Drug Use & HIV Risk Among Gay Men in the Dance/Club Scene in Toronto: How Should AIDS Prevention Programmes Respond?

AIDS Committee of Toronto

Acknowledgements

The AIDS Committee of Toronto is grateful to the National Health Research and Development Program’s Community-Based Research program, which provided funding for this project.

Original research for this project, including interviews and an on-line focus group, was organized and conducted by Chris Lau, ACT Research Assistant and James Murray, ACT Gay Men’s Community Development Coordinator. Chris Lau provided a summary of the themes and issues identified through the research.

Glen Brown & Associates Consulting provided the literature review and final report; Lori Lyons led the literature review, and Glen Brown wrote the final report.

We are thankful to the members of the Research Advisory Committee, who provided insight and guidance at many points during the development, implementation and interpretation of this project. Thanks are due to:

Daniel Bellavance
Roy Cain
Christopher Hadden
Peter Ho
Chad Lever
John Maxwell
James Murray

We are also extremely grateful to the participants in our interviews and focus group. They were generous with their time, frank in their views, and genuine in their desire to see improved harm reduction programming.

TABLE OF CONTENTS


Executive Summary 3
1) Introduction 5
2) Literature Review: Party Drugs & HIV Risk for Gay Men 6
2a) Context: Historical Trends in HIV Risk-taking and Drug Use Among Gay Men 6
2b) Context: The Gay Bar & Dance Party Institutions 6
2c) The Role of Social Networks 7
2d) Prevalence of Party Drug Use 8
2e) General Drug Use and Risky Sexual Behaviour in MSM 9
2f) “Party” Drug Use and Risky Sexual Behaviour in MSM 10
2g) Vulnerable Sub-groups 12
2h) Harm Reduction Interventions 12
3) Toronto Gay Men, Party Drugs & HIV Risk: Research Method 14
3a) Research Methodology 14
4) Toronto Gay Men, Party Drugs & HIV Risk: Research Conclusions 15
4a) Context: Involvement and Perceptions of Party Drugs and Venues 15
4b) Social Networks 15
4c) Prevalence of and Attitudes Towards Drug Use 16
4d) Motivations for Drug Use 17
4e) Sex and Party Drugs in Dance Venues 18
4f) Party Drug Use and Risky Sexual Behaviour 19
4g) Attitudes Towards HIV/AIDS 19
4h) Prevention Programming 20
5) Lessons Learned: Elements of Potential Prevention Strategies 22
5a) Use Social Networks & Peer Leaders 22
5b) Address Parallel Motivators Behind Drug Use and Sexual Behaviours 22
5c) Adopt a Harm Reduction Approach to Drug Use and Sexual Risk-Taking 22
5d) Help Users Control the Drug Experience 23
5e) Target ‘Gay-Identified’ Men 23
5f) Target Young Men with Peers 24
5g) Renew Bathhouse Focus 24
6) Directions for Future Research 25
6a) Best Practices for Community Based Research 25
6b) Directions for Future Research 26
7) Literature Review: References 27

Executive Summary

In the spring of 2000, the AIDS Committee of Toronto (ACT) received funding from the National Health Research and Development Program’s Community-Based Research program to develop a research project on the associations between party drug use and HIV risk among gay men involved in the Toronto dance scene. The project included a literature review and original research involving qualitative interviews with men who are active in the Toronto gay dance/club scene.

Literature Review Key Themes

Substantial attempts have been made over the last twenty years to document substance use in the gay community and to understand its role and its connection to behaviours that put men at risk of HIV transmission. To date, however, a relatively limited amount of material pertaining to party drugs has been published in the formal peer-reviewed literature.

Historically gay bars have played an important social function as a venue for gay men. The “dance party institution” is associated with new patterns of substance use, particularly the use of party drugs. Drug use is seen as a collective rather than individual practice. Social networks are the number one source of knowledge about drug use and how to combine and use different substances.

Some studies suggest that within the dance party scene, poly-drug use, prominently including party drugs, is normative and expected. However, such drug use is rarely excessive.

The degree to which party drugs are seen to enhance sexual activity is a matter of some debate. Qualitative studies of gay club patrons report that ecstasy and other party drugs are taken primarily to enhance dancing and the club going experience and not as sex drugs. Some gay men, however, report that party drugs do promote sexual contact in the “coming down” phase. Sexually inhibiting effects of some drugs are sometimes overcome by the use of other drugs that facilitate erection and sexual function, such as inhaled nitrates and Viagara.

A number of studies have demonstrated a link between sexual risk behaviour and the use of illicit drugs or the heavy use of alcohol. It is unclear, however, whether such links are causal or merely co-relational. Despite continued interest in this subject, a causal link has not been established. A collection of personality traits sometimes dubbed “sensation-seeking” may be associated with increased levels of both drug use and risky sexual activity.

Some interventions have been undertaken to reduce the harms associated with party-drugs and/or risky sexual activity in people using party drugs, but there is virtually no information available evaluating the outcomes. However, some key characteristics of effective interventions have been identified in the literature.

Focus Group Research Key Themes

There is a wide range of motivations for involvement in party drugs and dance venues. Most participants suggested that their involvement related to self-acceptance and the desire to belong.

Party drug use was not necessarily perceived as being negative. Drug use was perceived by most participants to be accepted as an aspect of the dance club scene. Most participants expressed particular concern for young men or newcomers. They were seen to be at greater risk since they tended to get “messed up” on drugs due to its novelty. Many participants expressed concern about addiction.

Participants agreed that sex and sexual tension permeated the club scene; most, however, said their involvement is not focused on the desire to meet other men for sex. Some participants said going to the bathhouse after going out to a bar or club was common. Participants generally rejected any direct causal link between drug use and risky sexual behaviour. Associations between drug use and risky sex seem to be dependent on the type of drug consumed.

Most participants believed there are not enough safer sex and harm reduction educational materials and information. Participants suggested a number of programming ideas as part of a harm reduction strategy.

Lessons Learned

The literature review and focus group research suggested a number of key lessons for ACT’s programming related to gay men who use party drugs:
· Use Social Networks & Peer Leaders
· Address Parallel Motivators Behind Drug Use and Sexual Behaviours
· Adopt a Harm Reduction Approach to Drug Use and Sexual Risk-Taking
· Help Users Control the Drug Experience
· Target ‘Gay-Identified’ Men
· Target Young Men with Peers
· Renew the Bathhouse Focus

Future research by ACT in this area should build upon existing knowledge as summarized in this report. Priority should be given to research projects that evaluate the impacts of prevention programs intended to affect the knowledge, attitudes and behaviours of gay men in Toronto who use party drugs.


1) Introduction

Recent epidemiological data shows that the rate of HIV transmission is increasing among men who have sex with men (MSM) in the city of Toronto (Calzavara, 2000). After years of declining HIV transmission in the MSM community, these numbers provide a compelling reason to re-examine both prevention strategies and the ever-changing dynamics of the gay community itself.

One reputed area of change is in the increased use of psychoactive substances (“party drugs”) in Toronto’s gay dance club scene. Anecdotal reports suggest that party drugs such as ecstasy, ketamine and GHB play an increasing role both in the bar-associated culture of Toronto’s gay community and in the sexual lives of many MSM.

These reports have prompted ACT to consider how AIDS prevention programs should respond to the possible connections between increasing HIV transmission and increasing party drug use. What (if any) connections exist between these two phenomena? What intervention strategies might ACT employ to support gay men in avoiding HIV and limiting any harmful consequences of drug use in this environment?

These questions arise while ACT is broadening its health promotion approach to include a more holistic understanding of gay men’s health. ACT, like many other AIDS organizations, is developing strategies to support gay men in all of their health decisions, recognizing that gay men do not make decisions about HIV risk in isolation from other health issues.

In the spring of 2000, ACT received funding from the National Health Research and Development Program’s Community-Based Research program to develop a research project on the associations between party drug use and HIV risk among gay men involved in the Toronto dance scene.

