The Context of HIV Risk Among Drug Users and Their Sexual Partners

Geographic differences found in the associations between high-risk sex
and NMPD use can be at least partially explained as social in origin;
differences in community norms regarding sexual and NMPD use
practices, legal prohibitions or restrictions on the sale or use of alcoholic
beverages or NMPDs in settings where sexual encounters may take place,
and local variations in the types of drugs available may all be reflected in
the resulting behavioral patterns of gay/bisexual men. For example,
amphetamine has never been as popular in the Midwestern United States
as in San Francisco, San Diego, or parts of New York City, and
amphetamine use has been traditional among specific sectors of the
gay/bisexual communities in those cities. To the extent that amphetamine
use has been popularized as a sex drug, one can expect it to be cited in
association with high-risk sex among subpopulations of gay/bisexual men
not yet committed to safer sexual practices. Similarly recent increases in
the popularity of the designer drugs ecstasy and ketamine (Special K)
among all-night partygoers might herald their association with high-risk
sexual activities.
In terms of legal constraints, it will be interesting to see if the nationwide
prohibition on sales of volatile nitrites in the United States, which went
into effect in mid-1992, has an effect on either the use of poppers or their
association with unprotected RAS among gay/bisexual men previously
reporting their use in sexual encounters. The recent proliferation of mailorder
popper advertisements in gay publications and their continued
availability at pornographic bookstores and movie theaters in some cities
would suggest not.
Despite these reasons for variability in the observed associations between
NMPD use and high-risk sex among gay/bisexual men, there appear to be
several important trends in the existing studies reviewed above that
should be emphasized. One trend is that as the studies move up the
methodological hierarchy in terms of methods that are less likely to reveal
coincidental associations or be subject to retrospective recall biases, the
focus is increasingly on the “Big 3” drug categories of volatile nitrites,
marijuana, and cocaine. The studies reviewed here all took care to
control for the numbers of sexual partners or other potential confounders
that one might expect to be involved with commonly used NMPDs.
However, the lack of any positive findings from intrapersonal
comparisons of sexual events that did or did not involve NMPD use does
not permit rejection of mechanisms that involve common underlying
factors for both types of behaviors. In fact, even if one or more of the
direct causal mechanisms were underlying the observed associations
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