Methamphetamine Use and HIV Symptom Self-Management

Features

Methamphetamine Use and HIV Symptom Self-Management Linda Robinson, PhD Harvey Rempel, MEd

This study describes HIV-related symptoms in a methamphetamine-using sample of 20 men living in southern California. Data were obtained in 2004 and 2005 using a cross-sectional design. Participants were administered the Revised Sign and Symptom Check-List for Persons With HIV Disease and the Addiction Severity Index and were engaged in a semistructured interview. Participants reported using methamphetamine to treat HIV-related depression, fatigue, and neuropathic pain. HIV-related diarrhea seemed to diminish with methamphetamine use, although this was not a motivation for use. These results, although preliminary, suggest that further study of the interplay between methamphetamine use and HIV symptom management is warranted. Key words: methamphetamine, HIV symptom selfmanagement

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iving with HIV disease involves daily self-management strategies to cope with HIV-related symptoms. Chou, Holzemer, Portillo, and Slaughter (2004), in a content analysis of symptom self-management strategies, showed that substance use represented a symptom self-management strategy used by persons with HIV. It is difficult to estimate how often persons with HIV use illicit drugs as a symptom management strategy, but there is growing evidence that methamphetamine is used for this purpose. Reback (1997) reported that methamphetamine was used to cope with the fear and guilt over transmitting HIV to others, to cope with the stigma of homosexuality and HIV-positive status, and to reduce physical and emotional pain. Other investigators have

shown that methamphetamine has been used to treat HIV-related depression and fatigue (Gorman & Carroll, 2000; Semple, Patterson, & Grant, 2002). The purpose of this study was to examine methamphetamine use in relation to HIV-related symptoms and to explore whether methamphetamine was used to manage those symptoms. The conceptual framework guiding this study was the University of California San Francisco Model of Symptom Management (Dodd et al., 2001). Three interrelated dimensions make up the model: symptom experience, symptom management strategies, and symptom outcomes. The dimension symptom experience includes patients’ perception of a symptom, their response to the symptom, and their evaluation or meaning attached to the symptom. The dimension symptom management strategies involve the “who, what, where, when, and how” of actions taken to reduce, mask, or avoid symptoms. The dimension symptom status refers to outcomes that can occur from the symptom experience and symptom management strategies. (For a complete discussion of the model see Dodd et. al., 2001.) Only two of the model dimensions are described in this study: the HIVrelated symptom experience and symptom self-management strategies, specifically in relation to methamphetamine use. Until there is more understanding about how methamphetamine is used in relation to Linda Robinson, PhD, is an associate professor at the Hahn School of Nursing and Health Science, University of San Diego. Harvey Rempel, MEd, is a research clinical associate at the University of San Diego.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 17, No. 5, September/October 2006, 7-14 doi:10.1016/j.jana.2006.07.003 Copyright © 2006 Association of Nurses in AIDS Care

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management of HIV-related symptoms, it will be impossible to plan other, more therapeutic symptom self-management strategies to be implemented in its place.

Methamphetamine and HIV The methamphetamine epidemic that began in the mid-1990s represents one of the most serious drug problems ever faced. Over 35 million people regularly use amphetamine and methamphetamine, the most widely abused illicit drugs after cannabis (Rawson, Anglin, & Ling, 2002). Methamphetamine is inexpensive, easy to manufacture, and produces a sustained stimulant effect compared with cocaine, increasing the likelihood it will remain a public health challenge far into the future. Data from the DAWN Drug Abuse Warning Network (2003) show increasing numbers of emergency room admissions involving amphetamines and methamphetamine. Methamphetamine’s strong enhancement of libido creates a context that promotes the spread of sexually transmitted diseases. Prevalence rates of HIV infection among methamphetamine users have been reported between 41% and 63.2% in the gay and bisexual community and can be expected to rise in tandem with rising rates of methamphetamine use (Reback, 1997; Shoptaw, Peck, Reback, & Rotheram-Fuller, 2003). Among men who have sex with men, high-risk sexual practices, such as unprotected anal intercourse and having multiple or anonymous sex partners, have been shown to occur with higher frequency among methamphetamine users compared with men who have sex with men and do not use methamphetamine (Rusch, Lampiene, Schilder, & Hogg, 2004; Semple et al., 2002; Shoptaw, Reback & Freese, 2002; Urbina & Jones, 2004). Also, methamphetamine users have acknowledged that they are less apt to disclose their HIV status to a sexual partner when high on methamphetamine, placing noninfected individuals at risk of becoming infected (Reback, 1997). Animal studies have shown increased rates of HIV replication and mutation associated with methamphetamine use (Ahmad, 2002; Gavrilin, Mathes, & Podell, 2002). Although it is unknown whether this will hold true in human studies, it has been shown