The project involved:
  • Establishment of partnerships with academic researchers and people knowledgeable about the Toronto gay dance scene.
  • A review of literature regarding best practices in community-based research, associations between substance use and HIV risk, and prevention interventions related to party drug use and HIV.
  • Interviews and an on-line focus group with men who are active in the gay dance/club scene.
  • Identification of lessons learned for prevention programming.
  • Identification of key questions for future research.


2) Literature Review: Party Drugs & HIV Risk for Gay Men

Substantial attempts have been made over the last twenty years to document substance use in the gay community and to understand its role and its connection to behaviours that put men at risk of HIV transmission. To date, however, a relatively limited amount of material pertaining to party drugs has been published in the formal peer-reviewed literature.

For the purposes of this review we will define “party drugs” as ecstasy, ketamine and GHB as well as a variety of other less common designer drugs. We have also reviewed literature that examines the interplay between these drugs and cocaine, Viagara and poppers, which are thought to be in wide use in the gay scene. We also attempt to take lessons from studies of gay men’s use of a variety of illicit substances.

For the purposes of this paper, “risky sexual activity” refers to unprotected anal intercourse (UAI) unless explicitly otherwise indicated.

2a) Context: Historical Trends in HIV Risk-taking and Drug Use Among Gay Men

Prior to the arrival of AIDS-related illness and the discovery of the causative role of the sexually transmitted HIV virus, unprotected anal intercourse with multiple partners was normative for the majority of gay men (Martin 1989). Throughout the late 1980s and early 1990s, levels of risky sexual activity dropped dramatically. These behavioural changes have been largely attributed to individual responses to AIDS bereavement and fear of infection combined with the efficacy of early gay community prevention programs in changing community norms (Ostrow, 2000). Despite the increased stresses and traumas of this era, illicit drug use also appeared to drop dramatically (Martin, 1989). In his historic review of the role of drugs in gay men’s sexual lives, Ostrow (2000) attributes this to changes in peer norms about risk-taking in general as well as a pervasive community belief in the immune suppressing actions of illicit drugs. Stall and Purcell report in a recent review of the literature that this decline appeared to occur across cohorts in men of varying ages.

2b) Context: The Gay Bar & Dance Party Institutions

Historically gay bars have played an important social function as a venue free from overt homophobia where gay men could meet and make social and sexual connections.

Although younger gay men interviewed in a recent ACT survey believed they had more social and family support around coming out than previous generations (Maxwell, 1998), the bar institution has remained. Most of the men reported that bars and/or dance clubs are still their primary connection to the community. According to an American study of young gay men’s HIV risk factors (Marsengh, 1998), younger gay men are more likely than their older counterparts to use bars to meet and socialize with others.

In the conclusions to their extensive ethnographic research of the gay dance sub-culture in Australia, Lewis and Ross (1995) argue that the current gay dance culture is in part a response to the HIV epidemic.
…There are many similarities between the gay communities life-affirming responses (including the dance party institution) to the HIV pandemic and reported behaviour among other populations facing life-threatening crises…This major social institution [the gay party scene] appears to be the main socio-psychological buffer or safety-valve for a considerable subgroup of gay men who have been immersed in one of the most existentially and scientifically distressing periods in recent history….Many of the party patrons intentionally used drugs to transform or control their internal moods or external environments.

This dance party institution is associated with new patterns of substance use, particularly the use of party drugs.

2c) The Role of Social Networks

Ethnographic studies conducted by the Australian Drug Use and Gay Men Project provide extensive descriptions of social drug-using networks in the gay party scene (Southgate, 1999). Drug use is seen as a collective rather than individual practice and a man’s drug-using network consists of friends and sexual partners. Social networks are also the number one source of knowledge about drug use and how to combine and use different substances.

Users view social networks as an important component in drug use safety (Southgate, 1999). Friends protect each other if the drugs have unpredicted effect or a user takes too much. They also learn protective behaviours from each other, such as sampling small amounts of drug before using more, or drinking lots of water to avoid dehydration. Social networks reinforce the norms around appropriate drug use (Southgate, 1999; Latkin, 1996). Non-injecting networks generally discourage the use of injection drugs, and reinforce the limits of use such as suggesting that drug use not interfere with work or spoil a good night out (Southgate, 1999). Social networks often form around one or more experienced and knowledgeable user who provides information about drug use and look after less experienced users. Australian researchers have dubbed these individuals “network nannies” (Southgate, 1999). Social networks also play an important role in enforcing norms of sexual risk behaviour (Kelly, 1992).

Social drug-using networks are vital to prevention efforts because they provide information and norms about drug-use and sexual behaviour and because they already have a protective element. Latkin et al showed that an intervention that specifically targeted a drug user’s social network was more effective than previous interventions with a more individual focus.

Network norms about sexual behaviour and drug use also influence behaviour of those who seroconvert to HIV. Kimberley and Serovich’s 1999 study demonstrated that men who received high levels of socials support from their biological families tended to reduce risk behaviour and be sexually abstinent. Conversely when an HIV+ gay man’s social support was primarily provided by his friends, there was no influence on risk behaviour and sexual abstinence was discouraged.

2d) Prevalence of Party Drug Use

There is limited quantitative data to confirm that the use of party drugs (or any other class of drugs) has recently increased in Toronto gay dance venues. However, research on other populations and in other cities would suggest the trend is probable.

General drug use surveys of young people in Toronto have shown a steady increase in ecstasy use (the only ‘party drug’ currently tracked) starting in 1991 and a more dramatic jump in recent years. Survey statistics show that use of ecstasy nearly doubled between 1997 and 1999, with seven percent of young people now reporting use (Research Group on Drug Use, 2000). This makes ecstasy use second only to the use of cannabis among Toronto high school students and suggests that the drug is readily available in the city. A study by the Centre for Addiction and Mental Health (2000) showed that designer drug use was significantly associated with raves: youth dance parties that parallel and overlap with the gay dance scene in many ways. Four times as many “ravers” used ecstasy in 1999 when compared to the general student population. For many young MSM raves may be the primary social outlet and the scene for both drug use and meeting sexual contacts.

Some studies suggest that within the dance party scene, poly-drug use, prominently including party drugs, is normative and expected (Southgate, 1999; Ireland, 1999; ACT, 2001). This appears to be true both for general populations of gay men (Southgate, 1999; Gorman, 2000; Klitzman, 2000; Ostrow, 2000) and for men whose drug use disrupts their lives to the point of seeking treatment (Shoptow, 2000; Frosch, 1996). Drug use is “regular and open” and is even more common in the after hours clubs than at gay dance bar venues. (ACT, 2001)

Thirteen percent of gay men surveyed in Vancouver (Trussler, 2000) reported using party drugs (including crystal methamphetamine). An anonymous survey at New York City gay and bisexual dance clubs (Klitzman, 2000) found at least monthly use of party drugs by the following percentage of club goers: 34% ecstasy, 23% ketamine and 6% GHB. Other illicit drugs used by this population at least once in the last month included 37% marijuana, 16% cocaine (including crack), 13% inhaled nitrates, 8% methamphetamines and 7% hallucinogens such as LSD.

A 1999 study of gay and bisexual circuit party participants from the San Francisco Bay Area (Mansergh, 2001) found seventy-four percent reporting using a psychoactive drug during their most recent circuit party. Twenty-five percent reported a drug "overuse" episode in which they passed out, required medical attention or were unable to care for themselves. Drug users reported using one to seven drugs.

Overlapping use of a variety of drugs is common in the gay club scene, and the appropriate pacing of drugs for optimal enjoyment is valued knowledge. (Southgate, 1999) Drugs are often used to counter the perceived negative effects of other drugs: for example, the use of inhaled nitrates or Viagra to get an erection when using ecstasy. Stall and Purcell (2000) observed in their survey of existing literature that men who have sex with men (MSM) are more likely than heterosexual men to use many different drugs either in combination or sequentially. However, they also note that MSM drug use is rarely excessive:
Although MSM use many different kinds of drugs in a year, few men seem to be characterized by the frequent use of one drug at any given time (in ways that might suggest abuse). Thus drug use by MSM may be more variable; that is, over time, many different drugs are used on specific occasions, but few men use any one drug to excess.

