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Methamphetamine use in South Africa: Do increased rates of methamphetamine smoking represent an HIV transmission threat?. Richard A. Rawson, Ph.D Adjunct Associate Professor Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine

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Richard a rawson ph d adjunct associate professor

Methamphetamine use in South Africa: Do increased rates of methamphetamine smoking represent an HIV transmission threat?

Richard A. Rawson, Ph.D

Adjunct Associate Professor

Semel Institute for Neuroscience and Human Behavior

David Geffen School of Medicine

University of California at Los Angeles

www.uclaisap.org

rrawson@mednet.ucla.edu

Supported by:

National Institute on Drug Abuse (NIDA)

Pacific Southwest Technology Transfer Center (SAMHSA)

International Network of Treatment and Rehabilitation Resource Centres (UNODC)


Acknowledgements
Acknowledgements methamphetamine smoking represent an HIV transmission threat?

  • Charles Parry, Ph.D. Alcohol and Drug Abuse, Medical Research Council, Capetown, RSA

  • Solomon Rataemane, M.D. Professor, University of Limpopo, Pretoria, RSA

  • Donnie Watson, Ph.D. Friends Research Institute, Los Angeles, California

  • Steven Shoptaw, Ph.D. UCLA

  • Walter Ling, MD, UCLA


Presentation summary
Presentation Summary methamphetamine smoking represent an HIV transmission threat?

  • SubSarahan Africa has 10% of the world’s population and 60% of the world’s HIV-positive individuals.

  • Transmission of HIV in this region of the world has primarily been via sexual behavior.

  • Although there has been considerable evidence that alcohol may play a role in facilitating high risk sexual activity and thereby contribute to HIV transmission, the use of illicit drugs in the transmission of HIV in this region has not been considered a major contributor to this problem


Presentation summary1
Presentation Summary methamphetamine smoking represent an HIV transmission threat?

  • The escalation of methamphetamine use in the Republic of South Africa (RSA) may change this situation.

  • Methamphetamine smoking has become a rapidly increasing public health problem in the Western Cape of RSA (Capetown).

  • Methamphetamine use appears to promote increased levels of sexual behavior, especially unprotected and high risk sexual behavior

  • In the US, among MSM, smoking of methamphetamine has been associated with substantially elevated HIV rates


Richard a rawson ph d adjunct associate professor

HIV Prevalence in Adults in Sub-Saharan Africa methamphetamine smoking represent an HIV transmission threat?


Richard a rawson ph d adjunct associate professor

30 methamphetamine smoking represent an HIV transmission threat?

%

Age:

15‒49

20

Women

Men

10

30

Women

Men

%

Age:

15‒24

20

10

30

%

Age:

15‒49

20

Urban

Rural

10

Lesotho

South

Africa

Zambia

Kenya

Uganda

UR

Tanzania

Burkina

Faso

Ghana

Guinea

Senegal

South

East

West

HIV prevalence (%) by gender and urban/rural residence,

selected sub-Saharan African countries, 2001‒2005

2.7

Sources: Demographic and Health Survey reports (Lesotho, Zambia, Kenya, Burkina Faso, Ghana, Guinea and Senegal). Nelson Mandela Foundation (South Africa) (2005). Ministry of Health (Uganda). Tanzania Commission for AIDS (UR Tanzania) (2005).


Hiv in rsa
HIV in RSA methamphetamine smoking represent an HIV transmission threat?

  • South Africa’s epidemic is one of the worst in the world with an estimated 5.5M people (18.8% of the adult population) living with HIV in 2005.*

  • Almost 1 in 3 pregnant women attending public antenatal clinics were living with HIV in 2004 and trends show a gradual increase in prevalence.*

  • Primary route of HIV transmission via heterosexual contact

    * UNAIDS 2006


Hiv in rsa1
HIV in RSA methamphetamine smoking represent an HIV transmission threat?

The fact that 18% of the adult population in RSA is infected with HIV and that the primary method of HIV transmission is via unprotected sexual activity, it seems that a development which would increase unprotected sexual activity in RSA could increase the transmission of HIV.


Scope of the methamphetamine problem worldwide

According to surveys and estimates by WHO and UNODC, methamphetamine is the most widely used illicit drug in the world except for cannabis.

World wide it is estimated there are over 26 million regular users of amphetamine/methamphetamine, as compared to approximately 16 million heroin users and 14 million cocaine users

Scope of the Methamphetamine Problem Worldwide


Methamphetamine

Methamphetamine methamphetamine is the most widely used illicit drug in the world except for cannabis.

The US Epidemic


Primary amphetamine methamphetamine teds admission rates 1992 per 100 000 aged 12 and over

> 58 methamphetamine is the most widely used illicit drug in the world except for cannabis.

35 - 58

12 - 35

< 12

No data

Primary Amphetamine/Methamphetamine TEDS Admission Rates: 1992(per 100,000 aged 12 and over)


Primary amphetamine methamphetamine teds admission rates 1997 per 100 000 aged 12 and over

> 58 methamphetamine is the most widely used illicit drug in the world except for cannabis.

