did not differentiate between gay and bisexual men. One study found older adults with HIV who used club drugs were twice as likely to report irregular condom use.29 In another, 60% of HIV-positive older gay/bisexual men reported using drugs/alcohol during sex and half reported inconsistent condom use.30 The use of nitrate inhalers (ie, poppers) as a sexual stimulant, used predominantly by gay and bisexual men, has received scant attention in the literature.31 However, popper use has been attributed to greater sexual-risk behaviors that results in HIV-seroconversion compared with other substances,32 especially among older men.33,34 Poppers reduce inhibitions, which promotes unprotected sex; as well as enlarge blood vessels, making it easier for the HIV virus to enter the bloodstream.31 Purpose and Rationale Substance use is associated with an increase in unprotected intercourse and HIV transmission in sexual minority men. Yet, gay and bisexual men are typically grouped together in studies of substance use and unprotected sex, though the available evidence, albeit incomplete, supports the view that bisexual men and gay men are unique populations. There are little data addressing the issues of substance use and sexual risk among older adults in general, and among older adults with HIV in particular. Since older
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HIV-positive adults are sexually active and are known to engage in unprotected intercourse, this lack of evidence hinders the development of informed secondary prevention efforts. The purpose of this article is to examine differences in substance use and sexual risk behavior among older HIV-positive self-identified bisexual and gay men. This study tested the following hypotheses: (1) There will be significant differences between older bisexual and gay men regarding lifetime and current use of alcohol and other substances; (2) alcohol and substance use correlates of unprotected intercourse will differ between bisexual and gay men; and (3) bisexual and gay men will differ in the odds of unprotected intercourse after controlling for socio-demographics and substance use.
Substance Use Respondents were asked if they had ever used any of the following substances and if they had used them in the past 3 months (ie, current use); cigarettes, alcohol, crystal meth, cocaine, crack cocaine, heroin, marijuana, ecstasy, GHB, ketamine, LSD/PCP, poppers, pain killers, or ED medications. The number of drugs used currently was calculated by summing responses to the above, exclusive of cigarettes and ED medications, but inclusive of alcohol. For logistic regression analyses, current drug use was collapsed into categories of (1) crystal meth, (2) marijuana, (3) crack or cocaine, (4) club drugs (ie, Ecstasy, GHB, ketamine), (5) heroin, (6) alcohol, (7) pain killers, (8) ED medications, and (9) poppers. Sexual Activity
METHODS Sample and Procedures The comprehensive research effort, Research on Older Adults with HIV (ROAH), was conducted in 2005–2006 in New York City.35 A convenience sample of 1,000 older HIV positive adults completed a self-administered survey, of which 914 were non-duplicative and usable. Eligibility criteria included being HIV-positive, 50 years or older, cognitively-intact, and sufficient English-language skills to complete the survey instrument. The selfadministered survey instrument and protocol were approved by the Copernicus Group Independent Review Board. Data were collected at community sites throughout New York City. Surveys took 1.5 to 2 hours to complete. Participants provided written informed consent before completing the survey, and received a $25 gift card. The 239 individuals who self-identified as male and either bisexual or gay were utilized for the analyses reported in this article. Measures Socio-demographics and Health Sexual identity was determined from an item that asked, “Do you consider yourself to be; (1) heterosexual or straight, (2) gay or lesbian, (3) bisexual, (4) queer, or (5) questioning.” Other single items assessed age, race, ethnicity, gender, education, employment, income adequacy, living alone, diagnosis of AIDS, use of anti-retroviral medications, and years since HIV diagnosis. How one was infected with HIV was a multiple-response question; possible answers were (1) anal intercourse, (2) vaginal intercourse, (3) sharing needles, and (4) other. The presence of comorbidities was self-reported from a list of 24 illnesses experienced other than HIV during the past year (yes/no) and summed for the number of comorbidities.