This seems typical of poly-drug use. According to a report prepared for the Australian Drug and Alcohol Directorate (1992), most psychostimulant users “parallel social drinkers in control of their consumption.”

One possible exception to this pattern of drug use is the use of methamphetamine among gay men, which does appear to conform to the stereotypical pattern of rapidly increasing use and abuse, particularly when injected (Reback, 1997).

2e) General Drug Use and Risky Sexual Behaviour in MSM

Studies show that rates of risky sexual activity have been increasing over the last several years (Stall, 2000). This is now beginning to be reflected in HIV seroconversion rates in Toronto MSM (Calzavara, 2000). Many factors may contribute to this increase; drug use patterns are only one possibility. Other studies have linked increased rates of seroconversion with treatment optimism, and the increasing numbers of young gay men who did not experience the wave of deaths which occurred in the 1980s and early 90s (Stall & Hays, 2000). HIV fatigue and relapse to unsafe behaviours have also been identified by several authors (Ostrow, 2000). Stall & Hays suggest that risk behaviour decreased in the late 80s and early 90s as the most risk-taking men died of AIDS related illness. They suggest that as new treatments reduce the death rate, and a new group of young gay men enter “the scene,” a new population of risk-takers emerges.

Some studies show that those men with a strong “bar orientation,” (i.e. men whose social and sexual lives revolve primarily around bar life) are more vulnerable to excessive substance use when exposed to discrimination or other life stresses (McKiran et al, 1988). A “bar orientation” remains independently associated with an increased number of unprotected anal intercourse partners and increased risk of seroconversion in the both older and younger gay men (Mansengh, 1998).

A number of studies over the past twenty years have demonstrated a link between sexual risk behaviour and the use of illicit drugs or the heavy use of alcohol (Chesney, 1998; Difrancesio, 1997; Kalichman, 1998; Kalichman, 1997; Klitzman, 2000; Mckiran, 1998; Ostrow, 2000; Reback, 1999; van de Ven, 1998; Woody, 1999). Moderate use of alcohol or marijuana is generally not associated with increased levels of risk (Kalichman, 1998; Klitzman, 2000; Stall & Purcell, 2000; Woody, 1999). Studies invariable show a dose-related effect with more frequent and/or heavier use of drugs and alcohol more likely linked to participation in risky sexual activity (Chesney, 1998; Ostrow, 2000; Stall & Purcell, 2000; van de Ven, 1998; Woody, 1999).

It is unclear, however, whether such links are causal or merely co-relational. Despite continued interest in this subject, a causal link has not been established. Methodological and ethical restrictions mean that it may never be possible to eliminate all confounding variables. However, an association between drug use and sex is widely accepted in popular culture (Woody, 1999). Some research suggests that this belief itself may perpetuate the link, because it allows people to cite drug use as an excuse for risky sex (Ostrow, 1993)

A collection of personality traits sometimes dubbed “sensation-seeking” may be associated with increased levels of both drug use and risky sexual activity (Kalichman, 1998; Kalichman, 1996; Ostrow, 1997; Dolezal, 1997). These traits also appear to predict HIV seroconversion (Kalichman, 1996). Higher levels of UAI and drug use are found among seropositive MSM, perhaps as a continuing reflection of these personality traits (Robins, 1994). HIV seroconversion does not appear to substantially influence either risky sexual activity or drug use (Robins, 1994).

A number of drugs are specifically associated with sex and are taken primarily to enhance sexual activity. Of all illicit drug use in the MSM community, the use of inhaled nitrates is most clearly and consistently associated in published research with high-risk sexual behaviour (Chesney, 1998; Difrancesio, 1997; Kalichman, 97; Ostrow, 1993). Other “sex drugs” which are thought to stimulate and enhance sexual activity, specifically cocaine and methamphetamines, also appear to be strongly associated with risky sexual activity (Paul, 96; Gorman, 2000; Difrancesio, 1997). The expectation that certain drugs may enhance sex and reduce inhibitions encourages the combination of drugs and risky sexual activity and may be particularly alluring for men whose personalities already promote risk-taking. (Kalichman, 1998) Studies have shown that modifying the use of drugs associated with sexual activity, if this use becomes destructive, is particularly difficult (Paul, 1996).

2f) Party Drug Use and Risky Sexual Behaviour in MSM

The degree to which party drugs are seen to enhance sexual activity is a matter of some debate. In a mixed sample of ecstasy users (52% female, 80% heterosexual) over 70 percent reported that ecstasy enhanced sexual experiences (Topp, 1999). However, qualitative studies of gay club patrons report that ecstasy and other party drugs are taken primarily to enhance dancing and the club going experience and not as sex drugs (Southgate, 1999; ACT 2001). Men interviewed in at least two ethnographic studies were adamant that party drug use did not increase the likelihood of unsafe sex (Southgate, 1999; ACT 2001). In fact ecstasy and many of the other current party drugs make it more difficult for men to obtain erections and reach orgasm (Pajouhi, 2000). For these reasons, some gay men view them as inhibiting sex, particularly penetrative sex.

Few quantitative studies of gay men’s use of party drugs and sexual risk-taking are available in the medical literature; most pertain primarily to ecstasy. A study of 169 gay and bisexual male club goers in New York City (Klitzman, 2000) reported a 23 percent increase in risky sexual activity among those who frequently used ecstasy (at least once a month). Although this population reported extensive poly-drug use, no other specific drug could be significantly associated with increased risky sexual activity. However, it is important to note that this population of frequent club-going, poly-drug-using men was reporting far higher levels of risky sexual activity than is generally reported in the MSM community regardless of the specific drugs used (57% reported UAI in the past year). Thus venue and peer norms may also be significant factors.

Supporting the link between ecstasy and risky sexual activity, the mixed sample of ecstasy users discussed above (Topp, 1999) reported that only 49% always used condoms when high compared to 59% who always used condoms when not using ecstasy.

In the San Francisco study of circuit party participants (Mansergh, 2001), two-thirds of the men reported having oral or anal sex during a party weekend. Twenty-six men (just under nine percent) had engaged in serodiscordant/serostatus-unknown (SD/SU) unprotected anal sex. The researchers report that their logistic regression model showed that the likelihood of having unprotected anal sex increased with the number of drugs used.

Ketamine is rarely reported as a sex drug, although its physiological effects undoubtedly also delay male orgasm (Pajouhi, 2000). Dextromethorphan effects are similar to ketamine, although it is more often ingested by people who believe they are buying ecstasy (SPHEHR, April 2001). GHB is associated with orgasmic delay and with increased pleasure (Pajouhi, 2000). It has become notorious in heterosexual environments as a “rape drug” that facilitates sexual manipulation. Although 2C-B is reputed to have some of the sensual body-focused effects of ecstasy, its effects are more hallucinogenic and it is not likely a stimulus of sexual activity (SPHEHR, April 2001). In the current poly-drug-using environment, however, it is important to note that the sexually inhibiting effects of these drugs are sometimes overcome by the use of other drugs that facilitate erection and sexual function, such as inhaled nitrates. Several reports now suggest that Viagra is becoming the drug of choice for this purpose (Pajouhi, 2000).

Although the role of party drugs in prompting sexual risk-taking is still debatable, the actions of these drugs make sexual activity more risky by slowing orgasm and reducing a man’s physical awareness. This may increase the risk of condom breakage or anal tearing (Pajouhi, 2000).

Some gay men report that party drugs, particularly ecstasy, do promote sexual contact in the “coming down” phase (ACT, 2001; Southgate, 1999; Ireland, 1999) and at least one qualitative study reports some men linking this phase to increased risky sexual activity (Southgate, 1999).

2g) Vulnerable Sub-groups

There is very little published research available about party drugs and groups particularly at risk such as youth and men from varying ethno-cultural communities

Some studies suggest that younger men engage in more risky sexual activity than older men (Kegeles, 1996), have higher levels of general substance use (Stall, Intertwining Epidemics, 2000) and are the predominant users of party drugs (Lewis and Ross, 1995).