35 - 58

12 - 35

< 12

No data

Primary Amphetamine/Methamphetamine TEDS Admission Rates: 1997(per 100,000 aged 12 and over)

< 12


Primary amphetamine methamphetamine teds admission rates 2003 per 100 000 aged 12 and over

< 5 methamphetamine is the most widely used illicit drug in the world except for cannabis.

60-126

5 - 59

127+

Primary Amphetamine/Methamphetamine TEDS Admission Rates: 2003(per 100,000 aged 12 and over)

Incomplete Data


The methamphetamine epidemic admissions 100 000 1992 2003
The Methamphetamine Epidemic: methamphetamine is the most widely used illicit drug in the world except for cannabis.Admissions/100,000: 1992-2003

It keeps going up


Richard a rawson ph d adjunct associate professor

Figure 1. Methamphetamine/Amphetamine Treatment Admission Rate per 100,000 Population Aged 12 or Older: 1992-2002

Source: 2002 SAMHSA Treatment Episode Data Set (TEDS).


Richard a rawson ph d adjunct associate professor

Figure 2. Methamphetamine/Amphetamine Treatment Admissions, by Route of Administration: 1992-2002

Source: 2002 SAMHSA Treatment Episode Data Set (TEDS).


Methamphetamine1

Methamphetamine by Route of Administration: 1992-2002

South Africa


Methamphetamine use in capetown 2005 summary
Methamphetamine use in Capetown 2005: Summary by Route of Administration: 1992-2002

“The increase in treatment admissions for methamphetamine-related problems in Cape Town represents the fastest increase in admissions for a particular drug ever noted in the country. Of particular concern is the large number of adolescent users presenting for treatment.” *

* Parry et al 2005


Methamphetamine in rsa
Methamphetamine in RSA by Route of Administration: 1992-2002

  • The use of illegal stimulants such as crack cocaine, cocaine hydrochloride, methamphetamine (‘tik’) and methcathinone (‘CAT’) is on the increase in South Africa, but trends differ according to where one is in the country.*

  • Cape Town appears to be the methamphetamine capital of South Africa, with 98% of methamphetamine patients seen across the provinces coming from this city. *

    * Parry et al 2005


Treatment admission data capetown rsa 2002 2005
Treatment Admission Data: by Route of Administration: 1992-2002Capetown, RSA 2002-2005

% of patients with methamphetamine as primary or secondary substance of abuse

2005a2002a2002b2003a2003b2004a2004b

Primary 0.3% 0.8% 2.2% 2.3% 10.7% 19.3% 26.1%

Secondary 0.4% 1.2% 2.5% 5.0% 8.3% 9.6% 9.7%

Overall 0.7% 2.1% 4.7% 7.3% 19.0% 28.9% 35.8%

Total N 1608   1551   1724   1659   2255   2308   2468 


Methamphetamine user characteristics in capetown rsa
Methamphetamine user characteristics in Capetown, RSA by Route of Administration: 1992-2002

  • The average age of patients who reported methamphetamine as their primary substance of abuse in 1st half of 2005 was 21 years and 76% were male.

  • Most of the patients (92%) were Coloured, 7% were White, 0.5 Indian/Asian and 0.5% were Black/African.

  • Almost 50% of the patients were younger than 20 years of age (see Figure 2). The ages ranged from 12 to 53 years.

  • 90+% report smoking methamphetamine as the preferred route of administration.

  • 41% report daily use.

    Parry et al 2005


Richard a rawson ph d adjunct associate professor
Why might an increase in methamphetamine-smoking in RSA represent a new potential vector in HIV-transmission?


Methamphetamine and sexual behavior
Methamphetamine and Sexual Behavior represent a new potential vector in HIV-transmission?


Drugs and sexual behavior
Drugs and sexual behavior represent a new potential vector in HIV-transmission?

A 25 item true-false survey of in-treatment individuals was conducted with 400 patient volunteers. Participants were 100 primary opiate users, 100 primary alcohol users, 100 primary cocaine users, 100 primary methamphetamine users. *

* Rawson, R.A., Washton, A.M. and Domier, C. (2002) Sexual behavior and drug effects. Journal of Substance Abuse Treatment 22, 103-108.


Q 2 my sexual drive is increased by the use of

Percent Responding represent a new potential vector in HIV-transmission?

"Yes"

Q.2:My sexual drive is increased by the use of …

100

90

85.3

80

70.6

70

55.6

55.3

60

50

43.9

male

40

20.5

30

female

18.1

20

11.1

10

0

opiates

alcohol

cocaine

meth

Primary Drug of Abuse


Q 4 my sexual performance is improved by the use of
Q.4: My sexual performance is represent a new potential vector in HIV-transmission?improved by the use of …

100

90

80

70

61.1

58.8

60

PercentResponding

"Yes"

50

32.4

male

40

24.4

19.1

30

female

18.4

15.9

20

11.1

10

0

opiates

alcohol

cocaine

meth

Primary Drug of Abuse


Q 6 my sexual pleasure is enhanced by the use of
Q.6: My sexual pleasure is represent a new potential vector in HIV-transmission?enhanced by the use of …


Q 8 my use of has made me become obsessed with sex or made my sex drive abnormally high
Q.8: My use of … has made me become represent a new potential vector in HIV-transmission?obsessed with sex &/or made my sex drive abnormally high.


