Stimulant Use Associated With Psychosocial Factors, HIV Risk, and Concurrent Hazardous Alcohol Use Among US Adults: Exploratory Cross-Sectional Questionnaire Study.

BACKGROUND: Stimulant use is a major public health problem that contributes to morbidity and mortality among men who have sex with men (MSM) in the United States. To reduce the harms associated with stimulant use, there is a need to identify the factors associated with stimulant use to inform interventions. Additionally, there is a need to use large crowdsourcing platforms like Amazon Mechanical Turk (MTurk) to engage more individuals who use substances across the United States. OBJECTIVE: We identified the correlates of stimulant use among people who use alcohol or stimulants in the United States recruited using MTurk. METHODS: Participants who were aged ≥18 years in the United States and reported alcohol or stimulant (ie, cocaine, crack cocaine, and methamphetamine) use were deemed eligible and recruited via the web platform MTurk. Participants completed a baseline survey, which assessed sociodemographics, psychosocial (ie, depression, affect, self-esteem, and stress) factors, substance use, and sexual behaviors. Data were collected and analyzed with STATA (version 17; StataCorp). Stratifying by MSM status, bivariate and multivariable logistic regression models were built in STATA to examine the correlates of stimulant use. Multivariable models controlled for age, race, health insurance, and relationship status. RESULTS: Of 272 participants, 201 (73.9%) identified as male, 134 (49.2%) were MSM, 52 (19.1%) were from racial and ethnic minoritized communities, and 158 (58%) were in a relationship. The mean age was 36.10 (SD 10.3) years. A total of 40 (14.7%) participants reported stimulant use in the past 6 months. Factors significantly associated with stimulant use were being MSM (adjusted odds ratio [aOR] 4.61, 95% CI 1.97-10.81), a higher Alcohol Use Disorders Identification Test-Concise score (aOR 1.24, 95% CI 1.08-1.42), more intense cravings for alcohol in the past 24 hours (aOR 1.03, 95% CI 1.01-1.04), a higher depression score (aOR 1.06, 95% CI 1.01-1.12), a greater number of male partners in the last 6 months (aOR 1.32, 95% CI 1.08-1.61), a greater number of female partners in the last 6 months (aOR 1.42, 95% CI 1.04-1.92), and being diagnosed with a sexually transmitted infection (eg, syphilis, gonorrhea, chlamydia, herpes simplex virus, human papillomavirus, and other) in the last 6 months (aOR 14.61, 95% CI 3.45-61.87). Additionally, there was a significant additive interaction between MSM status and negative affect, such that the impact of negative affect on stimulant use was significantly greater among MSM compared with non-MSM (relative excess risk due to interaction 0.085, 95% CI 0.037-0.13). CONCLUSIONS: Interventions that address stimulant use should use evidence-based approaches that reduce negative affect, depression, and cravings for alcohol. Additionally, interventions should be customized for MSM populations.

Targeted Oral Naltrexone for Mild to Moderate Alcohol Use Disorder Among Sexual and Gender Minority Men: A Randomized Trial.

OBJECTIVE: The authors sought to determine the efficacy of targeted naltrexone in sexual and gender minority men (SGM) who binge drink and have mild to moderate alcohol use disorder. METHODS: In a double-blind placebo-controlled trial, a total of 120 SGM who binge drink and have mild to moderate alcohol use disorder were randomized in a 1:1 ratio to receive targeted oral naltrexone (50 mg) or placebo with weekly counseling for 12 weeks. The study's primary endpoints were binge-drinking intensity, defined as 1) number of drinks in the past 30 days; 2) any binge drinking in the past week; 3) number of binge-drinking days in the past week; and 4) number of drinking days in the past week. The study also measured changes in alcohol use with two alcohol biomarker measures: ethyl glucuronide in urine samples and phosphatidylethanol (PEth) in dried blood spot samples. RESULTS: Ninety-three percent completed the trial, with 85% of weekly follow-up visits completed. In intention-to-treat analyses, naltrexone was associated with a significantly reduced reported number of binge-drinking days (incidence rate ratio [IRR]=0.74, 95% CI=0.56, 0.98; number needed to treat [NNT]=2), weeks with any binge drinking (IRR=0.83, 95% CI=0.72, 0.96; NNT=7.4), number of drinks per month (IRR=0.69, 95% CI=0.52, 0.91; NNT=5.7 for 10 drinks), and alcohol craving scores (coefficient=-9.25, 95% CI=-17.20, -1.31). In as-treated analyses among those who took their medication on average at least 2.5 days per week (the median frequency in the study), naltrexone reduced any binge drinking (IRR=0.84, 95% CI=0.71, 0.99), number of binge-drinking days (IRR=0.67, 95% CI=0.47, 0.96), and PEth concentrations (coefficient=-55.47, 95% CI=-110.75, -0.20). At 6 months posttreatment, naltrexone had sustained effects in number of drinks per month (IRR=0.69, 95% CI=0.50, 0.97), number of binge-drinking days (IRR=0.67, 95% CI=0.47, 0.95), and any binge drinking in the past week (IRR=0.79, 95% CI=0.63, 0.99). CONCLUSIONS: Targeted naltrexone significantly reduced drinking outcomes among SGM with mild to moderate alcohol use disorder during treatment, with sustained effects at 6 months posttreatment. Naltrexone may be an important pharmacotherapy to address binge drinking in populations with mild to moderate alcohol use disorder.