Respondents answered a series of gender-specific questions regarding their sexual behaviors in the past 90 days. Respondents were asked to report the number of times they had engaged in each type of sexual activity (ie, oral, anal or vaginal intercourse; insertive or receptive; protected or unprotected) by partner type (ie, main or non-main) and by serostatus (ie, HIV-negative, HIV-positive, or unknown status). A summary dichotomous dependent variable that identified participants who had at least one instance of unprotected anal/vaginal sex regardless of the partner’s serostatus was created based on these data. Design and Analysis The present study used a cross-sectional, correlational design to examine differences in substance use and unprotected sexual intercourse among older self-identified gay and bisexual men with HIV. Univariate statistics were calculated on all study variables prior to bivariate analysis. To examine significant differences in socio-demographics, health status, substance use, and unprotected sex differences between gay and bisexual men, bivariate analyses were conducted using ANOVA and chi-square analysis for continuous and categorical variables, respectively. To address the second hypothesis on differences in patterns of association of substance use and unprotected sex, Pearson correlations were calculated for the total group and each group individually. To address the third hypothesis, hierarchical logistic regression analyses were performed on the binary dependent measure of any unprotected anal/vaginal sex (yes/no). The first block contained socio-demographic and health covariates that differed significantly between the two groups as controls, and the second block added bisexual identity. The third block added the number of substances currently used, and the final block tested the effects of different classes of substances used on the odds of unprotected intercourse. Categorical variables (eg, bisexual identity) were dummy-coded prior to analyses. Only covariates that
OLDER BISEXUAL AND GAY MEN WITH HIV TABLE 1 Sociodemographic and Health Characteristics Total
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Variable Race/Ethnicity*** Non-Hispanic White Non-Hispanic Black Hispanic/Latino Education** Less than high school High school graduate Some college College graduate/post-grad Employment Working (Full or part time) Not working Disabled Other Income Adequacy Not enough money Just manage Enough, a little extra Money not a problem Lives alone (yes) How infected with HIV*** Anal intercourse Vaginal intercourse Sharing needles Multiple/Other/Not known Diagnosed with AIDS (yes) Anti-retroviral therapy (yes)* Age Year since HIV diagnosis Number of comorbidities Self-rating of health Number of substances (3 mo.)
Bisexual
Gay
N
%
N
%
N
%
77 75 74
34.1 33.2 32.7
5 27 22
9.3 50.0 40.7
72 48 52
41.9 27.9 30.2
16 43 66 112
6.8 18.1 27.8 47.3
8 14 17 17
14.3 25.0 30.4 30.4
8 29 49 95
4.4 16.0 27.1 52.5
34 54 130 9
15.0 23.8 57.3 4.0
9 14 30 0
17.0 26.4 56.6 0.0
25 40 100 9
14.4 23.0 57.5 5.2
37 127 49 23 197
15.7 53.8 20.8 9.7 82.4
11 30 8 7 48
19.6 53.6 14.3 12.5 82.8
26 97 41 16 149
14.4 53.9 22.8 8.9 82.3
173 7 9 50 145 214 M 56.4 14.2 3.2 6.9 1.7
72.4 2.9 3.8 20.9 61.4 89.5 SD 5.5 5.0 2.2 1.7 1.5
27 6 7 18 31 48 M 55.8 13.4 3.1 7.0 1.4
46.6 10.3 12.1 31.0 55.4 82.8 SD 5.4 5.4 2.2 1.6 1.6
146 1 2 32 114 166 M 56.6 14.5 3.2 6.9 1.8
80.7 .6 1.1 17.7 63.3 91.7 SD 5.5 4.9 2.2 1.8 1.5
Notes. N D 239 (Bisexual, n D 58, Gay, n D 181). *p < .05, ** p < .01, ***p < .001.
were significantly related to either bisexual identity or unprotected intercourse were retained in the regression model. Potential multicollinearity of covariates was examined (ie, r 0.7), and no potential problems were identified. Listwise deletion of missing values was used.
RESULTS Comparison of Older HIV-Positive Bisexual and Gay Men The average age of the sample was 56.4 years (see Table 1). Bisexual men were more likely to be ethnic/racial minorities (91%) as compared with gay men (58%). Gay men reported higher levels of educational attainment compared with bisexual men. However, these groups did not differ significantly with respect to employment, income
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adequacy, or living alone. Gay men were more likely to report contracting HIV through anal intercourse (81%) versus 47% of bisexual men, but there were no significant differences in years since HIV diagnosis (14.2) or the likelihood of an AIDS diagnosis (61%). However gay men were more likely to report being on anti-retroviral therapy compared to bisexual men (92% and 83%, respectively). The two groups did not differ significantly with regard to the number of comorbid conditions in addition to HIV (3.2), self-ratings of health (6.9), or the number of substances used in the past 3 months (1.7).