Even less is known about the use of party drugs by MSM from ethnic and racial minorities and the risk that might be associated with this use. Studies have demonstrated higher rates of risky sexual activity among minority men (Stall, The Gay Nineties, 2000) making this a particularly urgent question for further study.

At least one study has demonstrated a link between “negative affectivity” and excessive substance use (McKiran, 1988), which is in turn linked to risky sexual activity. Negative affectivity is a composite variable that includes low self-esteem, alienation and moderate signs of depression.

2h) Harm Reduction Interventions

Although a few interventions have been undertaken in various settings to reduce the harms associated with party-drugs and/or risky sexual activity in people using party drugs, there is virtually no information available evaluating the outcomes of these interventions.

An Australia monograph on models of intervention and care for psychostimulant users (Kamieniecki et al, 1998) reported on three such programs (including one with a focus on sexual risks) but noted that none had sufficient evaluation components to assess their effects. None of these interventions dealt specifically with gay men.

Harm reduction campaigns focusing on party drugs have been conducted by a number of AIDS prevention agencies including the Gay Men’s Health Crisis in New York city, AIDS Atlanta, Northwest AIDS Foundation (Seattle), and the San Francisco AIDS Foundation. The AIDS Committee of Toronto itself has worked with the Toronto Raver Info Project (TRIP) and Toronto Public Health’s Drug Prevention Centre to produce basic harm reduction materials. None of the campaigns listed above has prioritized testing and evaluation of the intervention’s efficacy.

Although information is lacking about specific harm reduction strategies with regards to MSM’s use of party drugs, some key characteristics of effective interventions have been identified in the literature. The Academy for Educational Development’s1997 publication on HIV Prevention for drug users summarized effective interventions as interventions that:
· are designed according to the results of a comprehensive needs assessment, including an identification of target group members’ level of motivation to change risk behaviors
· are affordable and easy to access by the target population served and are able to respond to other expressed needs of the community
· are culturally competent, relevant to the targeted population (i.e., consistent with norms, attitudes, beliefs and attitudes), and include members of the target population in program planning and implementation
· have clearly defined target group(s), interventions and program components, and objectives
· focus on behavioral skills, which include how to carry out low-risk, safer behaviors as well as how to avoid and cope with high-risk situations
· do not provide messages that are judgmental, moralistic, or attempt to instill fear
· have ample duration and intensity to achieve lasting behavior change, and provide support and skills necessary to cope with lapses and setbacks in maintaining safe behaviors
· address the social and community norms of the target population so that program participants receive consistent messages and reinforcement for the prescribed behavior change
· are offered to the target group as part of a continuum of health care (e.g., drug and alcohol treatment, STD treatment, family planning, other health services)
· address other basic needs of the targeted population (e.g., housing, food) in order for HIV prevention to be considered a priority
· are regularly monitored to assure implementation is according to plan and that outcomes are being met.


3) Toronto Gay Men, Party Drugs & HIV Risk: Research Method

Our literature search confirmed that there are many gaps in current knowledge about the drug-using and sexual behaviours of gay men who use party drugs, about whether or how those behaviours are linked, and about what might motivate them to reduce drug or sexual risk behaviours.

ACT set out to explore these questions with qualitative interviews with a number of gay men who participate in and are knowledgeable about party drugs and dance clubs.

3a) Research Methodology

A major component of this project was a series of qualitative focus group interviews with 14 gay men active in the Toronto dance/club scene. In addition, an on-line focus group was conducted with two other men. The interviews were organized and conducted by Chris Lau, ACT Research Assistant and James Murray, ACT Gay Men’s Community Development Coordinator.

The participants were recruited primarily from contacts identified by ACT staff, volunteers and advisory committee members. Some participants were recruited through flyers handed out one evening at a gay dance club. Online participants were recruited via the same flyer.

Focus groups interviews consisted of open-ended questions exploring key themes. The questions were drafted by participating ACT staff and reviewed by the advisory committee. Participants also filled out a questionnaire providing demographic, drug use and sexual behaviour data.

All 16 participants self-identified as gay men. They varied in age from 25 to 43, with the mean being 33. 7 identified themselves from a non-Caucasian ethno-cultural background. 7 attended gay bars or clubs at least once a week. 6 had less than 5 sex partners in the prior year; 10 had 5 or more sex partners. One participant was HIV positive. All but one participant had used one or more drugs in the prior year.



4) Toronto Gay Men, Party Drugs & HIV Risk: Research Conclusions

4a) Context: Involvement and Perceptions of Party Drugs and Venues

Participants described a wide array of activities within and attachments to party drugs and/or party venues. They described activities within and attachments to specific venues, social networks, and types of music; for some, these factors overlap.

Participants expressed a range of positive and negative perceptions of party drug use and attending dance clubs and bars. For the majority of participants, the club scene, especially gay clubs, and drug use were intrinsically linked.

There is a wide range of motivations for involvement in party drugs and dance venues. One common response given by participants was that they were single and wanted to socialize with other men. One participant further explained he wanted to escape from the responsibilities of daily life, to gain a sense of freedom: “I wanna be irresponsible, fuck around, be single, be crazy, meet people, have fun (…) I don’t want to be this person that does what everyone expects from him”. Wanting to experiment with illicit drugs motivated one participant to get involved in dance venues. As another explained, drug use tends to be more acceptable in the scene. For some, involvement is principally rooted in their passion for music, or for playing music (as a DJ). Finally, for another group of gay men, their motivation rests, to varying degrees, upon the economic gains they incur either from drug dealing, or from managing or working “behind-the-scene”.

4b) Social Networks

Most participants suggested that involvement in party drugs and dance clubs related to self-acceptance and the desire to belong. There was a common perception that there are few other spaces where gay/bisexual men, particularly youth, can come out, socialize, and feel accepted with the larger mainstream gay community.

Most participants said drug use is primarily a social experience, something that you do with friends. Some participants stated they would not do drugs if they were alone, or if they went out alone. Another participant explained that people want to be around others who are also doing drugs, since there is a feeling of acceptance for ones’ drug use. Friends were also considered by many participants to be a trustworthy source of information about drugs and safer drug use.

Participants overwhelmingly agreed that the friendships made sharing drugs within dance clubs and bars tended to be superficial. Some preferred qualifying many of these friendships more as acquaintances. Participants explained the only thing commonality they had with these friends was partying and drug use. One participant explained it was very difficult to leave these friendships, even though they were simply “clubbing friends”.

Despite the superficial nature of many of these friendships, participants generally agreed that friends were important and a source of support in various ways. One participant explained that, with the intent to “look out” for each other, his circle of friends had a common understanding that nobody left the venue without informing the others. Another explained that it was friends who tended to help those who were getting too involved in the scene, or into the drugs. Another participant explained it could be fun to have these superficial friendships: “You’re there to dance, party and do drugs, you’re not there to have a deep conversation”.

Body image was also seen to be an integral part of the club scene. One participant acknowledged his participation in dance clubs has led him to be more aware about his body image. One non-Caucasian participant stated his image of the scene was of “white buff men”, reinforcing other participants’ perception that the scene is predominantly Caucasian. Another participant noted that there were not many older gay men in dance clubs and bars. Diversity tended to rest upon the different sub-groups of people involved in different venues and social networks. Some participants acknowledged that some groups choose not to interact with each other due to the negative stereotypes each holds about the other. Thus, ironically, many individuals who involve themselves with party drugs and dance clubs to feel accepted seemingly end up perpetuating some of the views they seek to escape.

4c) Prevalence of and Attitudes Towards Drug Use

Of the 16 participants, all but one reported using illicit drugs within the prior year. For those who consumed, the most common recreational drugs included: Ecstasy, alcohol, Ketamine, cannabis (pot/weed), cocaine, Viagra, GHB, and steroids.

Party drug use was not necessarily perceived as being negative. As one participant stated: “Drugs can play a positive role too”, as long as it is used responsibly and in moderation. Drug use was perceived by most participants to be accepted as an aspect of the dance club scene. As a result, many men are comfortable openly doing drugs at venues. Some proudly boast about their drug use to others, or their overdose experiences. This openness with drug use is even more prevalent at after-hours clubs, as compared to the regular-hour bars and clubs.