Correlates of high phosphatidylethanol (PEth) levels and their concordance with self-reported heavy alcohol consumption among men who have sex with men who binge drink alcohol.

BACKGROUND: Heavy alcohol use, including binge drinking, is associated with high morbidity and mortality among men who have sex with men (MSM). Self-reported alcohol measures may lead to inaccurate estimates due to recall and social desirability biases. Objective alcohol biomarkers like phosphatidylethanol (PEth) can be used to corroborate self-report and could help to inform treatment approaches and research strategies for alcohol using MSM. METHODS: From 2015 to 2020, alcohol using MSM ≥18 years were enrolled in a randomized controlled trial evaluating the efficacy of naltrexone in reducing binge drinking. Using this trial's baseline data, we applied multivariable logistic regression to identify the correlates of high PEth levels (i.e., ≥87 ng/ml) and concordance between PEth levels and self-reported heavy drinking. RESULTS: Of 118 MSM, 64% had PEth levels ≥87 ng/ml and 72% had PEth levels that were concordant with self-reported heavy alcohol use. Factors significantly associated in separate models with elevated PEth levels were income ≥$60,000 (adjusted odds ratio [aOR] = 4.09; 95% CI = 1.13 to 14.82), being employed (aOR = 4.04; 95% CI = 1.45 to 11.32), episodic cannabis use (aOR = 4.63; 95% CI = 1.27 to 16.92), and any alcohol/substance use prior to or during anal intercourse (aOR = 2.52; 95% CI = 1.08 to 5.90). Living with HIV was associated with significantly lower odds of elevated PEth levels (aOR = 0.23; 95% CI = 0.09 to 0.61). Factors associated with significantly higher concordance between PEth levels and self-reported heavy alcohol use included at least weekly use of poppers (aOR = 6.41; 95% CI = 1.27 to 32.28) and polysubstance use (aOR = 2.53; 95% CI = 1.02 to 6.27). Living with HIV was associated with lower odds of concordance (aOR = 0.36; 95% CI = 0.14 to 0.97). CONCLUSIONS: PEth may enhance the detection of heavy drinking among MSM, including the identification of subpopulations that may benefit from targeted alcohol reduction interventions. However, PEth values for MSM living with HIV showed modest concordance with self-reported alcohol use and may need to be supplemented with additional biomarkers or evaluated against a different cutoff.

Pilot study of extended-release lorcaserin for cocaine use disorder among men who have sex with men: A double-blind, placebo-controlled randomized trial.

OBJECTIVE: To determine if men who have sex with men (MSM) with cocaine use disorder (CUD) and actively-using cocaine could be enrolled and retained in a pharmacologic intervention trial of lorcaserin-a novel 5-HT2cR agonist-and determine the degree to which participants would adhere to study procedures. METHODS: This was a phase II randomized, double-blind, placebo-controlled pilot study with 2:1 random parallel group assignment to daily extended-release oral lorcaserin 20 mg versus placebo (clinicaltrials.gov identifier-NCT03192995). Twenty-two of a planned 45 cisgender MSM with CUD were enrolled and had weekly follow-up visits during a 12-week treatment period, with substance use counseling, urine specimen collection, and completion of audio-computer assisted self-interview (ACASI) behavioral risk assessments. Adherence was measured by medication event monitoring systems (MEMS) caps and self-report. This study was terminated early because of an FDA safety alert for lorcaserin's long-term use. RESULTS: Eighty-six percent completed the trial, with 82% of weekly study follow-up visits completed. Adherence was 55.3% (lorcaserin 51.6% vs. placebo 66.2%) by MEMS cap and 56.9% (56.5% vs. placebo 57.9%) by self-report and did not differ significantly by treatment assignment. Intention-to-treat analyses (ITT) did not show differences in cocaine positivity by urine screen between the lorcaserin and placebo groups by 12 week follow-up (incidence risk ratio [IRR]: 0.96; 95%CI = 0.24-3.82, P = 0.95). However, self-reported cocaine use in timeline follow-back declined more significantly in the lorcaserin group compared to placebo (IRR: 0.66; 95%CI = 0.49-0.88; P = 0.004). CONCLUSION: We found that it is feasible, acceptable, and tolerable to conduct a placebo-controlled pharmacologic trial for MSM with CUD who are actively using cocaine. Lorcaserin was not associated with significant reductions in cocaine use by urine testing, but was associated with significant reductions in self-reported cocaine use. Future research may be needed to continue to explore the potential utility of 5-HT2cR agonists.

