1. Crystal Meth Anonymous: Peer support for drug-related HIV risk reduction Thomas Lyons Ph.D., Gopika Chandra,M.D., MPH and Jerome Goldstein, MPH University of Illinois at Chicago

2. 2 Methamphetamine use among men who have sex with men Linked with unprotected anal sex (Clatts & Sotheran. 2000; Gorman et al., 1997 ; Semple et al., 2002; Klitzman et al., 2000) Linked with unprotected anal sex (Clatts & Sotheran. 2000; Gorman et al., 1997 ; Semple et al., 2002; Klitzman et al., 2000) “Marathon" sex sessions and increased desire for receptive anal sex. “Marathon" sex sessions and increased desire for receptive anal sex. Used intentionally for disinhibiting effects (Gorman et al., 1997; Semple et al., 2002) Used intentionally for disinhibiting effects (Gorman et al., 1997; Semple et al., 2002) “Time outs" from stress, including HIV (Clatts et al., 2001; Semple et al., 2002) “Time outs" from stress, including HIV (Clatts et al., 2001; Semple et al., 2002)

3. 3 Meth use-unprotected sex link Risk-taking and sensation seeking (Halkitis, 2005) Risk-taking and sensation seeking (Halkitis, 2005) Cognitive “escape” from the depressing reality of HIV (Parsons, 2005, McKirnen et al.,1996) Cognitive “escape” from the depressing reality of HIV (Parsons, 2005, McKirnen et al.,1996) Situational factors: drugs and sex partners available in same places (Ostrow, 2000; McKirnen et al., 1996) Situational factors: drugs and sex partners available in same places (Ostrow, 2000; McKirnen et al., 1996)

4. 4 Current Study The impact of 12 step program participation on sexual behavior The impact of 12 step program participation on sexual behavior

5. 5 Methods Baseline and six month followup interviews Baseline and six month followup interviews Qualitative and quantitative measures Qualitative and quantitative measures

6. 6 Recruitment Convenience sample Convenience sample Actively recruited at meetings of Crystal Meth Anonymous Actively recruited at meetings of Crystal Meth Anonymous Passively recruited Passively recruited snowball sampling/word of mouthsnowball sampling/word of mouth fliersfliers

7. 7 Sample 62 men entered into the study 62 men entered into the study Eligibility criteria Eligibility criteria Participation in 12 step program during the past 3 monthsParticipation in 12 step program during the past 3 months Male and reported having sex with menMale and reported having sex with men Lifetime use of meth and use of meth or cocaine within the past three months.Lifetime use of meth and use of meth or cocaine within the past three months.

8. 8 Baseline Results Mean (SD) or Percent Range Age 41.4(6.9)26-58 Days Clean At Time Of Interview 67(54.4)2-210 Race/Ethnicity White 40% African-Amer 55% Hispanic 5% Meetings attended/ week in previous 90 days 5 (4.0) 0-16 HIV Status Negative 24% Positive 73% Unknown 2%

9. 9 Baseline Results (cont’d) Baseline Results (cont’d) Substance % Who Used in Prior 30 Days Avg Days Used Methamphetamine76%13 Cocaine/Crack52%15 Alcohol67%15 Marijuana30%12 Heroin15%11

10. 10 Unprotected Anal/Vaginal Intercourse (UAI) Overall and by HIV Status Before Program Entry After Program Entry % with any UAI partner Mean partners /mo (SD) % with any UAI partners Mean partners/ mo Overall70% 4.61 (6.45) 24% 0.37 (1.04) HIV+ (n=42) 75% 4.65 (5.24) 19%* 0.27 (0.80) HIV- (n=15) 60% 4.80 (9.24) 40%* 0.72 (1.56) Χ 2 of comparison between subgroups: *p<0.1

11. 11 Percent Engaged in UAI, By HIV Status *Χ 2 of comparison between subgroups: p<0.1 *

12. 12 Use in sexual context Using [meth] was a psychological breakthrough for me. I saw my masculine aggressive side. I discovered I could be the sexual being I never thought I could be.… [From that point on] my confidence improved even without the drugs. Using [meth] was a psychological breakthrough for me. I saw my masculine aggressive side. I discovered I could be the sexual being I never thought I could be.… [From that point on] my confidence improved even without the drugs. My front lobe shuts off and the rat brain takes over My front lobe shuts off and the rat brain takes over Getting high is part of the sexual thing. It was a package deal… Getting high is part of the sexual thing. It was a package deal…

13. 13 Sex in Sobriety The desire for sex in me is so strong, that I might consider using [drugs if I had sex] just because the sex is nothing without it. The desire for sex in me is so strong, that I might consider using [drugs if I had sex] just because the sex is nothing without it. Whenever I start having sex I start thinking about crystal, because I remember all those experiences I had with it. Whenever I start having sex I start thinking about crystal, because I remember all those experiences I had with it. I want to find a name for what I was doing while on crystal. Because I want to have sex again: that’s one of the things I hope for. I want to find a name for what I was doing while on crystal. Because I want to have sex again: that’s one of the things I hope for.