Q 10 i am more likely to have sex e g intercourse oral sex masturbation etc when using
Q.10: I am represent a new potential vector in HIV-transmission?more likely to have sex (e.g. intercourse, oral sex, masturbation, etc.) when using …


Q 12 i am more likely to practice risky sex under the influence of
Q.12: I am represent a new potential vector in HIV-transmission?more likely to practice “risky”* sex under the influence of …

* not use condoms, be less careful about who you choose as a sex partner, etc.


Richard a rawson ph d adjunct associate professor

Methamphetamine Use and HIV Risk Behaviors Among Heterosexual Men – Preliminary Results from Five Northern California Counties, December 2001 – November 2003* *

Methamphetamine Use and HIV Risk Behaviors Among Heterosexual Men - Preliminary Results from Five Northern California Counties, December 2001 – November 2003. Morbidity and Mortality Weekly Report. 2006;55:273-277.


Results
Results Heterosexual Men – Preliminary Results from Five Northern California Counties, December 2001 – November 2003


Female methamphetamine users social characteristics and sexual risk behavior

Female Methamphetamine Users: Social Characteristics and Sexual Risk Behavior

Semple SJ, Grant I, Patterson TLWomen and HealthVol. 40(3), 2004


Sexual risk behavior
Sexual Risk Behavior Sexual Risk Behavior

  • Participants engaged in an average of 79.2 sex acts over a two-month period.

  • Most sexual activity was unprotected. The average number of unprotected and protected sex acts over the two-month period was 70.3 and 8.8, respectively.

  • In terms of unprotected sex:

    • 56% of all vaginal sex acts were unprotected

    • 83% of all anal sex acts were unprotected

    • 98% of all oral sex acts were unprotected


Men who have sex with men hiv and methamphetamine use

Men-Who-Have-Sex-With-Men Sexual Risk BehaviorHIV and Methamphetamine Use


Hiv prevalence msm in the us
HIV Prevalence: MSM in the US Sexual Risk Behavior

“In general, HIV prevalence levels of US urban MSM were similar to those of subSaharan Africa, where 7 countries have estimated adult prevalence levels of 14%-25%.”

Catania et al. 2001 Am Jnl of Public Health


Methamphetamine use among msm
Methamphetamine use among MSM Sexual Risk Behavior

“In Los Angeles County, approximately 11% of GBM report using methamphetamine in the previous 6 months, a prevalence 20 times that in the general populations”

Shoptaw et al 2005


Methamphetamine hiv and msm
Methamphetamine, HIV and MSM Sexual Risk Behavior

In San Francisco, among those MSM who used methamphetamine, rates of HIV infection were 3X higher than among MSM who did not use methamphetamine.


Crystal methamphetamine use by latino men
Crystal Methamphetamine Use by Latino Men Sexual Risk Behavior

  • Study conducted by Los Angeles County’s HIV Epidemiology Program

    • Over 1500 participants of all race and ethnic groups

      • Newly diagnosed HIV-positive Latino men who have sex with men were almost 9 times more likely to report crystal use than HIV-negative men

      • Crystal use was highest among Latinos (20%)

      • Crystal was associated with a higher prevalence of unprotected anal sex and with newly diagnosed HIV

        Source: Bienestar (March 21, 2006). State and local Leaders Call for Action on Alarming New Latino HIV/AIDS Trends. Day Laborers, Crystal Meth emerge on Latino HIV prevention agenda. Press release.


Drug abuse problem or public health problem
Drug Abuse Problem or Public Health Problem Sexual Risk Behavior

LA County

  • Heroin Injectors: Low Risk

  • Gay Male Meth Users:

    Extreme Risk

LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)


Presentation summary2
Presentation Summary Sexual Risk Behavior

  • SubSarahan Africa has 10% of the world’s population and 60% of the world’s HIV-positive individuals.

  • Transmission of HIV in this region of the world has primarily been via sexual behavior.

  • Although there has been considerable evidence that alcohol may play a role in facilitating high risk sexual activity and thereby contribute to HIV transmission, the use of illicit drugs in the transmission of HIV in this region has not been considered a major contributor to this problem


Presentation summary3
Presentation Summary Sexual Risk Behavior

  • The escalation of methamphetamine use in the Republic of South Africa (RSA) may change this situation.

  • Methamphetamine smoking has become a rapidly increasing public health problem in the Western Cape of RSA (Capetown).

  • Methamphetamine use appears to promote increased levels of sexual behavior, especially unprotected and high risk sexual behavior

  • In the US, among MSM, smoking of methamphetamine has been associated with substantially elevated HIV rates


Presentation conclusion
Presentation Conclusion Sexual Risk Behavior

At present, it is not known if HIV rates among methamphetamine users in RSA differ from the general population. However, there is concern that the increases in high risk sexual activity that is associated with methamphetamine use may pose an important new HIV transmission vector.