Social and Behavioral Correlates of Sexually Transmitted Infections among Men who Have Sex with Men who Use Alcohol in the San Francisco Bay Area.

The risk of acquiring sexually transmitted infections (STIs) among men who have sex with men (MSM) is driven by various socio-behavioral factors. From 2015-2017, 247 MSM ≥ 18 years-old who reported alcohol use in the past year, were recruited into a cross-sectional study in San Francisco. Participants completed a survey assessing socio-demographics, substance use and treatment, sexual behaviors, HIV status and self-reported STI diagnosis in the past 6 months. Multivariable logistic regression models stratified by HIV status were used to identify the correlates of STIs. Of 247 MSM, the prevalence of bacterial STIs were: gonorrhea (12.9%), chlamydia (9.3%) and syphilis (6.0%). Among 177 MSM living without HIV, factors significantly associated with recent STI diagnosis were: current pre-exposure prophylaxis (PrEP) use (aOR = 3.53, 95% CI: 1.42-8.75, p ≤ .01), popper use during sex in the past 6 months (aOR = 3.16, 95% CI = 1.34-7.47, p ≤ .01) and a history of alcohol treatment (aOR = 0.17, 95% CI = 0.04-0.68, p = .01). Also, in a sensitivity analysis (removing PrEP), any receptive condomless anal sex was independently associated with recent STI diagnosis (aOR = 2.86, 95% CI = 1.15-7.08, p = .02). Among 70 MSM living with HIV, factors significantly associated with recent STI diagnosis were: White race/ethnicity (adjusted odds ratio [aOR] = 7.36, 95% confidence interval [CI] = 1.48-36.62, p = .01), younger age (aOR = 0.90, 95% CI: 0.84-0.97, p < .01) and a higher number of male sexual partners in the past 6 months (aOR = 1.03, 95% CI = 1.00-1.06, p = .02). Sexual health interventions that address the unique needs of MSM living with and without HIV who use alcohol in San Francisco are needed to reduce STI acquisition and transmission.

Accuracy of the tuberculosis point-of-care Alere determine lipoarabinomannan antigen diagnostic test using α-mannosidase treated and untreated urine in a cohort of people living with HIV in Guatemala.

BACKGROUND: Improved point-of-care diagnostic tests for tuberculosis (TB) in severe immune suppressed people living with HIV (PLWH) are needed to decrease morbidity and mortality outcomes. The aim of the study is to evaluate the performance of the lipoarabinomannan antigen test (LAM-test) with and without α-mannosidase pre-treated urine in a cohort of PLWH in primary care clinics in Guatemala. We further determined TB incidence, and mortality rates and its risk factors in PLWH with TB symptoms. METHODS: Prospective longitudinal study of PLWH with TB symptoms. Urine samples were collected at 2 HIV sites to test the sensitivity of the LAM-test in urine with and without α-mannosidase pre-treatment. A composite reference standard of either a positive Mycobacterium tuberculosis complex culture and/or GeneXpert® MTB/RIF (Xpert, Cepheid, Sunnyvale, CA, USA) results was used in the LAM-test diagnostic accuracy studies. Cox proportional hazards regression was used to study mortality predictors. RESULTS: The overall sensitivity of the LAM-test was of 56.1% with 95% CI of (43.3-68.3). There were no differences in the LAM-test sensitivity neither by hospital nor by CD4 T cell values. LAM-test sensitivity in PLWH with < 200 CD4 T cells/µl was of 62.2% (95% CI 46.5-76.2). There were no significant differences in sensitivity when comparing LAM-test results obtained from untreated vs. α-mannosidase treated urine [55.2% (95% CI 42.6-67.4) vs. 56.9% (95% CI 44-69.2), respectively]. TB incidence in our cohort was of 21.4/100 person years (PYs) (95% CI 16.6-27.6), and mortality rate was of 11.1/100 PYs (95% CI 8.2-15.0). Importantly, PLWH with a positive LAM-test result had an adjusted hazard ratio (aHR) of death of 1.98 (1.0-3.8) with a significant p value of 0.044 when compared to PLWH with a negative LAM-test result. CONCLUSIONS: In this study, α-mannosidase treatment of urine did not significantly increase the LAM-test performance, however; this needs to be further evaluated in a large-scale study due to our study limitations. Importantly, high rates of TB incidence and mortality were found, and a positive LAM-test result predicted mortality in PLWH with TB clinical symptoms.