Sexual Identity, Substance Use, and Unprotected Sex There were myriad statistically significant differences in lifetime and current substance use between older HIV-positive bisexual and gay men (see Table 2). Bisexual men were twice as likely to be current smokers compared to gay men (60% and 30%, respectively). Lifetime (90%) and current alcohol use (53%) was not related to sexual identity. Gay men were more likely than bisexual men to have ever used crystal meth (14% and 3%, respectively), but there were no significant differences in the proportion currently using this substance (4%). Lifetime use of both cocaine (62%) and crack (41%) did not differ significantly between the two groups, however bisexual men were twice as likely to report the current use of these substances (24% and 24%, respectively) compared with gay men (12% and 12%, respectively). Bisexual men were also significantly more likely to have ever used heroin (38%) or to currently be using this drug (7%) as compared with gay men (16% and 1%, respectively). While gay men were significantly more likely to report ever using marijuana (83%) as compared to bisexual men (71%), there were no significant differences in current use (28% overall). Lifetime and current use of club drugs, such as Ecstasy, GHB, and ketamine ranged from 5% to 15%. Only with respect to lifetime use of ketamine did bisexual and gay men differ (2% and 11%, respectively). Nearly half (45%) had used a hallucinogen like LSD or PCP, but current use was infrequent (1%) and did not differ by sexual orientation. Gay men were significantly more likely to report lifetime or current use of poppers (81% and 26%, respectively) compared with bisexual men (45% and 7%, respectively). A similar pattern was observed with pain killers, with gay men more likely than bisexual men to report lifetime (75% and 55%, respectively) and current use (36% and 21%, respectively). While older HIVpositive gay men were more likely to report having used ED medications (53%) than bisexual men (31%), current use did not differ significantly between the two groups (29%). Lastly, bisexual men were less likely (12%) to have reported unprotected intercourse in the past 3 months compared with gay men (22%), but this was not significant at the p < .05 level.
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BRENNAN-ING ET AL. TABLE 2 Patterns of Alcohol, Substance Use, and Unprotected Sex among Older HIV-positive Bisexual and Gay Men Total
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Substance Cigarettes – Lifetime Cigarettes – 3 months*** Alcohol – Lifetime Alcohol – 3 months Crystal Meth – Lifetime* Crystal Meth – 3 months Cocaine – Lifetime Cocaine – 3 months* Crack – Lifetime Crack – 3 months* Heroin – Lifetime*** Heroin – 3 months** Marijuana – Lifetime* Marijuana – 3 months Ecstasy – Lifetime Ecstasy – 3 months GHB – Lifetime GHB – 3 months Ketamine – Lifetime* Ketamine – 3 months LSD/PCP – Lifetime LSD/PCP – 3 months Poppers – Lifetime*** Poppers – 3 months** Pain Killers – Lifetime** Pain Killers – 3 months* ED medications – Lifetime** ED medications – 3 months Any Unprotected Anal/Vaginal IntercourseCCC
Bisexual
Gay
N
%
N
%
N
%
185 86 215 122 27 9 148 35 97 34 50 6 190 65 37 0 11 1 21 1 105 1 171 50 168 75 114 68 47
77.4 36.8 90.0 53.0 11.3 3.8 61.9 15.0 40.6 14.6 20.9 2.5 80.2 28.0 15.5 0.4 4.6 0.4 8.8 0.4 44.5 0.4 71.8 21.4 70.3 32.2 47.9 28.9 19.7
49 33 50 24 2 0 33 13 29 13 22 4 41 12 6 0 2 0 1 0 22 0 26 4 32 12 18 14 7
84.5 60.0 86.2 44.4 3.4 0 56.9 23.6 50.0 24.1 37.9 7.1 70.7 21.4 10.3 0 3.4 0 1.7 0 38.6 0 44.8 6.9 55.2 21.4 31.0 24.1 12.1
136 53 165 98 25 9 115 22 68 21 28 2 149 53 31 1 9 1 20 1 83 1 145 46 136 63 96 54 40
75.1 29.6 91.2 55.7 13.8 5.0 63.5 12.4 37.6 11.7 15.5 1.1 83.2 30.1 17.1 0.6 5.0 0.6 11.0 0.6 46.4 0.6 80.6 26.1 75.1 35.6 53.3 30.5 22.1
Notes. N D 239 (Bisexual, n D 58; Gay, n D 181). CCCp < .10, * p < .05, **p < .01, ***p < .001.
