AIDS and Behavior

, Volume 16, Issue 6, pp 1394–1410 | Cite as

A Review of the Literature on Event-Level Substance Use and Sexual Risk Behavior Among Men Who Have Sex with Men

  • H. Waverly VosburghEmail author
  • Gordon Mansergh
  • Patrick S. Sullivan
  • David W. Purcell
Substantive Review


In the United States, there continues to be high incidence of HIV infection among men who have sex with men (MSM), who represent 57% of new infections in 2009. While many studies report associations between non-injection substance use and sexual risk behavior among MSM, overall results are mixed. Summarizing these studies is difficult because researchers have used a variety of assessment periods for substance use and sexual behavior. We review the scientific literature on event-level measures, which assess substance use and sexual risk behavior immediately before or during a sexual encounter and provide the most precise link between these two behaviors. From January 2009 through March 2010, we searched four databases: Ovid (MEDLINE and PsycINFO), Web of Knowledge, and Sociofile. Across studies, results varied by substance with little within substance consistency or a lack of research except for two notable exceptions: methamphetamine and binge alcohol use. The findings underscore the importance of providing HIV risk-reduction interventions for substance-using MSM.


MSM Substance Sexual risk HIV 


En los Estados Unidos, incidencia alta de la infección por VIH entre los hombres que tienen sexo con hombres (HSH) sigue, y HSH representaron 57% de las infecciones nuevas en 2009. Estudios múltiples han demostrado que asociaciones existe entre el uso de drogas no inyectables y el comportamiento sexual riesgoso entre HSH. Estudios del uso de drogas y del comportamiento sexual han usado tres tipos de evaluacíon (global, circunstancial y nivel del acontecimiento) y han proporcionado resultados variados. Las medidas al nivel del acontecimiento sexual determinan uso de sustancias y comportamiento sexual riesgoso de inmediato antes de o durante el encuentro sexual. Se revsamos la literatura científica acerca de la conexión más precisa entre el uso de drogas y el comportamiento sexual riesgoso, lo cual es evaluacíon al nivel del acontecimiento. Desde enero de 2009 hasta marzo de 2010, buscamos en cuatro bases de datos repetidamente: Ovid (MEDLINE y PsycINFO), Web of Knowledge, y Sociofile. Resumimos la investigación cuantitativa acerca de nivel del acontecimiento, discutimos la consistencia de la evidencia, y recomendamos las direcciones para las investigaciónes futuras. Los resultados subrayan la importancia de proporcionar las intervenciones para la reducción del riesgo por el VIH para HSH que usan drogas.



The authors thank Grant Colfax, Nicole Crepaz, Julia Deluca, Marie Morgan, Mary Neumann, and Thomas Painter for their input in this project, and greatly appreciate the scientific contributions of the authors and the men who participated in the studies cited in this review.


