Day 2   0900 - ashleigh rich
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  • *I’m going to present the findings from qualitative interviews that were conducted with 20 gay and bisexual men here in Vancouver, as part of the larger longitudinal bio-behavioral Momentum Health Study
  • *gay/bi/other MSM represent more than 50% of new infections in BC, as well as over half of those living with HIV in the province*While development, implementation and uptake of HAART has greatly reduced HIV-associated morbidity and mortality, the potential of HAART to act as a preventative measure at the population level depends on what happens with HIV risk behaviours at the individual levelIn this environment of expanded access to treatment technologies, including (PrEP) and(PEP), it is increasingly crucial to understand how sexual health and drug use attitudes and behaviours change over time for gay, bisexual and other men who have sex with men (MSM).This qualitative inquiry was designed to explore the socio-cultural context of substance use among Vancouver gay men
  • Study objectives include examination of relationship between substance use and HIV sexual risk behaviour, in the context of expanded ART access over time, as well as contribution of drug use before and during sex relates to HIV sexual risk
  • *We conducted an initial exploratory formative phase of research to inform the design and implementation of the Momentum study, in particular the use of Respondent Driven Sampling among Vancouver gay men.*The research team conducted 24 KIIS and 39 FGDs among demographically diverse groups of gay men to better understand how the various local communities are structured*Findings indicated that substance use patterns structure geographic and social-sexual environments for Vancouver gay men
  • *Previous research has demonstrated linkages between substance use, high risk sexual behaviour and seroconversion*Specifically, research has recognized an increased likelihood to use substances for gay versus heterosexual men*Specific substances have particular uses for this population, -distinction between recreational and sex drugs -some substances used for multiple purposes, like crystal meth -some substances serving distinct sexual functions (poppers associated with receptive AI b/c of muscle relaxant effect / Viagra/Cialis assoc with insertive AI)*and that substance use may be associated with an elevated HIV transmission risk. *In light of this evidence, we conducted a qualitative inquiry to explore the socio-cultural context of substance use among local gay communities.
  • *Semi-structured in-depth interviews were conducted with 20 purposively sampled gay/bisexual men, between August and October 2012*Respondents were recruited from those who had previously completed a quantitative questionnaire and clinical study visit, as part of the Momentum Health Study cohort, a five-year bio-behavioural research study*Interviews lasted from 1-2 hours*Interviews were structured through the use of an interview guide, as well as community maps as prompts. These maps were produced by individual participants in Focus Group Discussions conducted during formative research for Momentum*Formative research findings and literature guided the development of open-ended interview questions*We employed a broad definition of substance use in the interviews to include all drug and alcohol use
  • *Audio recorded interviews were transcribed verbatim and a thematic analysis was conducted*A phenomenological methodological approach informed data analysis*Interview transcripts were systematically reviewed to identify emergent themes within the data*Transcript data was analyzed using the qualitative analysis software Nvivo *Individual accounts were grouped into discrete categories which described common themes of experience*Regular member checking during analysis helped guide interpretation of findings
  • *20 gay and queer identified menwere purposefully sampled from the larger Momentum Health Study cohort for a diversity of sero-status, age, income, race/ethnicity, and area of residence. *Participants were eligible for inclusion in the cohort who were16 years of age or older, living in the Greater Vancouver area, who had been sexually active with other men within the previous 6 months, and were able to do a questionnaire in English*Ages ranged from 20s to 60s, participant median age category: 20s
  • RESULTSThe perspectives of gay, bisexual men in this study indicate that:Theme 1: Substance use is a social activity, taking place in gay social spaces Theme 2: Use of drugs and alcohol facilitates social-sexual inclusionTheme 3: Use of substances changes over the lifetime
  • Participants described substance use as a social activity and sites of consumption as social spaces. A distinction was made between types of substance use, with certain drugs being deemed casual while others were party or hard. Type of substance use is related to social sub-group participation, and social setting. Some substances are more available in certain settings, such as harder drugs at house parties.
  • *Beyond talking about this data in terms of HIV risk, I also wanted to highlight elements of resiliency that the men I interviewed spoke to.*Some participants described using drugs and alcohol as a way of participating in gay communities*Using drugs, and especially MDMA, created a space of social participation and community connectedness
  • *Use of drugs and alcohol facilitated entry into and participation in social-sexual scenes within local gay communities*Drugs and alcohol are used as a strategy for coping with social pressure or cultural anxiety, making people feel more comfortable with themselves in gay social settings.*Participants described using alcohol and drugs acting as a facilitator of social inclusion*Someparticipants narratives identified substance use as necessary for entry into gay social spaces, and some an inability to be in certain social settings without consuming alcohol or drugs.
  • The use of substances, including specifically alcohol affected people’s sex seeking behavior, both making potential sexual partners seem more desirable and making it easier to pursue a sexual encounter
  • Substance use changes across the lifetime. Narratives indicated that alcohol and drug use is an integral part of the gay community for all members at some point in their livesPeople’s attitudes and behaviours around substance use will shift over their lifetimes, with more substance use among younger men, who may experience cultural pressures more acutely.