Improved Alere Determine Lipoarabinomannan Antigen Detection Test for the Diagnosis of Human and Bovine Tuberculosis by Manipulating Urine and Milk.

Tuberculosis (TB) disease still kills 1-person every 21-seconds. Few TB diagnostic tests are considered truly appropriate for point of care settings. The WHO-endorsed immunodiagnostic Alere Determine Lipoarabinomannan Ag-test (LAM-test) detects Mycobacterium tuberculosis complex LAM in urine, and its use is recommended for TB diagnosis among HIV co-infected individuals with low CD4 T-cell counts. Here we found that a simple 15-minute enzymatic treatment at room temperature of LAM-spiked urine with α-mannosidase (for human TB), and LAM-spiked milk with combined lactase and caseinase (for bovine TB), enhanced 10-fold the detection levels of the LAM-test and thus, improved the detection of LAM by the LAM-test in urine and milk that otherwise could be missed in the field. Future separate clinical research studies specifically designed to address the potential of these findings are required.

Risk Behaviors and Perceptions Among Self-identified Men Who Have Sex with Men (MSM), Bisexuals, Transvestites, and Transgender Women in Western Guatemala.

Guatemala has a concentrated HIV epidemic disproportionately affecting men who have sex with men (MSM) and transgender women. We recruited 205 self-identified MSM, bisexuals, transvestites, and transgender women in western Guatemala using long-chain peer referral, wherein "seed" participants were asked to invite as many as three acquaintances to participate in the study. Self-reported sexual or gender identity was MSM, 46%; bisexual, 28%; transvestite, 21%, and transgender woman, 5%. Median age of the participants was 23 years, and 36% self-identified as being indigenous. Indigenous persons were more likely to self-identity as transvestite (32.9% vs 13.8%, P = 0.04), strongly perceive themselves at risk for HIV (87.7% vs 51.5%, P = 0.001), have had an HIV test in the last 12 months and know the result (97.3% vs 85.4%, P = 0.008), and experience barriers to testing and treatment (86.3% vs 67.7%, P = 0.004). HIV prevention services for indigenous MSM should especially target transvestites and how to overcome stigmatization and barriers to care.

Impact of integrating HIV and TB care and treatment in a regional tuberculosis hospital in rural Guatemala.

Resource-limited settings have made slow progress in integrating TB and HIV care for co-infected patients. We examined the impact of integrated TB/HIV care on clinical and survival outcomes in rural western Guatemala. Prospective data from 254 newly diagnosed TB/HIV patients (99 enrolled in the pre-integrated program from August 2005 to July 2006, and 155 enrolled in the integrated program from February 2008 to January 2009) showed no significant baseline differences between clients in the two periods. They were principally male (65.5 %), Mayan (71 %), median age 33 years, and CD4 count averaged 111 cells/mm³. TB/HIV co-infected patients were more likely to receive antiretroviral therapy in the integrated program than in the pre-integrated program (72 vs. 22 %, respectively) and had lower mortality (HR 0.22, 95 % CI 0.14­0.33). This study shows how using a TB setting as the entry point for integrated TB/HIV care can improve health outcomes for HIV-positive patients in rural Guatemala.

Risk of sexually transmitted infections among Mayan women in rural Guatemala whose partners are migrant workers.

HIV and sexually transmitted infection (STI) are of concern in Mayan districts of Guatemala in which labor migration is common. This study assessed whether the migration status of men is associated with reported STI symptoms among their female primary partners. In a multivariate analysis of survey data taken from a larger Mayan sexual health study, the odds of reporting STI symptoms were twofold higher among women who reported that their partner migrated (OR 2.08, 95 % CI, 1.16-3.71), compared to women whose partners did not. Women from the Mam and Kaqchikel ethnolinguistic groups reported higher rates of STI symptoms after adjustment for their partners' migration status.