  1. 1.
    Centers for Disease Control and Prevention. HIV Surveillance Report, 2009. vol. 21, p. 17. Published February 2011. Accessed May 24, 2011.
  2. 2.
    Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008;300(5):520–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Hamers FF, Downs AM. The changing face of the HIV epidemic in Western Europe: what are the implications for public health policies? Lancet. 2004;364(9428):83–94.PubMedCrossRefGoogle Scholar
  4. 4.
    Wand H, Wilson D, Yan P, et al. Characterizing trends in HIV infection among men who have sex with men in Australia by birth cohorts: results from a modified back-projection method. J Int AIDS Soc. 2009;12(1):19.PubMedCrossRefGoogle Scholar
  5. 5.
    Grulich AE, Kaldor JM. Trends in HIV incidence in homosexual men in developed countries. Sex Health. 2008;5(2):113–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Sullivan PS, Hamouda O, Delpech V, et al. Reemergence of the HIV epidemic among men who have sex with men in North America, Western Europe, and Australia, 1996–2005. Ann Epidemiol. 2009;19(6):423–31.PubMedCrossRefGoogle Scholar
  7. 7.
    Stall R, Duran L, Wisniewski SR, et al. Running in place: implications of HIV incidence estimates among urban men who have sex with men in the United States and other industrialized countries. AIDS Behav. 2009;13(4):615–29.PubMedCrossRefGoogle Scholar
  8. 8.
    Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 2001;96(11):1589–601.PubMedCrossRefGoogle Scholar
  9. 9.
    Cochran SD, Ackerman D, Mays VM, Ross MW. Prevalence of non-medical drug use and dependence among homosexually active men and women in the US population. Addiction. 2004;99(8):989–98.PubMedCrossRefGoogle Scholar
  10. 10.
    Mansergh G, Flores S, Koblin B, Hudson S, McKirnan D, Colfax GN. Alcohol and drug use in the context of anal sex and other factors associated with sexually transmitted infections: results from a multi-city study of high-risk men who have sex with men in the USA. Sex Transm Infect. 2008;84(6):509–11.PubMedCrossRefGoogle Scholar
  11. 11.
    Van Tieu H, Koblin BA. HIV, alcohol, and noninjection drug use. Curr Opin HIV AIDS. 2009;4(4):314–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Hirshfield S, Remien RH, Humberstone M, Walavalkar I, Chiasson MA. Substance use and high-risk sex among men who have sex with men: a national online study in the USA. AIDS Care. 2004;16(8):1036–47.PubMedCrossRefGoogle Scholar
  13. 13.
    Leigh BC, Stall R. Substance use and risky sexual behavior for exposure to HIV: issues in methodology, interpretation, and prevention. Am Psychol. 1993;48(10):1035–45.PubMedCrossRefGoogle Scholar
  14. 14.
    Ostrow DG. Substance-abuse and HIV-infection. Psychiatr Clin North Am. 1994;17(1):69–89.PubMedGoogle Scholar
  15. 15.
    Stall R, Purcell DW. Intertwining epidemics: a review of research on substance use among men who have sex with men and its connection to the AIDS epidemic. AIDS Behav. 2000;4(2):181–92.CrossRefGoogle Scholar
  16. 16.
    Celentano DD, Latimore AD, Mehta SH. Variations in sexual risks in drug users: emerging themes in a behavioral context. Curr HIV/AIDS Rep. 2008;5(4):212–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Woolf SE, Maisto SA. Alcohol use and risk of HIV infection among men who have sex with men. AIDS Behav. 2009;13(4):757–82.PubMedCrossRefGoogle Scholar
  18. 18.
    Shuper PA, Joharchi N, Irving H. Alcohol as a correlate of unprotected sexual behavior among people living with HIV/AIDS review and meta-analysis [published online ahead of print July 18, 2009]. AIDS Behav. 2009;13(6):1021–36.PubMedCrossRefGoogle Scholar
  19. 19.
    Shoptaw S, Reback CJ. Methamphetamine use and infectious disease-related behaviors in men who have sex with men: implications for interventions. Addiction. 2007;102(Suppl 1):130–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Halkitis PN, Parsons JT, Stirratt MJ. A double epidemic: crystal methamphetamine drug use in relation to HIV transmission among gay men. J Homosex. 2001;41(2):17–35.PubMedCrossRefGoogle Scholar
  21. 21.
    Romanelli F, Smith KM. Recreational use of sildenafil by HIV-positive and -negative homosexual/bisexual males. Ann Pharmacother. 2004;38(6):1024–30.PubMedCrossRefGoogle Scholar
  22. 22.
    Swearingen SG, Klausner JD. Sildenafil use, sexual risk behavior, and risk for sexually transmitted diseases, including HIV infection. Am J Med. 2005;118(6):571–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Drumright LN, Patterson TL, Strathdee SA. Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review. Subst Use Misuse. 2006;41(10–12):1551–601.PubMedCrossRefGoogle Scholar
  24. 24.
    Heath J, Lanoye A, Maisto SA. The role of alcohol and substance use in risky sexual behavior among older men who have sex with men: a review and critique of the current literature. AIDS Behav. Online first: Mar 10 2011. doi:  10.1007/s10461-011-9921-2.
  25. 25.