14. 14 Six Month Followup Total followed up at six months: 48 (77%) Total followed up at six months: 48 (77%) Followed up do not differ significantly from lost- to-followup on age, HIV status, race Followed up do not differ significantly from lost- to-followup on age, HIV status, race % Used at Baseline Mean Days/Month Used at Baseline % Used at Followup Mean Days/Month Used at Followup Cocaine52%15.132%2.06 Meth76%13.236%2.25 Either100%48%

15. 15 Percent Engaged in Any Sexual Activity (n=43)

16. 16 Percent Engaged in UAI

17. 17 Changes in Sexual Experience at Followup Diminishing Interest in Sex Diminishing Interest in Sex I’m not seeking it like I once was. It isn’t what drives me.I’m not seeking it like I once was. It isn’t what drives me. Conscious Choice Conscious Choice Using crystal triggers sex and vice versa…That is why we should stay abstinent [from sex] during recovery for a period of time-6 months or 1 year--whatever it takes.Using crystal triggers sex and vice versa…That is why we should stay abstinent [from sex] during recovery for a period of time-6 months or 1 year--whatever it takes. I think I need to get a firm foundation of recovery before even I think about sex.I think I need to get a firm foundation of recovery before even I think about sex.

18. 18 Changes in Sexual Experience at Followup Monogamy/Partner Intimacy Monogamy/Partner Intimacy I’m very reclusive now …Just me and my partner.I’m very reclusive now …Just me and my partner. My partner and I have very good sex. It's different, it's intimate, you know what I mean. But it's good.My partner and I have very good sex. It's different, it's intimate, you know what I mean. But it's good. Healthier Sex Healthier Sex I had started to feel myself again after 6 months. I came back to healthy functioning as a human being after 6 months, enjoying sex…I had started to feel myself again after 6 months. I came back to healthy functioning as a human being after 6 months, enjoying sex… Slow it down; have more time to think about what I am going to do; lesser partners.Slow it down; have more time to think about what I am going to do; lesser partners.

19. 19 Changes in Sexual Experience at Followup I don’t really know what turns me on…But it tends to be more on the ordinary side. Like I just want, just a very basic, homey sex life, you know. ….Maybe some more exotic behavior can come out of trust and love, rather than… having the exotic behavior come first and then trying to get some of the trust… I don’t really know what turns me on…But it tends to be more on the ordinary side. Like I just want, just a very basic, homey sex life, you know. ….Maybe some more exotic behavior can come out of trust and love, rather than… having the exotic behavior come first and then trying to get some of the trust…

20. 20 Changes in Sexual Experience at Followup Responsibility/Safer Sex Guidelines Responsibility/Safer Sex Guidelines Relatively less common responseRelatively less common response The last time [I had sex] it was condom time… it was not terrible.The last time [I had sex] it was condom time… it was not terrible. [Sex] with condoms does not give the same pleasure. But I realize how important it is to have safe sex, not always but most of the time.[Sex] with condoms does not give the same pleasure. But I realize how important it is to have safe sex, not always but most of the time. In order to stay clean I need to have safe sex.In order to stay clean I need to have safe sex.

21. 21 Discussion Program helps deal with the problems surrounding sex in sobriety. Program helps deal with the problems surrounding sex in sobriety. “Finding another name” for meth- related sex: need to rupture the ties between meth use and sexual experience. “Finding another name” for meth- related sex: need to rupture the ties between meth use and sexual experience. Sexual activity resumes by six months, while UAI still low for those who do not relapse on coke/meth Sexual activity resumes by six months, while UAI still low for those who do not relapse on coke/meth

22. 22 Limitations No comparison group of stimulant users who did not engage in 12-step programs No comparison group of stimulant users who did not engage in 12-step programs Small sample size Small sample size Can be generalized only to 12-step program participants Can be generalized only to 12-step program participants Selection bias at followup, social desirability bias Selection bias at followup, social desirability bias

23. 23 Conclusions Decline in sexual behavior immediately after quitting use may have neurobiological roots Decline in sexual behavior immediately after quitting use may have neurobiological roots Decline in unprotected sex may reflect improvements in sexual health Decline in unprotected sex may reflect improvements in sexual health Twelve step meetings a good place to work out sexual issues Twelve step meetings a good place to work out sexual issues First pilot data on effectiveness of Crystal Meth Anonymous: a social movement rather than treatment program First pilot data on effectiveness of Crystal Meth Anonymous: a social movement rather than treatment program

24. 24 Acknowledgements National Institute on Drug Abuse Grant R03-DA 16539 National Institute on Drug Abuse Grant R03-DA 16539 Jacob Grossman and Chris Duquette, research assistants Jacob Grossman and Chris Duquette, research assistants Michele Shedlin, consultant Michele Shedlin, consultant Research Participants Research Participants