1. 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) National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) Pacific Southwest Technology Transfer Center (SAMHSA) International Network of Treatment and Rehabilitation Resource Centres (UNODC)

2. Acknowledgements 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

3. Presentation Summary 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

4. Presentation Summary 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

5. HIV Prevalence in Adults in Sub-Saharan Africa

6. HIV prevalence (%) by gender and urban/rural residence, selected sub-Saharan African countries, 2001 ‒ 2005 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). 2.7

7. HIV in RSA 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

8. HIV in RSA 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.

10. 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

11. Methamphetamine The US Epidemic

12. Primary Amphetamine/Methamphetamine TEDS Admission Rates: 1992 (per 100,000 aged 12 and over) 35 - 58 12 - 35 < 12 No data > 58

13. < 12 Primary Amphetamine/Methamphetamine TEDS Admission Rates: 1997 (per 100,000 aged 12 and over) 35 - 58 12 - 35 < 12 No data > 58

14. Primary Amphetamine/Methamphetamine TEDS Admission Rates: 2003 (per 100,000 aged 12 and over) 127+ < 5 5 - 59 60-126 Incomplete Data

15. The Methamphetamine Epidemic: Admissions/100,000: 1992-2003 It keeps going up

16. 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).

17. Figure 2. Methamphetamine/Amphetamine Treatment Admissions, by Route of Administration: 1992-2002 Source: 2002 SAMHSA Treatment Episode Data Set (TEDS).

18. Methamphetamine South Africa

19. Methamphetamine use in Capetown 2005: Summary “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

20. Methamphetamine in RSA 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

21. Treatment Admission Data: Capetown, RSA 2002-2005 % of patients with methamphetamine as primary or secondary substance of abuse % of patients with methamphetamine as primary or secondary substance of abuse 2005a 2002a 2002b2003a2003b2004a2004b 2005a 2002a 2002b2003a2003b2004a2004b 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% Overall0.7%2.1% 4.7% 7.3% 19.0% 28.9%35.8% Total N 1608 1551 1724 1659 2255 2308 2468 Total N 1608 1551 1724 1659 2255 2308 2468

22. Methamphetamine user characteristics in Capetown, RSA 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

23. Why might an increase in methamphetamine-smoking in RSA represent a new potential vector in HIV- transmission?

24. Methamphetamine and Sexual Behavior

25. Drugs and sexual behavior 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.

26. Q.2: My sexual drive is increased by the use of … 18.1 20.5 43.9 70.6 55.3 11.1 85.3 55.6 0 10 20 30 40 50 60 70 80 90 100 Percent Responding "Yes" opiatesalcoholcocainemeth Primary Drug of Abuse male female

27. Q.4: My sexual performance is improved by the use of … 19.1 15.9 24.4 32.4 18.4 11.1 58.8 61.1 0 10 20 30 40 50 60 70 80 90 100 Percent Responding "Yes" opiatesalcoholcocainemeth Primary Drug of Abuse male female

28. Q.6: My sexual pleasure is enhanced by the use of …

29. Q.8: My use of … has made me become obsessed with sex &/or made my sex drive abnormally high.

30. Q.10: I am more likely to have sex (e.g. intercourse, oral sex, masturbation, etc.) when using …

31. Q.12: I am 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.

32. 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.

33. Recent MA use n = 58 Never used MA n = 817 No.(%)No.(%) Sexually active, past 6 mos5493.158372.2 Anal sex with a female, past 6 mo1629.66911.9 Casual or anonymous female partner3564.825944.4 No. of female partners 12138.936763.1 21833.38714.8 3 to 5916.710017.2 >5611.1284.8 Ever received money or drugs for sex915.5283.5 Results

34. Female Methamphetamine Users: Social Characteristics and Sexual Risk Behavior Semple SJ, Grant I, Patterson TL Women and Health Vol. 40(3), 2004

35. 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

36. Men-Who-Have-Sex-With-Men HIV and Methamphetamine Use

37. HIV Prevalence: MSM in the US “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

38. Methamphetamine use among MSM “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

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

40. Crystal Methamphetamine Use by Latino Men 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.

41. Drug Abuse Problem or Public Health Problem LA County - Heroin Injectors: Low Risk - Gay Male Meth Users: Extreme Risk LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)

42. Presentation Summary 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

43. Presentation Summary 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

44. Presentation Conclusion 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.