    Prestage G, Van de Ven P, Mao L, Grulich A, Kippax S, Kaldor J. Contexts for last occasions of unprotected anal intercourse among HIV-negative gay men in Sydney: the Health in Men cohort. AIDS Care. 2005;17(1):23–32.PubMedCrossRefGoogle Scholar
  26. 26.
    Benotsch EG, Mikytuck JJ, Ragsdale K, Pinkerton SD. Sexual risk and HIV acquisition among men who have sex with men travelers to Key West, Florida: a mathematical modeling analysis. AIDS Patient Care STDS. 2006;20(8):549–56.PubMedCrossRefGoogle Scholar
  27. 27.
    Drumright LN, Little SJ, Strathdee SA, et al. Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection. J Acquir Immune Defic Syndr. 2006;43(3):344–50.PubMedCrossRefGoogle Scholar
  28. 28.
    Holtgrave DR, Crosby R, Shouse RL. Correlates of unprotected anal sex with casual partners: a study of gay men living in the southern United States. AIDS Behav. 2006;10(5):575–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Mansergh G, Shouse RL, Marks G, et al. Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men. Sex Transm Infect. 2006;82(2):131–4.PubMedCrossRefGoogle Scholar
  30. 30.
    Benotsch EG, Nettles CD, Wong F, et al. Sexual risk behavior in men attending Mardi gras celebrations in New Orleans Louisiana. J Community Health. 2007;32(5):343–56.PubMedCrossRefGoogle Scholar
  31. 31.
    Chiasson MA, Hirshfield S, Remien RH, Humberstone M, Wong T, Wolitski RJ. A comparison of on-line and off-line sexual risk in men who have sex with men: an event-based on-line survey. J Acquir Immune Defic Syndr. 2007;44(2):235–43.PubMedCrossRefGoogle Scholar
  32. 32.
    Koblin BA, Murrill C, Camacho M, et al. Amphetamine use and sexual risk among men who have sex with men: results from the National HIV Behavioral Surveillance study—New York City. Subst Use Misuse. 2007;42(10):1613–28.PubMedCrossRefGoogle Scholar
  33. 33.
    Prestage G, Fogarty AS, Rawstorne P, et al. Use of illicit drugs among gay men living with HIV in Sydney. AIDS. 2007;21(Suppl 1):S49–55.PubMedCrossRefGoogle Scholar
  34. 34.
    Read TRH, Hocking J, Sinnott V, Hellard M. Risk factors for incident HIV infection in men having sex with men: a case-control study. Sex Health. 2007;4(1):35–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Mustanski B. Moderating effects of age on the alcohol and sexual risk taking association: an online daily diary study of men who have sex with men. AIDS Behav. 2008;12(1):118–26.PubMedCrossRefGoogle Scholar
  36. 36.
    Wilson PA, Cook S, McGaskey J, Rowe M, Dennis N. Situational predictors of sexual risk episodes among men with HIV who have sex with men. Sex Transm Infect. 2008;84(6):506–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Wilson PA, Diaz RM, Yoshikawa H, Shrout PE. Drug use, interpersonal attraction, and communication: situational factors as predictors of episodes of unprotected anal intercourse among Latino gay men. AIDS Behav. 2009;13(4):691–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Drumright LN, Gorbach PM, Little SJ, Strathdee SA. Associations between substance use, erectile dysfunction medication and recent HIV infection among men who have sex with men. AIDS Behav. 2009;13(2):328–36.PubMedCrossRefGoogle Scholar
  39. 39.
    Lambert G, Cox J, Hottes TS, et al. Correlates of unproteted anal sex at last sexual episode: analysis from a surveillance study of men who have sex with men in Montreal. AIDS Behav. 2011;15(3):584–95.PubMedCrossRefGoogle Scholar
  40. 40.
    Ober A, Shoptaw S, Wang PC, Gorbach P, Weiss RE. Factors associated with event-level stimulant use during sex in a sample of older, low-income men who have sex with men in Los Angeles. Drug Alcohol Depend. 2009;102:123–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Prestage G, Grierson J, Bradley J, Hurley M, Hudson J. The role of drugs during group sex among gay men in Australia. Sex Health. 2009;6(4):310–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Ibanez GE, Purcell DW, Stall R, Parsons JT, Gomez CA. Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who also inject drugs. AIDS. 2005;19(Suppl 1):S49–55.PubMedCrossRefGoogle Scholar
  43. 43.
    Gold RS, Skinner MJ. Situational factors and thought processes associated with unprotected intercourse in young gay men. AIDS. 1992;6(9):1021–30.PubMedCrossRefGoogle Scholar
  44. 44.
    Gold RS, Skinner MJ, Grant PJ, Plummer DC. Situational factors and thought processes associated with unprotected intercourse in gay men. Psychol Health. 1991;5:259–78.CrossRefGoogle Scholar
  45. 45.
    Gold RS, Skinner MJ, Ross MW. Unprotected anal intercourse in HIV-infected and non-HIV-infected gay men. J Sex Res. 1994;31(1):59–77.CrossRefGoogle Scholar
  46. 46.
    Crosby GM, Stall RD, Paul JP, Barrett DC, Midanik LT. Condom use among gay bisexual male substance abusers using the timeline follow-back method. Addict Behav. 1996;21(2):249–57.PubMedCrossRefGoogle Scholar
  47. 47.