One participant explained that he did not know of any people who would go to a specific after-hours club without the intention of getting high. He explained that although he attempted to go to this club without consuming drugs, it was “just too impossible to be there sober”. Perhaps because drug use seems to be driven be the desire to socialize, choosing not to consume drugs and to get high while your friends have chosen to do so can be very difficult. Further, men who use drugs tend to be swift in offering drugs to those whom they think might be interested or curious to experiment for the first time.

Individual experiences of drugs are highly subjective; the experience often depends on the amount consumed, method of administration, the individual’s mood during consumption, location/venue, reason for use, etc. This could explain why several participants’ experiences with the same drug on different occasions were drastically different.

Some described a transition from sporadic to regular use.

Most participants expressed particular concern for young men, or men who only have recently gotten involved with party drugs (regardless of their age); these two groups were seen to be at greater risk since they tended to get “messed up” on drugs due to its novelty at the beginning. Participants believed this initial phase of involvement was critical, and it is often difficult for novices to know when to limit drug use. Young men and newcomers to drug use also tended not to know the negative effects of their drug use.

4d) Motivations for Drug Use

Participants discussed a range of motivations for drug use. Drug use is perceived by some men as being “cool” and exciting. Many men want to be perceived as being “cool” by not missing out on the drug experience that so many other gay/bisexual men talk about. One participant spoke about the desire to make larger dance events more “special” by taking drugs, as this differentiated these parties from going out on a regular weekend. Others’ drug use is initiated more out of curiosity, to experience what others have described. For some, drug use is primarily motivated by the desire to enhance the music and the dancing. As some participants explained, drug use can also be motivated by the desire to be more sociable. For instance, Ecstasy was said to produce a sensation of wanting to feel connected with others. Some men also take Ecstasy because it makes them feel better looking and makes other people look better. Many participants said drug use is often motivated by the desire to be in the same emotional state as the people surrounding you.

For those working behind-the-scenes, drug use is sometimes motivated by the desire to relieve stress.

Identified factors influencing one’s drug use included: having easy access to drugs (for instance, personally knowing a drug dealer, or dating a drug dealer), being certain that the drug will not be addictive, the desire to be active and productive the following day, the choice of venue, the event, and the lateness of the evening.

Many participants expressed concern about addiction. One participant explained that it bothers him to realize that he must either do K or E if he wants to have a good time when he goes out. He also explained “once you’re high, you want to get higher”. For most participants, the danger of a drug is associated with its perceived level of addictiveness. Some participants also had concerns about how much money they spend on drugs. One participant said some men prioritize spending money on drugs and going out rather than paying their bills.

Drug use in the circuit party scene is seen to be even more central, more common, more diverse, more intense and more socially accepted. One participant said that the circuit scene would not exist without the drugs.

Drug use has many ramifications on gay/bisexual men’s health and overall well-being. Participants talked about the impact of coming down from certain drugs, even leading a few towards suicidal emotions. Also, many men feel guilty for their drug use, lowering their self-esteem, and leading towards more intense drug use. One participant who worked behind-the-scenes emphasized his desire to create positive spaces in which gay men could party and feel good about themselves at the same time.

4e) Sex and Party Drugs in Dance Venues

Although all participants agreed that sex and sexual tension permeated the club scene, most said their involvement is not focused on, or driven by, the desire to meet other men for casual sexual encounters.

Sex sometimes occurs at the venues, such as in washrooms, but this is not believed to be pervasive. Some participants said sex was more common at the larger events and circuit parties, particularly in the middle of the dance floor or in the darker corners of the room. One participant explained that the lessening of social restrictions at these venues, and particularly within circuit parties, may lead some men to be more open-minded about public displays of affection and sex.

Venues in which gay/bisexual men tend to consume drugs also tend to be spaces where many men seek their sexual partners. As one participant explained, if an individual is under the influence of drugs or alcohol, thus lowering their inhibitions, and if this person is in a venue where sex is focal and sexual tension is strongly present (dancers, topless men, sex on TV screens, etc), this can easily lead men to think about sex and to seek sex while they are high or intoxicated. The link can extend beyond dance venues: users may still be coming down from a high after they leave the venue. Some participants said going to the bathhouse after going out to a bar or club was common. Such experiences tended to be unsuccessful in meeting sexual partners, due to the drug side effects. Several participants also spoke about their involvement with sex parties, in which risky sexual behaviours seemed more common.

One participant said sex is never planned in advance when deciding to go out. Because it is never planned, he does not have any condoms with him when he meets a potential sexual partner at the clubs.

Most participants said drugs had some form of association with sexual behaviour. Some gay/bisexual men consume drugs mainly for sexual reasons (to enhance sexual pleasure, to lower inhibitions, to make anal sex less painful, or to make it easier to socialize), although others consume drugs more for non-sexual reasons (to enhance the music, to relax, or simply out of curiosity).

Some participants said their drug use made it more difficult to have sex, due to problems with maintaining erections due to the drugs, or the drugs reducing their desire for sex. Different drugs tend to have different effects on different individuals; some drugs are generally associated with enhancing sex (crystal, GHB, cocaine, steroids, alcohol) while others inhibit sex (Ecstasy, K, cocaine).

Same-sex prostitution was discussed as another form of association between sex and drug use. One participant explained that some gay/bisexual men engage in prostitution to financially maintain their drug use.

4f) Party Drug Use and Risky Sexual Behaviour

Participants generally rejected any direct causal link between drug use and risky sexual behaviour. Some participants indicated their negotiation of safer sex was not affected when high, or at least not greatly affected. Others, however, contended that being high made them more likely to partake in risky sexual behaviours, or made it more difficult to insist on safer sex practices.

Some participants indicated that drug use tended to make their sexual experiences more “superficial”, less intimate. One service provider working with drug use issues said some clients were “more sexually active when they are high, and not necessarily making the same choices around where, with who, and what they do, what kind of sexual behaviour they engage in”.

Associations between drug use and risky sex seem to be dependent on the type of drug consumed. One participant said GHB makes the individual feel extremely sexual: “You’re ready to do it with anybody”. Steroid use also has a unique association with sex. One participant spoke of the widespread use of steroids among gay/bisexual men in the circuit scene to build up their bodies to enhance their chances of meeting other muscular men.

Ecstasy was generally agreed to be a drug that does not lead to sex or to unsafe sexual behaviours. However, participants spoke about the feelings of trust and wanting to be physically and emotionally close with others that result from E. One participant explained that doing E made him more sensitive and emotional towards others, and made him more vulnerable towards others. He explained how he could see himself agreeing to partake in unsafe sexual behaviours, should he feel even greater trust towards a sexual partner due to being high on E. He acknowledged how others could potentially take advantage of him when he was high on E: “If you asked me for my wallet (while high on E), I’d give it to you”.

Drug use may have other psychological and emotional effects after the drug experience (such as the guilt and lower self-esteem) that may be associated with risky sexual behaviour.

4g) Attitudes Towards HIV/AIDS

It was commonly agreed by participants that HIV/AIDS is not generally discussed in the dance club scene. Several participants had the perception that many gay/bisexual men simply don’t care about getting infected with HIV, or they still believe it will never happen to them. Others may perceive HIV/AIDS as a manageable disease, due to changing face of AIDS that presents people living healthier and longer with HIV.

One participant acknowledged that some friends tended to discuss other people’s HIV status. This was perceived as somewhat acceptable if it was done with the intention of informing friends about their partners’ status, for the protection of their friends. This participant went on to acknowledge that this may make disclosure of sero-status difficult for those who are HIV-positive.

One participant believed many dance-clubbers are still not fully educated about HIV/AIDS, even though educational materials are being made available to them at the venues. He believes they may be too embarrassed to read and to take these materials at these venues.

Another participant talked about the HIV risk of sharing equipment such as straws and bumpers when consuming drugs. Sharing equipment seems to be common among friends, reinforcing the social aspect of drug use.

4h) Prevention Programming

Most participants believed there are not enough safer sex and harm reduction educational materials and information. They urged the management teams of gay bars, clubs, and other establishments, as well as promoters and organizers of gay parties, to take greater responsibility by networking with AIDS Service organizations to develop and coordinate effective health promotion strategies.

