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We hypothesized that MA use among sexual minority drug users would be associated with differing exposure to individual, social, and structural HIV vulnerabilities. In an effort to build on previous studies [ 16 , 23 , 24 ], we sought not only to examine individual-level HIV risk behaviour but also contextual factors including homelessness, neighbourhood of residence, the consumption of drugs in public, and the regulation of these spaces by law enforcement personnel. We also considered the relationship between MA use and physical violence and depression, which have been identified as independent risk factors for HIV infection [ 9 , 25 ].
Finally, we hypothesized that the relationship between MA use and these factors would differ significantly between sexual minority males and females. The primary outcome of interest was ascertained by examining responses to the questions, "In the last six months, did you use non-injection crystal methamphetamine? We also determined the proportion of participants reporting daily or greater use of injection or non-injection MA use in the past 6 months, respectively.
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All variables examined in this study, including the outcomes and independent variables of interest, were assessed consistently and equivalently across all three studies. Based on prior literature examining MA use among marginalised populations [ 12 , 26 — 29 ], we assessed as explanatory variables a broad set of sociodemographic characteristics, drug use variables, sexual activities, markers of violence and depression, and contextual factors.
These variables were also chosen to represent both "micro"- i. All other variables unless otherwise indicated referred to behaviours or activities in the past 6 months since the date of the interview. Drug use variables assessed included other stimulant use i. As defined previously [ 30 ], the latter was operationalised as the self-reported use of drugs more often than usual. We ascertained involvement in i. Finally, contextual factors examined included: residency in the Downtown South DTS , an area known as a mixed business and entertainment district that is also inhabited by a large street youth population [ 32 ]; homelessness yes versus no ; having a warrant or area restriction i.
Warrants and area restrictions are legal orders to restrict access to certain areas of the city, and are commonly issued by law enforcement personnel in an attempt to disrupt crime and reduce street level disorder [ 33 ]. As a preliminary analysis, we compared the baseline sociodemographic characteristics and MA use patterns between heterosexual and sexual minority participants, stratified by biological sex at birth. The Pearson chi-square test was used to compare categorical variables and the Wilcoxon rank sum test was used for continuous variables.
We then identified the longitudinal correlates of MA use by using generalized estimating equations GEE with a logit link for binary outcomes.
GEE were appropriate for this analysis since the factors associated with recent MA use over the baseline and four follow-up periods were serial i. GEE account for the correlation between repeated measures for each subject; thus, valid estimates of association and standard errors are obtained [ 34 ]. Since GEE models incorporate periods during which participants report engaging and not engaging in the outcome, data from all baseline and follow-up interviews were used in this analysis. Since a primary objective of this study was to determine whether the correlates of MA use differed between males and females, we stratified the analyses by biological sex at birth and constructed two multivariate models.
We applied a modified backward stepwise procedure to select covariates based on two criteria: the Akaike information criterion AIC and type-III p -values [ 35 ]. Lower AIC values indicate a better overall fit and lower p -values indicate higher variable significance. To compensate for potential variations in recruitment and selection procedures between studies, we also adjusted each model for cohort of enrolment. At each step, the p -values of each variable and the overall AIC were recorded, with the final model having the lowest AIC.
Statistical analysis was conducted using SAS version 9. A total of 14 0. Of the eligible participants, Among all participants, the median age at baseline was Among those who reported their biological sex at birth as female, Sociodemographic characteristics and methamphetamine use patterns for males and females stratified by sexual orientation are displayed in Table 1. In contrast, sexual minority females were less likely to be of Aboriginal ancestry Among both males and females, sexual minority participants were significantly more likely to report injection and non-injection MA use in the past 6 months Table 1.
Notably, over half In Table 2 , we report the results of the longitudinal analysis examining the factors associated with MA use among sexual minority males. Several associations that were observed among MA-using males were also significant among females.
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In a multivariate analysis, several unique correlates of MA use emerged among sexual minority females. In the current study, we observed a high prevalence of MA use among sexual minority males and females in comparison to heterosexual participants. We also found that, consistent with the risk environment framework, MA use was associated with an array of individual, social, and contextual HIV-related risks and vulnerabilities among sexual minority drug users.
Although some correlates of MA use e. For example, unprotected intercourse involving regular or casual partners was more common among males who reported using methamphetamine, while unprotected intercourse in the context of sex work was associated with MA use among females. Furthermore, only MA-using males were more likely to experience depressive symptoms and report having area restrictions i. These findings may be due to the fact that sexual minority males reported heavier MA use patterns compared to females, and thus may be more likely to experience individual i.