    Seage GR 3rd, Mayer KH, Wold C, et al. The social context of drinking, drug use, and unsafe sex in the Boston Young Men Study. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17(4):368–75.PubMedCrossRefGoogle Scholar
  48. 48.
    Vanable PA, McKirnan DJ, Buchbinder SP, et al. Alcohol use and high-risk sexual behavior among men who have sex with men: the effects of consumption level and partner type. Health Psychol. 2004;23(5):525–32.PubMedCrossRefGoogle Scholar
  49. 49.
    Smith AM, Grierson J, Pitts M, Pattison P. Individual characteristics are less important than event characteristics in predicting protected and unprotected anal intercourse among homosexual and bisexual men in Melbourne Australia. Sex Transm Infect. 2006;82(6):474–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Clatts MC, Goldsamt LA, Yi H. Drug and sexual risk in four men who have sex with men populations: evidence for a sustained HIV epidemic in New York City. J Urban Health. 2005;82(1 Suppl 1):i9–17.PubMedCrossRefGoogle Scholar
  51. 51.
    Mansergh G, Colfax GN, Marks G, Rader M, Guzman R, Buchbinder S. The Circuit Party Men’s Health Survey: findings and implications for gay and bisexual men. Am J Public Health. 2001;91(6):953–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Colfax GN, Mansergh G, Guzman R, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison. J Acquir Immune Defic Syndr. 2001;28(4):373–9.PubMedGoogle Scholar
  53. 53.
    Gillmore MR, Morrison DM, Leigh BC, Hoppe MJ, Gaylord J, Rainey DT. Does “high = high risk”? An event-based analysis of the relationship between substance use and unprotected anal sex among gay and bisexual men. AIDS Behav. 2002;6(4):361–70.CrossRefGoogle Scholar
  54. 54.
    Stueve A, O’Donnell L, Duran R, San Doval A, Geier J. Being high and taking sexual risks: findings from a multisite survey of urban young men who have sex with men. AIDS Educ Prev. 2002;14(6):482–95.PubMedCrossRefGoogle Scholar
  55. 55.
    Colfax G, Vittinghoff E, Husnik MJ, et al. Substance use and sexual risk: a participant- and episode-level analysis among a cohort of men who have sex with men. Am J Epidemiol. 2004;159(10):1002–12.PubMedCrossRefGoogle Scholar
  56. 56.
    Clutterbuck DJ, Gorman D, McMillan A, Lewis R, Macintyre CC. Substance use and unsafe sex amongst homosexual men in Edinburgh. AIDS Care. 2001;13(4):527–35.PubMedCrossRefGoogle Scholar
  57. 57.
    Halkitis PN, Mukherjee PP, Palamar JJ. Longitudinal modeling of methamphetamine use and sexual risk behaviors in gay and bisexual men. AIDS Behav. 2008;13(4):783–91.PubMedCrossRefGoogle Scholar
  58. 58.
    Colfax G, Coates TJ, Husnik MJ, et al. Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. J Urban Health. 2005;82(1 Suppl 1):i62–70.PubMedCrossRefGoogle Scholar
  59. 59.
    Koblin BA, Husnik MJ, Colfax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS. 2006;20(5):731–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Stall R, Wiley J. A comparison of alcohol and drug-use patterns of homosexual and heterosexual men—the San Francisco Men’s Health Study. Drug Alcohol Depend. 1988;22(1–2):63–73.PubMedCrossRefGoogle Scholar
  61. 61.
    Cochran SD, Mays VM. Relation between psychiatric syndromes and behaviorally defined sexual orientation in a sample of the US population. Am J Epidemiol. 2000;151(5):516–23.PubMedCrossRefGoogle Scholar
  62. 62.
    Drabble L, Midanik LT, Trocki K. Reports of alcohol consumption and alcohol-related problems among homosexual, bisexual and heterosexual respondents: results from the 2000 National Alcohol Survey. J Stud Alcohol. 2005;66(1):111–20.PubMedGoogle Scholar
  63. 63.
    Wolitski RJ, Stall R, Valdiserri RO. Unequal opportunity: health disparities affecting gay and bisexual men in the United States. New York: Oxford University Press; 2008.Google Scholar
  64. 64.
    Greenwood GL, White EW, Page-Shafer K, et al. Correlates of heavy substance use among young gay and bisexual men: the San Francisco Young Men’s Health Study. Drug Alcohol Depend. 2001;61(2):105–12.PubMedCrossRefGoogle Scholar
  65. 65.
    Shoptaw S. Methamphetamine use in urban gay and bisexual populations. Top HIV Med. 2006;14(2):84–7.PubMedGoogle Scholar
  66. 66.
    Woody GE, VanEtten-Lee ML, McKirnan D, et al. Substance use among men who have sex with men: comparison with a national household survey. J Acquir Immune Defic Syndr. 2001;27(1):86–90.PubMedCrossRefGoogle Scholar
  67. 67.
    Semple SJ, Patterson TL, Grant I. Motivations associated with methamphetamine use among HIV plus men who have sex with men. J Subst Abuse Treat. 2002;22(3):149–56.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2012

Authors and Affiliations

  • H. Waverly Vosburgh
    • 1
    • 2
    Email author
  • Gordon Mansergh
    • 1
  • Patrick S. Sullivan
    • 2
  • David W. Purcell
    • 1
  1. 1.Division of HIV/AIDS Prevention, Mailstop E37Centers for Disease Control and PreventionAtlantaUSA
  2. 2.Rollins School of Public HealthEmory UniversityAtlantaUSA

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