Although one participant suggested closing the bathhouses, most participants advocated for a harm reduction approach when addressing HIV/AIDS and drug use. Such a harm reduction approach would be non-judgmental, information-based, and relevant to the immediate concerns of gay/bisexual men.

One participant expressed interest in learning about short- and long-term effects of certain drugs on the body. One participant exclaimed: “No preaching!” Education, explained another participant, needs to remain “light and fabulous”, since nobody wants to talk about something that will bring the mood down.

Several participants believed that personal outreach at bars and clubs is much less effective than educational materials, as people tend not to be interested in talking about such issues when they are at the venues. Further, one participant explained that when he is high on E, he tends to be self-absorbed, not noticing or caring what is happening around him. Suggestions included: having information or phone numbers on matchboxes, educational posters/flyers in washrooms. One participant urged management, promoters, and organizers to include safer sex and harm reduction messages and phone numbers on their existing promotional materials.

Many participants also advocated for the initiation of drug testing kits, either for personal use or at large parties.

One participant believed that harm reduction strategies should address the guilt and low self-esteem experienced by many men who use drugs.

Participants suggested other components of a harm reduction strategy, including:
· Moderation in terms of drug use, as well as frequency/involvement in the dance club scene;
· The importance of having life priorities that are not related to drugs or dance clubs;
· The importance of having a supportive network of friends, as well as taking care of friends;
· Reflection on the reasons behind drug use;
· Knowledge of what other substances may be laced with the drug;
· More information for HIV-positive people about the effects and risks of drug interactions with HIV medication;
· The provision of free condoms and lube at venues and parties;
· A recognition that there may need to be specific strategies geared for the different sub-groups within in the scene.


5) Lessons Learned: Elements of Potential Prevention Strategies

Our literature review and original interviews provide some key themes that may be useful in devising an effective HIV prevention strategy for gay men using party drugs.

5a) Use Social Networks & Peer Leaders

Since men in the scene already build up trusting relationships and protective social networks, peer-based interventions using these networks might be particularly effective. Drug using men will likely be resistant to an intervention that appears judgemental of drug use, since many men do not view drug use per se as a problem (Ireland, 1999; ACT, 2001). Recruiting men involved in the club scene as information couriers might be one way to address these issues. An example of this strategy is the study by Kelly et al (1992), which identified popular peers in gay male communities and trained them to act as peer educators to effectively reduce the risky sexual activity of others. Strategies designed to use social networks have also been used to reduce HIV risk behaviour in straight intravenous drug-using communities (Latkin, 1996). Australia prevention workers are already making efforts to recruit “network nannies” to provide harm reduction and safe sex messages (Southgate, 1999) a strategy that has some elements of the popular peers strategy. Participatory research that further explores and tests possible interventions might also involve these men in the design of interventions.

5b) Address Parallel Motivators Behind Drug Use and Sexual Behaviours

Educational efforts should address the social and psychological factors that attract or detract gay men from excessive drug use or risky sexual behaviour. Whether the link between drug use and risky sexual behaviour is causal or not, there are many parallel motivations, rewards and risks motivating drug and sexual behaviour. Prevention programming should address those motivators that increase risk and acknowledge those motivators that reduce risk.

5c) Adopt a Harm Reduction Approach to Drug Use and Sexual Risk-Taking

Our interviews and literature search suggest that gay men will be unreceptive to heavy-handed “just say no” messages related to either drug use or sexual health. Rather, messaging should emphasize personal choice, holistic health and options to reduce the harm of drug use and sexual engagement. (Other elements of a harm reduction approach are suggested by interview participants in section 4 (h) above.)

Messages should be cautious in asserting a link between drug use and risky sexual activity. Current research does not confirm a causal link between the two. Further, several sources suggest that gay men simply don’t accept or believe this, at least with regard to party drugs (Southgate, 1999; ACT, 2001). Additionally, some research suggests that a belief that drugs cause risky sex may give a person an excuse for sexual risk-taking (Ostrow, 1993). Therefore promoting the idea that drug use causes risky sexual activity might have a counter-productive effect.

Excessive use of drugs is, nonetheless, associated (causally or co-relationally) with a greater likelihood of risky sexual activity. Therefore harm reduction messages that simply promote safer and more controlled drug use may support safer sexual behaviour. It is important to note that although some researchers have argued for this approach (Shoptow, 2000), it has not yet been proven. The current literature does seem to suggest that an approach that emphasises controlled drug use more prominently than safer sex messages would be effective.

5d) Help Users Control the Drug Experience

In general, users want to know as much as possible about what they are taking and how it will affect them in order to optimize their drug use experience. This is a particularly relevant concern with party drugs, which are often and easily cut with other substances. Controlling the drug experience is a dominant theme in ethnographic studies of MSM drug use (Ireland, 1999; Southgate, 1999; Lewis and Ross, 1995). In our own interviews of individuals in the scene men expressed concern about the contents of drugs and the possibly of a drug being laced with other substances to reduce the sellers costs or to “hook” less experienced users. They also expressed significant concern about the risks of becoming dependent on recreational drugs.

Lewis and Ross (1995) suggest that this issue of control is a significant element of gay men’s drug use and an important element to utilize in harm reduction and HIV prevention strategies. In addition to suggesting a theme for prevention messages, this also suggests that strategies that help men control the effects of drug use might help draw men to intervention campaigns. For instance, early Dutch campaigns about ecstasy use focused on “market pollution,” the idea that many party drugs are not what they purport to be (Fromberg, 1990). Mobile drug testing, the distribution of drug testing kits, or even just flyer-based information about the contents of recent batches of drugs available in the city (with images of the pills) would provide valued information and a focal point for intervention messages. This might be particularly important since our interviews suggest there is a reticence in the club scene to discuss HIV risk. Conversely, information about contents of drugs is valued and desired. At least one program is already experimenting with a variety of these approaches (Sferios, 1999) and could be a useful source of lessons learned.

5e) Target ‘Gay-Identified’ Men

Studies suggest that party drug use is more common among gay-identified men who frequent gay community venues. (This would include bisexual men who actively and openly participate in gay community events.) Ethnographic studies suggest that party drug use is an integral part of gay dance venues. These factors argue for targeting gay identified men as those most at risk.

We have little information about the use and risk behaviours of non-gay-identified MSM, or young gay men who primarily socialize in the rave scene. Further ethnographic work may be necessary before interventions could be designed to specifically target these groups. More ethnographic work may to investigate other “gay venues” such as circuit parties or private sex parties would be helpful in designing specific interventions.

5f) Target Young Men with Peers

A number of studies have suggested that HIV rates are rising dramatically among young gay men (Kegeles, 1996; Mansergh, 1998). At least within the group of men who patronize gay clubs, young men may be the group whose social life is most “bar oriented,” a factor which may increase their risk (Mansergh, 1998). Men interviewed for the Toronto young men’s study suggested they feared being preyed on by older gay men (Maxwell, 1998). Other studies have suggested that young men in North America are often suspect of their older peers (Mansergh, 1998) and reluctant to seek out AIDS prevention information (Kegeles, 1996). These barriers suggest the importance of using peers to reach young, gay-identified, party-drug-using men. Other projects, which involved peers in both design and implementation, have created successful HIV prevention projects for young gay men (Kegeles, 1996).

Our own interviews identified a common concern for younger drug users (or older participants new to party drug use). This suggests the need for programming aimed at party-drug novices. It also suggests an opportunity for programming to explore the concerns expressed by seasoned party scene participants, perhaps to unearth worries about their own risky behaviours.

5g) Renew Bathhouse Focus

As noted earlier, men may be particularly vulnerable to risky sexual activity during the coming down phase of party drug use. Lewis and Ross (1995) note that their research found the most risky post-party venues to be explicitly sexual ones like bathhouses which encourage a certain degree of anonymity and a diffusion of responsibility. Men in these locations reported a greater likelihood of risky sexual activity than men who used post-party parties in private homes to meet sexual partners. Men in the Toronto interviews also frequently reported bathhouse visits. A renewed focus on bathhouses, particularly a late night campaign targeted to men coming down, may be appropriate.

