1. M ETHAMPHETAMINE USE IS ASSOCIATED WITH HIV SEXUAL RISK AMONG PATRONS OF ALCOHOL SERVING VENUES IN C APE T OWN Christina S. Meade, PhD Department of Psychiatry & Behavioral Sciences Duke University

2. Authors *Christina Meade, PhD Melissa Watt, PhD *Kathleen Sikkema, PhD Lisa Deng Krista Ranby, PhD Duke University *Donald Skinner, PhD Desiree Pieterse, MPH University of Stellenbosch *Seth Kalichman, PhD University of Connecticut Funding:NIAAA R01-AA018074 NIDA K23-DA028660 *Principal investigators No conflicts of interest

3. South Africa has the largest number of people living with HIV/AIDS in the world Cape Town 17.9% ANC prevalence 3

4. Meth use is rising in Cape Town Proportion of patients entering drug treatment for meth abuse in the Western Cape, 2000-2010 Data from the South African Community Epidemiological Network on Drug Use (SACENDU)

5. Meth use as a risk factor for HIV Meth is a highly addictive stimulant Euphoria, increased energy, sexual desire Globally, meth users have increased rates of sexual risk behavior and HIV infection (Degenhardt, 2010) Injection drug use Men who have sex with men (MSM) In South Africa, meth is: Smoked, not injected (“tik”) Prevalent among heterosexuals

6. Specific aims 1. Describe the prevalence of meth use and its association with sexual risk behavior 2. Test whether meth use mediates the relationship between childhood sexual abuse and current sexual risk behavior

7. Research setting

8. Study design 12 alcohol-serving venues Cross-sectional surveys Every 4 months over 1 year 1-week data collection Brief, anonymous surveys Self-administered Completed in the venues

9. Measures Substance use Alcohol use (AUDIT) Drug use Childhood abuse Sexual and physical (TEQ) Sexual risk behaviors Number of sex partners Number of protected and unprotected intercourse acts Engagement in transactional sex STD diagnosis HIV testing Ever been tested for HIV Most recent test result

10. Sample characteristics TOTAL N = 3,328 Women N = 1,455 Men N = 1,360 Age (18-50 years)29.9 (5.6)30.1 (9.2)29.7 (8.1) Black (vs. Coloured)59%46%69% Finished secondary school47%34%58% Currently employed46%27%61% Married22%23%21%

11. Prevalence of recent meth use – 6.4% Women N = 1,455 Men – no MSM N = 1,655 Men – MSM N = 218 Coloured10.4%10.6%11.5% Black2.1%3.6%8.9% Frequency of recent meth use (among meth users) Occasionally63.7% Weekly20.3% Daily16.0% Past 4 months:

12. Prevalence of other substance use

13. AIM 1: ARE METH USERS MORE LIKELY THAN NON USERS TO ENGAGE IN SEXUAL RISK BEHAVIOR?

14. Data analysis Differences between meth users and non users on: Multiple partners Unprotected intercourse Sex trading (“selling”) Sex trading (“buying”) Sexually transmitted infection HIV-positive status Series of logistic regressions Separated by gender Adjusting for age, race, and education Past 4 months Lifetime

15. Meth is associated with sexual risk behavior Multiple partnersUnprotected intercourse AOR = 2.42**AOR = 1.79*AOR = 2.45** AOR = 1.45 *p <.01; **p<.001

16. With alcohol I can make rational decisions concerning sex... With drugs it’s a completely different case. I won’t remember to use a condom. The last time I had unsafe sex, it was with a guy I would never in my wildest dreams even look at. That’s drugs for you. (Male, former meth user) [Tik] might kill your human feelings, but it certainly raises your sexual feelings. (Male, former mandrax user )

17. Meth is associated with sex trading “Sold” sex“Bought” sex AOR = 6.43**AOR = 4.64**AOR =3.45**AOR = 4.80** *p <.01; **p<.001

18. Let’s say I feel like having sex. Now I’ll see a woman who is a drug addict. I’ll tell her that I’m gonna buy her some tik in exchange for sex, and she’ll agree. (Male, former meth user) Where tik is concerned, you meet a guy and you know what it’s about. It’s what you can get, no love or any other emotion. If he dangles his money and you get your share to feed your habit, you’ll sleep with that person. It’s the norm these days. (Female, current meth user)

19. Meth is associated with STI and HIV status Sexually transmitted infection AOR = 3.84**AOR = 2.95* HIV-positive status AOR = 1.46AOR = 3.92** *p <.01; **p<.001

20. AIM 2: DOES METH USE MEDIATE THE RELATIONSHIP BETWEEN CHILDHOOD SEXUAL ABUSE AND CURRENT SEXUAL RISK BEHAVIOR?

21. Data analysis Conceptual model Childhood sexual abuse Drug useSexual risk

22. Data analysis Conceptual model Childhood sexual abuse Meth useSexual risk

23. Data analysis Conceptual model Structural equation modeling examining multiple sex risk outcomes simultaneously: Multiple partners Unprotected intercourse “Selling” sex “Buying” sex STI diagnosis Childhood sexual abuse Meth useSexual risk

24. Meth users are more likely to have a history of childhood sexual abuse AOR = 3.42**AOR = 3.31*** *p <.01; **p<.001

25. Meth partially mediates the relations between childhood sex abuse and current sexual risk Childhood Sex Abuse Meth Use R 2 =.03 Multiple partners R 2 =.02 Unprotected sex R 2 =.04 “Sold” sex R 2 =.21 “Bought” sex R 2 =.12 STI diagnosis R 2 =.08.10*.19**.35**.25**.20**.17** *p <.01; **p<.001

26. Summary Meth use is fairly common among patrons of alcohol serving venues in this South African township Meth users are more likely to engage in sexual risk behavior associated with HIV infection Meth use may partially mediate the relationship between childhood sexual abuse and sexual risk behavior Many meth users reported injection drug use, which may further contribute to HIV risk

27. Implications and future research Meth users need integrated interventions that address drug abuse, sexual risk behavior, and sexual trauma Meth users are hard to reach and engage in interventions Alcohol-serving venues – owners may keep them out Substance abuse treatment – many do not access Ongoing research to examine HIV risk among meth users: 1. In the community, chain referral recruitment (R03-DA033828, pending) Mixed-methods study 2. Entering substance abuse treatment (P30-AI064518) HIV seroprevalence and sexual risk

28. Melissa Watt, PhD Kathleen Sikkema, PhD Lisa Deng Krista Ranby, PhD Donald Skinner, PhD Desiree Pieterse, MPH Seth Kalichman, PhD Our excellent fieldworkers NIH funding: R01-AA018074 K23-DA028660 Duke Center for AIDS Research Acknowledgements