  • While participants accounts identified drugand alcohol use as part of gay men’s lives generally, substance use was described as more common for those recently coming out or entering gay social-sexual scenes for the first time. *Drugs and alcohol was described as a means of coping with the stresses of coming out as well as the intragroup stresses of initiation into gay communities*Motivations for using drugs and alcohol changed over the course of gay men’s lives, as competing social, professional or financial pressures supersede those that prioritize substance use, and as men aged past the coming out period in their lives
  • *Risk environment*Gay men’s accounts suggest that substance use takes place within what Tim Rhodes and collegues term a complex HIV risk environment, in which complex social, economic and physical level factors interact to produce individual drug and alcohol use and related health risk and outcomes*LifecourseThe findings demonstrate that substance use changes over time for gay men, affected by age and historical time, particularly the ‘coming out’ periodEffective health prevention and promotion interventions must take into account that substance use changes over the life course for gay men
  • Where do we go from here?1) Future research plans include analyzing these qualitative data in conjunction with relevant psychosocial data from the Momentum behavioural survey. We have eventlevel data from the egocentric sexual network matrix documenting last five previous partners, and associated substance use in 2 hours prior to and during sexIt would also be interesting to look at these qualitative findings in relation to quantitative data on mental health variables, sexual-sensation seeking scales, and social connectedness measures2) Potential for further qualitative exploration of how the interaction between substance use and social coping changes over time during gay men’s lives, and its relationship to HIV transmission risk-better understand differences in substance use patterns by birth cohort, relationship to minority stress/coping/coming out timeline, and how this changes over historical time
  • *Funding agencies: NIH and CIHR*Research Program coordinated by the BC Centre for Excellence in HIV & AIDS housed at St. Paul’s Hospital*Academic Investigators & Governing Research Ethics Councils: UBC, SFU and University of Victoria

Transcript

  • 1. The Socio-Cultural Context of Substance Use among Gay Communities in Vancouver, BC Ashleigh Rich1, Jamie Forrest1, Allan Lal1, Terry Howard2, Robert Hogg1, 3, David Moore1, 4, Eric Roth5 1 BC Centre for Excellence in HIV/AIDS, Living Society of British Columbia 3 Simon Fraser University 4 University of British Columbia 5 University of Victoria 2 Positive Page 1
  • 2. Momentum Health Study • Access to HIV treatment technologies continues to expand in BC • Important to understand how sexual health & substance use beliefs and behaviours change over time for gay/bi/MSM • Qualitative inquiry to explore the socio-cultural context of substance use among Vancouver gay men Treatment as Prevention ART Optimism Sexual Altruism Substance Use Risk Behaviour Page 2
  • 3. Study Objectives include: CIHR Examine sexual behaviour and recreational drug use among a representative sample of MSM in BC over a period of five years, and to monitor changes in these behaviours as ART access expands NIH Examine how self-reported drug-use before and during sex contributes to HIV sexual risk behaviour Page 3
  • 4. Formative Research Purpose Study design & planning Methods 24 KII, 6 FGD, 39 community mapping exercises Key questions Where do MSM live, gather and play? Which sub-groups of MSM might be difficult to reach? By which categories does the community self-organise? • Findings from Momentum formative research indicated that substance use patterns structure social-sexual environments for Vancouver gay men.1  Substance use patterns were associated with particular neighbourhoods and social spaces  Social identity groups have unique substance use patterns and those who abstain from use may be socially isolated 1. Forrest JI, Stevenson B, Pai J, Michelow W, Roth EA, Moore D, & Hogg RS. Substance use preference and social-sexual desire in structuring social environments for MSM in Vancouver, BC: implications for Respondent Driven Sampling (RDS). 21st Annual Canadian Conference on HIV/AIDS Research (CAHR). April 2011. Montreal, Quebec. Page 4
  • 5. Substance use and sexual risk • MSM more likely to use multiple substances, and use substances with sex1 • Certain substances have specific sexual uses for gay men • Substance use may be associated with a greater risk of transmission of HIV2 1. Stall R, McKusick L, Wiley J, Coates TJ, Ostrow DG. Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: the AIDS behavioral research project. Health Educ Behav. 1986;13:359–71. 1. Beckett M, Burnam A, Collins RL, Kanouse DE, Beckman R. Substance use and high-risk sex among people with HIV: a comparison across exposure groups. AIDS Behav. 2003;7:209–19. Page 5
  • 6. Methods • Semi-structured qualitative interviews were conducted with twenty (20) respondents • Purposely sampled from the Momentum Health Study cohort • Interviews were structured through use of an interview guide and community maps as prompts • Open ended interview questions were developed based on formative research findings and literature Page 6
  • 7. Analysis • Audio recorded interviews were transcribed verbatim and a thematic analysis was conducted • Phenomenological approach framed the analysis1 • Transcripts were systematically reviewed to identify emergent themes • Transcript data was analyzed using Nvivo Green J & Thorogood N. Qualitative methodology and health research. In: Qualitative Methods for Health Research. 2nd ed. Los Angeles: Sage; 2009. p. 3-34. Page 7