6) Directions for Future Research

6a) Best Practices for Community Based Research

Our literature review suggested that a community-based approach has several important advantages for researching HIV prevention interventions. Because the research is based on a community initiative, it is more likely to accurately reflect the community’s needs and to be relevant and culturally competent. (Harper, 1999; Trussler, 1998). Community-based approaches can quickly tap into existing community knowledge allowing interventions to make a more timely and effective response. (Trussler, Knowledge from Action, 1998) Community based research may also be more effective at developing interventions with an action agenda which are focused on influencing community and social norms.

Most sources agree that the strengths of community-based research apply most readily to qualitative research (Trussler, 1997). Qualitative research is also most like to be manageable given the resource limitations of most community agencies.

In addition to the resource limitations of CBR, there may be other significant barriers. Numerous sources (Giesbrecht, 1993; Harper, 1999; Allman, 1997; Rotheram-Borus, 2000) describe conflicts between researchers and community members even when the researchers are also community members. These conflicts are attributed to the divergent agendas and cultures of community-based agencies and researchers, and as well as a failure to clearly establish decision-making power and other roles. The constant process of negotiation is routinely cited as the most demanding challenge of CBR.

Other significant challenges exist for community agencies in designing and implementing CBR (Allman, 1997). Staff may be confident in the value of their current services and reticent to become involved in work that challenges it. An individual’s lived experience working in the community is often seen as more directly relevant. Staff may simply be over-burdened by the demands of working in a frontline service agency. As well, sufficient skills may not be present in the agency to design effective evaluations.

A community-based approach is a relatively new strategy for research. As such, no cohesive body of literature detailing best practices exists. However authors publishing in the field have made several specific suggestions about how to improve the practice of CBR:
· published outcomes should include detailed information about the design and implementation of the intervention to facilitate implementation elsewhere (Kegeles, 2000; Ostrow, 2000)
· interventions should be based on thorough enthnographic study to insure that they are not tapping into a single (non-representative) social network (Ostrow, 2000; O'Connell, 2000)
· a strategic plan detailing the expertise required as each stage of the project is vital for the project’s credibility (Giesbrecht, 1993)
· negotiation between research and community agendas is key: resting projection control completely in one camp, or assign a veto power can lead to unnecessary complications (Giesbrecht, 1993)
· agencies should employ “research translators”, individuals that understand research design and goals and that can effectively convey information to staff and community members (Kelly)
· clear policies about confidentiality and the ethical handling of information should be developed, conveyed to all participants, and reinforced frequently, particularly in research that has significant peer involvement (Harper)

6b) Directions for Future Research

Future research by ACT in this area should build upon existing knowledge as summarized in this report. Efforts should be made to collaborate with and avoid duplication with other ongoing studies. Priority should be given to research projects that evaluate the impacts of prevention programs intended to affect the knowledge, attitudes and behaviours of gay men in Toronto who use ‘party drugs’.

Among the questions that future research projects should consider:

· What are the health concerns of drug-using communities of gay men?
· What protective strategies do these men already employ, and how might these be employed in prevention strategies?
· Are there other messages useful to this community that intervention strategies for HIV risk and drug use risk could incorporate?
· What factors lead people from occasional to excessive drug use?
· What attracts gay men to party drug venues or networks that is not found in the mainstream gay community?
· How can the communal and social aspects of drug use be employed in intervention strategies?
· How can specific sub-groups of gay men be targeted by intervention strategies?
· What intervention strategies might be successful for novices to drug use?
· How can specific venues be targeted by intervention strategies? (Circuit parties, gay clubs, dance clubs, bathhouses)? What are key elements of intervention strategies at each venue? How can venue owners and staff be successfully involved?
· How does the likely impairment of subjects at contact venues influence both the research and more crucially subsequent interventions?
· How should intervention strategies address the issue that many users (perhaps correctly) see little linkage between HIV risk behaviours and drug use?
· To what degree are participants in drug-use or at drug-using venues willing to discuss/consider HIV risk and drug use behaviour?


7) Literature Review: References

Academy for Educational Development. HIV Prevention among drug users, Funding provided by the Centers for Disease Control and Prevention, June 1997.

Allman D, Myers T et al. Concepts, Definitions and Models for Community-based HIV prevention research in Canada. Toronto, ON. University of Toronto, 1997.

Adlaf, E. & Smart, R. (1997). Party subculture or dens of doom? An epidemiological study of rave attendance and drug use patterns among adolescent students . Journal of Psychoactive Drugs, 29 (2), 193-198.

Beardsley, M., Goldstein, M. F., Deren, S., and Tortu, S. (1996). Assessing intervention efficacy: An example based on change profiles of unprotected sex among drug users. Journal of Drug Issues, 26, 635–648.

Boyd C. Sexless Ecstasy. Xtra! Jun 1 2000

Calzavara L, Remis R et al. Increasing HIV incidence among MSM repeat testers in Ontario, Canada, 1992-1998. XIII International AIDS Conference, Durban, 2000.

Centre for Addictions and Mental Health (CAMH). Population Studies eBulletin, No 1, June 2000.

Chesney Ma, Barrett DC et al. Histories of substance use and risk behavior: Precursors to HIV seroconversion in homosexual men. Public Health Briefs 1998 January;88(1):113-116.

Clatts MC, Sotheran JL. Challenges in research on drug and sexual risk practices of men who have sex with men: Applications of ethnography in HIV epidemiology and prevention. AIDS and Behavior 2000;4(2):169-179.

DiFranceisco, W., Ostrow, D. G., and Chmiel, J. S. (1997). Sexual adventurism, high-risk behavior, and human immunodeficiency virus-1 seroconversion among the Chicago MACS-CCS cohort, 1984–1992. Sexually Transmitted Diseases 1996;23, 453–460.

Dolezal C. Meyer-Bahlburg HFL. Remien RH. Petkova E. Substance use during sex and sensation seeking as predictors of sexual risk behavior among HIV+ and HIV- gay men. AIDS & Behavior, 1(1):19-28, 1997 Mar.

Fromberg E. A Harm-Reduction Educational Strategy Towards Ecstasy (MDMA). 1st International Conference on the Reduction of Drug-related Harm, Liverpool, 1990.

Frosch, Dominick; Shoptaw, Steven; Huber, Alice; Rawson, Richard A; et al. Sexual HIV risk among gay and bisexual male methamphetamine abusers. Journal of Substance Abuse Treatment. Vol 13(6), Nov-Dec 1996, 483-486.

Giesbrecht, Norman; Ferris, Jacqueline Community-based research initiatives in prevention. Addiction. Vol 88(Suppl), Jan 1993, 83-93.

Gillis JR, Meyer-Bahlburg HFL, et al. The predictive utility of an expanded AIDS risk model (ARRM) among adult gay and bisexual men. The Canadian Journal of Human Sexuality 1998 Spring;7(1):31-49.

Gorman E, Purcell DW et al. HIV Prevention Approaches for Men Who Have Sex with Men and Use Alcohol and Other Drugs. AIDS and Behavior 2000; 4(2): 167-8.

Gorman, E. Michael; Carroll, Robert T. Substance abuse and HIV: Considerations with regard to methamphetamines and other recreational drugs for nursing practice and research. Journal of the Association of Nurses in AIDS Care. 2000 Mar-Apr;11(2):51-62.

Harper GW, Carver LJ. "Out-of-the-mainstream" youth as partners in collaborative research: exploring the benefits and challenges. Health Education and Behaviour. 1999 Apr;26(2):250-65.

Ireland K, Southgate E et al. Using & ‘the scene’ - Patterns and contexts of drug use among Sydney gay men. Sydney: National Centre in HIV Social Research, 1999

Kalichman, Seth C; Kelly, Jeffrey A; Rompa, David. Continued high-risk sex among HIV seropositive gay and bisexual men seeking HIV prevention services. Health Psychology. Vol 16(4), Jul 1997, 369-373.