Associations of Substance Use and Unprotected Intercourse
pain killers was not related to unprotected intercourse in either group.
Neither past nor current use of alcohol was correlated with unprotected sex in either older bisexual or gay men with HIV. Lifetime and current use of crystal meth or cocaine were significantly related to unprotected sex among gay men, but not bisexual men. Lifetime crack use was related to unprotected sex in both groups, but current crack use was only significantly related to unprotected sex among gay men. Lifetime and current use of Ecstasy was related to unprotected sex in gay men but not bisexual men. This observation was the same for the other “club” drugs GHB and ketamine. Heroin use was not related to unprotected sex, nor was lifetime use of LSD or PCP. Current use of LSD/PCP trended toward a significant correlation with unprotected sex among gay men only. With regard to marijuana and poppers, only current use was associated with unprotected intercourse for both bisexual and gay men. While lifetime use of ED medications was not related to unprotected sex, current use was significantly associated with unprotected intercourse only among gay men. Use of
Logistic Regression on Unprotected Anal/Vaginal Intercourse The first block of socio-demographic control factors that differed between bisexual and gay older men with HIV explained 8% of the variance in unprotected intercourse; however, none of the covariates was significant. In the second block, bisexual identity was added, and found to reduce the odds of unprotected intercourse by 65% (see Table 3), and increase the explained variance to 11%. In the third block, the number of substances used, including alcohol, was entered. Bisexual identity was no longer significant, but there was a 50% increased odds of unprotected intercourse for every substance used. The final block tested the current use of different classes of drugs on the odds of unprotected sex. Alcohol, LSD/PCP, heroin, and pain killers were not examined due to their nonsignificant or tenuous relationships to the dependent variable. Current use of ED medications increased the odds of unprotected intercourse by 2.5,
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OLDER BISEXUAL AND GAY MEN WITH HIV
while current use of poppers resulted in a 2.7 greater odds of unprotected sex. When controlling for the specific use of ED medications and poppers, current use of crystal meth, marijuana, crack/cocaine, and club drugs did not significantly increase the odds of unprotected intercourse.
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TABLE 3 Correlates of Unprotected Anal/Vaginal Intercourse among HIVC Bisexual and Gay Men
Alcohol – Lifetime Alcohol – 3 Months Crystal meth – Lifetime Crystal meth – 3 months Cocaine – Lifetime Cocaine – 3 months Crack – Lifetime Crack – 3 months Ecstasy – Lifetime Ecstasy – 3 months Heroin – Lifetime Heroin – 3 months GHB – Lifetime GHB – 3 months Ketamine – Lifetime Ketamine – 3 months LSD/PCP – Lifetime LSD/PCP – 3 months Marijuana – Lifetime Marijuana – 3 months Poppers – Lifetime Poppers – 3 months ED medications – Lifetime ED medications – 3 months Pain killers – Lifetime Pain killers – 3 months
Total
Bisexual
Gay
r
r
R
.03 .07 .22*** .18** .13* .13* .21*** .14* .20* .13* .03 .06 .19** .13* .22*** .13* .09 .13* .12 .23*** .08 .23*** .12 .22*** ¡.03 .01
¡.01 ¡.03 ¡.07 ... .00 ¡.18 .27* .01 .05 ... .04 .16 ¡.07 ... ¡.05 ... ¡.08 ... .12 .29* ¡.02 .32* .10 .16 .02 ¡.01
.03 .07 .25*** .18** .16* .25*** .22** .22** .22** .14CC .07 .07 .25** .14CC .24*** .14CC .12 .14CC .10 .21** .06 .20** .10 .23** ¡.07 ¡.01
Notes. N D 239 (Bisexual, n D 58; Gay, n D 181). CCp