Finally, Aboriginal ancestry was positively associated with MA use among males but inversely associated with MA use among females. Consistent with other studies [ 7 , 8 , 36 ], MA use was linked with unprotected intercourse among sexual minority men. Although we were unable to ascertain the context in which instances of unprotected intercourse occurred, we point to other research indicating that homeless sexual minority males frequently experience sexual victimization and abuse from partners [ 37 ].
Although more research is required to fully elucidate casual mechanisms, we hypothesize that the relationship between sexual risk and MA use observed among this sample of street-involved sexual minority men is less a function of desire to enhance sex but is in fact a marker of increased vulnerability within sexual relationships. A similar pathway may also explain the marginal association between MA use and experiencing physical violence observed among males in this study.
In multivariate analysis, among the subsample of females engaging in sex work, MA use was associated with unprotected intercourse with clients. This finding can be situated within a growing literature demonstrating how social and structural inequities hinder the individual agency of drug-using survival sex workers to practice HIV prevention and harm reduction with clients [ 38 ]. These areas have been shown in previous research to be settings of increased risk of violence and pressure from clients to engage in unprotected sex [ 40 ]. Our results support this work and indicate that MA use may augment the adverse impact of social-structural factors in the production of HIV risk among sexual minority women involved in survival sex work.
The strongest correlate of MA use among sexual minority men was reporting that a warrant or area restriction impacted access to services or influenced where drugs are consumed or purchased. The socio-legal regulation of public space and its negative impact on the health of homeless people and street-level drug users has been described previously [ 41 ]. Recent work also suggests that the displacement of street-involved young people using warrants or area restrictions exacerbates stigma and increases sexual vulnerability and HIV risk [ 42 ].
Our findings suggest that having one's movements restricted may also encourage transitions in drug use including initiation of MA use , due perhaps to the forced removal of drug users from normative environments and social networks. It is also possible that MA users are at an increased risk of incarceration and other interactions with the legal system, and are thus more likely to be affected by punitive policies such as warrants and area restrictions.
This form of marginalisation produced by policies and practices meant to reduce exposure to street-level drug use and violence is one example of a population-level intervention that may exacerbate inequity and worsen the health of vulnerable groups [ 43 ]. These findings also support the urgent need for increased resources and programming directed towards LGBT people who use methamphetamine. Once clearly identified, these factors can then be the target of broad sets of evidence-based interventions to reduce health inequities and improve overall health.
For example, changes in government policy along with community mobilization and solidarity programs have been shown to be highly successful at reducing HIV risk among survival sex workers [ 44 ].
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Programs that support capacity-building in marginalised communities have also been shown to reduce health inequity and improve health outcomes [ 45 ]. Although further research is required to elucidate the potential impact of specific enforcement practices e. Finally, additional research is required to identify specific programmatic needs of subpopulations within sexual minority communities, including for example transgendered youth.
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To complement structural interventions, some behavioural approaches e. For example, LGBT-specific substance abuse treatment programs have been found to reduce engagement in high-risk sex among drug-using gay men [ 48 ]. Harm reduction programs, particularly those offering tailored services for MA users, are effective and well received by clients [ 49 ]. Finally, given the associations between Aboriginal ancestry, sexual orientation, and MA use observed in this study, methamphetamine-specific programming should carefully identify the manner in which cultural and sexual identities shape drug use and HIV risk within specific contexts and settings.
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This study has a number of limitations that should be noted. The small sample sizes may have resulted in insufficient power to detect true associations, particularly after adjustment for confounding. Furthermore, data from three studies with different inclusion criteria were combined and analysed, which may have resulted in cohort or selection effects. To mitigate the potential impact of these biases, all sampling and data collection procedures were harmonized, and all multivariate models were adjusted for cohort of recruitment.
We note that all behaviours ascertained in this study were self-reported, and we were unable to confirm MA use with urine samples or other measures. We also recognize that our primary analysis was restricted to individuals who self-identified as a sexual minority; therefore, heterosexual-identified individuals who engaged in same-sex activity were excluded. We chose not to rely on behavioural eligibility criteria e. We were unable to ascertain motivations for MA use, which if examined may have accounted some of the observed differences in the characteristics and consequences of MA use between male and female participants in this study.
Finally, although our data are longitudinal, we do not wish to imply that this analysis provides thorough insight into the causal pathways linking MA use and HIV risk with broader social and structural inequities. We have demonstrated in a longitudinal data set a high prevalence of MA use among a cohort of street-involved sexual minority drug users. To our knowledge, this is the first study to extend the risk environment approach as a theoretical foundation from which to understand the contexts of risk associated with MA use among LGBT populations.