  • 8. Interview participants • 20 gay and queer identified men • Mixed sero-status sample (HIV+ n=6, HIV- n=14) • Living in the Greater Vancouver Region • Had been sexually active with other men within the previous six months • Age range: 20’s to 60’s (median age category: 20’s) Page 8
  • 9. Results The perspectives of gay, bisexual men in this study indicate that: • Theme 1: Substance use is a social activity, taking place in gay social spaces • Theme 2: Use of drugs and alcohol facilitates social-sexual inclusion • Theme 3: Use of substances changes over the lifetime Page 9
  • 10. Substance use as a social activity The narratives of gay men indicate that substance use is a social activity among Vancouver gay communities and sites of consumption as social spaces A lot of the time social events are catered towards drinking or drug use even if it isn’t heavy drug use. It could be casual or recreational. … A lot of the time those are in the environment of our social spaces that we share.” (HIV negative, 20’s) Page 10
  • 11. Substance use as a social activity Participants described drug and alcohol use as way to participate in gay communities And I think a lot of drug use is like a social activity and a way to find community and I think that’s what most guys are looking for and I think that’s probably one of the ways to get it, just like going to like a church or whatever. I think that’s what people are often looking for and I think a lot of people in the city are super isolated and that’s probably one of the ways that they can find people. (HIV negative, 20’s) And then of course when you start doing MDMA at a club, it becomes this dance fast and everyone’s loving each other and like it kind of forms this like really beautiful community for like a really specific amount of time. (HIV negative, 20’s) Page 11
  • 12. Social-sexual context of substance use Gay men’s narratives described substance use as a barrier/facilitator of social participation And, you know, whether you’re included in that or not it tends to be obviously, people who are using drugs tend to congregate together and if you’re not using drugs you get somewhat excluded or you self exclude just because you don’t feel like you belong. (HIV negative, 30’s) It’s like I can’t do sober. I got to drink something because then I’ll like put aside my thoughts and I’ll actually start talking to random people and hopefully I’ll meet some people to hang out with. (HIV negative, 20’s) Page 12
  • 13. Social-sexual context of substance use Participants described alcohol and drug use affecting sex-seeking behaviour within social spaces If you don’t do drugs then you’re not invited to any parties or you’re not, a lot of people I found also sexually, if you’re not doing drugs then you’re out. (HIV positive, 50’s) Typically that I’m drunk my like inhibition lowers and I might as well just go find someone. (HIV negative, 20’s) I never knew a bathhouse when I was sober. (HIV negative, 20’s) Page 13
  • 14. Substance use over the life course Participant reported that gay men’s attitudes and behaviours around substance use will shift over their lifetimes, with more use among younger men There was a time where my friend circle was … doing a lot of different drugs…And then the group dynamic all just kind of like went from there and just slowly kind of changed and that kind of just went away and so it’s just kind of how … maybe because we grew up a little bit and so we just stopped and so like now it’s very infrequent and some of them are in jobs where they might be drug tested so they’re just totally … they’re like no, can’t do it, job’s more important…the dynamic just changed over time. (HIV negative, 20’s) Page 14
  • 15. Substance use over the life course Participant narratives indicated substance use as more common during the ‘coming out’ period of gay men’s lives I think when you’re first coming out, it’s really hard to go into a gay club without being drunk. I know I had that struggle, like just I’ve been to a gay club sober and it was terrible. (HIV negative, 20’s) When you’re young you like to experiment, okay? And so there’s that, the curiosity of experimentation. Also, because you’re young I see that as wanting to belong, ‘cause they have an assumption that, “I should be trying these things or doing these activities to belong and be accepted.” So … because I think they haven’t lived long enough to gain a confidence of who they are and … and feeling confident enough who they are no matter where they go and they have to feel they have to belong to the certain group or whatever, to feel this confidence of acceptance. (HIV positive, 60’s) Page 15
  • 16. Conclusions The perspectives of gay men participating in this study suggest that:  Substance use takes place within a complex HIV risk environment1, serving a number of social-sexual functions among Vancouver gay communities.  While drug and alcohol use can be associated with HIV transmission risk for gay men, it can also be a form of resiliency and community connectedness  Effective health prevention and promotion interventions must take into account that substance use changes over the life course for gay men 1. Rhodes T. The risk environment': a framework for understanding and reducing drug-related harm. International Journal of Drug Policy. 2002;13(2):85-94. Page 16
  • 17. Next Steps • Mixed methods analysis:  Use Momentum psychosocial data • Further qualitative exploration:  How the interaction between substance use and social coping changes over the life course Page 17
  • 18. Acknowledgements Funding Agencies Research Program Coordination Academic Investigators & Governing Research Ethics Councils Clinical Coordination & STI Screening Community Partnerships Research Consultation Page 18
  • 19. Thank you. Questions, suggestions? www.momentumstudy.ca arich@cfenet.ubc.ca Page19 19