Kalichman SC, Tannenbaum L et al. Personality and cognitive factors influencing substance use and sexual risk for HIV infection among gay and bisexual men. Psychology of Addictive Behavior 1998; 12(4): 262-271.

Kalichman, SC, Kelly JA, et al. Sensation seeking as an explanation for the association between substance use and HIV-related risky sexual behavior. Archives of Sexual Behavior 1996;25(2):141-154.

Kamieniecki G, Vincent N et al. Models of intervention and care for psychostimulant users. Monograph Series No 32, Commonwealth of Australia Department of Health and Family Services, 1998.

Kegeles SM, Hays RB et al. The Mpowerment project: A community level prevention intervention for young gay men. American Journal of Public Health, 1996 August;86(8):1129-1136.

Kegeles SM, Rebchook GM, From science to application: the development of an intervention package. AIDS Education and Prevention 2000;12(5 Suppl):62-74.

Kelly JA, Heckman TG, Transfer of research-based HIV prevention interventions to community service providers: fidelity and adaptation. AIDS Education and Prevention 2000;12(5 Suppl):87-98.

Kelly JA, St Lawrence JS et al. Community AIDS/HIV Risk Reduction: The effects of endorsements by popular people in three cities. American Journal of Public Health, 1992 November;82(11):1483-1489.

Kimberley JA, Serovich JM. The role of family and friend social support is reducing risk behaviors among HIV-positive gay men. AIDS Education and Prevention 1999;11(6):465-475.

Klitzman, Robert L; Pope, Harrison G. Jr; MDMA ("Ecstasy") abuse and high-risk sexual behaviors among 169 gay and bisexual men. American Journal of Psychiatry. Vol 157(7), Jul 2000, 1162-1164.

Latkin CA, Mandell W, et al. The long-term outcome of a personal network-oriented HIV prevention intervention for injection drug users: the SAFE study. American Journal of Community Psychology 1996;24(3):341-364.

Leigh BC, Stall R. Substance use and risky sexual behavior for exposure to HIV. American Psychologist 1993 Oct:1035-43.

Levers C. Dual Risk for HIV? Drug Use and Sexual Behaviour among MSM in Toronto. (unpublished)

Lewis, L., and Ross. M. A select body: The gay dance party subculture and the HIV/AIDS pandemic, New York: Cassell, 1995.

Mane, Purnima; Aggleton, Peter Summary of track D: Social science: Research, policy and action. AIDS. Vol 10(Suppl 3), Dec 1996, S123-S132.

Mansergh, G., Colfax, G., Marks, G., Rader, M., Guzman, R., and Buchbinder, S. The Circuit Party Men's Health Survey: Findings and Implications for Gay and Bisexual Men. American Journal of Public Health Vol 91(6), June 2001, 953- 958.

Mansergh, G, Marks, G. Age and risk of HIV infection in men who have sex with men. AIDS 1998;12:1119-28.

Martin, J., Dean, L., Barcia, M., and Hall, W. (1989). The impact of AIDS on a gay community: Changes in sexual behavior, substance use and mental health. American Journal of Community Psychology, 17, 269–293.

Maxwell J. Young gay and bisexual men and HIV. A report for the AIDS Committee of Toronto, May 1998.

McKirnan, David J; Peterson, Peggy L. Stress, expectancies, and vulnerability to substance abuse: A test of a model among homosexual men. Journal of Abnormal Psychology. Vol 97(4), Nov 1988, 461-466.

O'Connell AA. Sampling for evaluation. Issues and strategies for community-based HIV prevention programs. Evaluation Health Professionals. 2000 Jun;23(2):212-34. Review.

Ostrow DG. The role of drugs in the sexual lives of men who have sex with men: continuing barriers to researching this question. AIDS & Behavior, 4(2):205-19, 2000 Jun.

Ostrow, D. G., Beltran, E. D., Joseph, J. G., DiFranceisco, W., Wesch, J., and Chmiel, J. S. (1993). Recreational drugs and sexual behavior in the Chicago MACS/CCS cohort of homo-sexually active men. Journal of Substance Abuse, 5, 311–325.

Ostrow DG. DiFranceisco W. Kalichman S. Sexual adventurism, substance use, and high-risk sexual behavior: a structural modeling analysis of the Chicago MACS/Coping and Change Cohort. AIDS & Behavior, 1(3):191-202, 1997 Sep.

Pajouhi P. Party drugs. HIV Counselor Perspectives 2000 April;9(2):1-8.

Paul, J. P., Barrett, D. C., Crosby, G. M., and Stall, R. D. (1996). Longitudinal changes in alcohol and drug use among men seen at a gay-specific substance abuse treatment agency. Journal of Studies on Alcohol, 57, 475–485.

Reback, Cathy J; Grella, Christine E. HIV risk behaviors of gay and bisexual male methamphetamaine users contacted through Street Outreach. Journal of Drug Issues. Vol 29(1), Win 1999, 155-166.

Research Group on Drug Use. Drug Use In Toronto, 2000. Available: www.city.toronto.on.ca/drugcentre

Rietmeijer CA, Kane MS, et al. Increasing the use of bleach and condoms among injecting drug users in Denver: outcomes of a targeted community-level HIV prevention program. AIDS 1996;10(3):291-298.

Rhodes T, Quirk A. Drug users’ sexual relationships and the social organisation of risk; the sexual relationship as a site of risk management. Social Science Medicine 1998;46(2):157-169.

Robins AG. Dew MA. Davidson S. Penkower L. Becker JT. Kingsley L. Psychosocial factors associated with risky sexual behavior among HIV-seropositive gay men. AIDS Education & Prevention, 6(6):483-92, 1994 Dec.

Rotheram-Borus MJ, Rebchook GM,. Bridging research and practice: community-researcher partnerships for replicating effective interventions. AIDS Education & Prevention 2000;12(5 Suppl):49-61.

Seage GR, Mayer KH et al. The social context of drinking, drug use, and unsafe sex in the Boston young men study. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology 1998;17:358-75.

Sferios E. The Ecstasy Harm Reduction Project. The Bulletin of the Multidisciplinary Association for Psychedelic Studies (MAPS) 1999 Spring;9(1):37-38.

Shoptaw S. Frosch D. Substance abuse treatment as HIV prevention for men who have sex with men. AIDS & Behavior, 4(2):193-203, 2000 Jun.

Southgate E, Hopwood M. The drug use and gay men project issue papers. New South Wales: National Centre in HIV Social Research, 1999.

Stall RD, Hays RB et al. The Gay ‘90s: A review of research in the 1990s on sexual behavior and HIV risk among men who have sex with men. AIDS 2000;14(supple3):S101-S114.

Stall R. Purcell DW. Intertwining epidemics: a review of research on substance use among men who have sex with men and its connection to the AIDS epidemic. AIDS & Behavior, 4(2):181-92, 2000 Jun.

Stevens PE, Hall JM. Participatory action research for sustaining individual and community change: a model of HIV prevention education. AIDS Education & Prevention 1998 Oct;10(5):387-402.

Topp L, Hando J et al. Sexual behaviour of ecstasy users in Sydney, Australia. Culture, Health and Sexuality 1999;1(2):147-159.

Trussler T. Gay Health in Vancouver: a quality of life survey for gay men. July, 2000.

Trussler,T, Marchand, R. Knowledge from Action: Community-Based Research in Canada's HIV Strategy. AIDS Vancouver & Health Canada, 1998

Trussler T. Taking care of each other. Vancouver : AIDS Vancouver, 1997.

van de Ven, Paul; Campbell, Danielle. Gay men who engaged repeatedly in unprotected anal intercourse with casual partners: The Sydney Men and Sexual Health Study. International Journal of STD & AIDS. Vol 9(6), Jun 1998, 336-340.

Wickes W. Amphetamines and Other Psychostimulants - A Guide To The Management Of Users. New South Wales, Australia: Drug and Alcohol Directorate, 1992.

Woody, George E; Donnell, Deborah; Non-injection substance use correlates with risky sex among men having sex with men: Data from HIVNET. Drug & Alcohol Dependence. Vol 53(3), Feb 1999, 197-205.