that both HIV and methamphetamine independently damage the nervous system and that this cumulative damage is associated with a higher incidence of strokes (Langford et al., 2003; Rippeth et al., 2004). Structural and metabolic abnormalities have been reported in brain studies of methamphetamine users. These include gray matter deficits and impaired glucose metabolism (London et al., 2004; Thompson et al., 2004). Combined, these abnormalities have been associated with mood disorders such as depression and anxiety and cognitive deficits including memory loss. In comparing cognitive performance among methamphetamine users, cocaine users, and a control group, Simon et al. (2002) showed that methamphetamine users had the most difficulty organizing and manipulating information. This neuropsychological impairment resultant from methamphetamine is magnified in HIV-infected populations (Rippeth et al., 2004). It remains unclear whether certain symptoms (e.g., mood disorders) precede methamphetamine use and motivate some people to initiate methamphetamine use. What is clear is that methamphetamine has positive effects, at least temporarily, elevating mood and enhancing mental alertness. These positive effects in an HIV-infected population already suffering from high levels of fatigue and depression may provide a strong motivation for use and deserve further study. Methamphetamine use has been associated with less effectiveness of antiretroviral (ARV) therapy and poorer adherence to ARV therapy, which can lead to increased viral load burdens (Ellis et al., 2003; Reback, Larkins, & Shoptaw, 2003). Protease inhibitors have been shown to have a 3- to 10-fold increased effect when taken with methamphetamine, and this has resulted in at least one known fatality (Urbina & Jones, 2004). The growing methamphetamine epidemic has created serious challenges to the HIV epidemic. New infections are occurring because of a rise in unsafe sexual practices. HIV-infected persons who use methamphetamine are experiencing magnified neuropsychological impairment and are at greater risk for cardiac complications including stroke. Methamphetamine use compromises HIV treatment because it affects adherence to ARVs and has been shown to have life-threatening interactions with protease in-

Robinson and Rempel / Methamphetamine and HIV

hibitors. Importantly, methamphetamine use may be related to attempts to self-manage HIV symptoms.

Methods A cross-sectional, descriptive design was chosen to describe drug use and HIV symptoms in a methamphetamine-using population. Quantitative data were determined using standardized instruments, and qualitative data were gathered during a semistructured interview. A convenient, community-based sample (n ⫽ 20) was recruited between October 2004 and August 2005 in a metropolitan area of southern California. Fliers advertising the study were posted at HIV social support agencies and 12-step meeting rooms and were given to HIV/AIDS case managers. Individual interviews of study participants occurred in public settings such as coffee houses and cafés where privacy could be maintained. The study protocol was approved through the University of San Diego Institutional Review Board. Because admission of illegal drug use could result in legal consequences, a certificate of confidentiality was obtained through the National Institutes of Health allowing the principal investigator to refuse to disclose identification of information on research participants in any civil, federal, state, or local level proceedings (Lutz, Shelton, Robrecht, Hatton, & Beckett, 2000). This assurance was included in the consent form that every participant read and signed. Sample A total of 20 men between the ages of 32 and 49 years (x៮ ⫽ 39) agreed to participate in the study. Although efforts were made to recruit women by placing fliers in social service agencies serving women only, no women were enrolled. A number of women called about the study because they were using methamphetamine, but they were not HIVinfected and therefore were ineligible. Race/ethnicity of the participants was 60% White, 25% Black, 10% Hispanic, and 1 participant (5%) was Native American. Over half of the sample (65%) had a high school diploma or higher. One third were homeless (n ⫽ 7), one third were living independently (n ⫽ 7),

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and one third were living in transitional housing designated for people with HIV/AIDS (n ⫽ 6). Instruments HIV information form. A 10-item questionnaire was developed for this study to gather information about patients’ HIV histories, CD4 count, whether they were on ARVs, and whether they were receiving HIV care on a regular basis. Sign and Symptom Check-List for Persons With HIV Disease. HIV-related symptoms were measured using the Revised Sign and Symptom CheckList-for Persons With HIV Disease (SSC-HIVrev) (Holzemer et al., 1999; Holzemer, Hudson, Kirksey, Hamilton, & Bakken, 2001). The SSC-HIVrev assesses symptom intensity that patients are experiencing “today” on a 4-point scale ranging from 0 (not today) to 3 (severe). This instrument is divided into three parts: Part I includes 45 items that, through factor analysis, resulted in an 11-factor solution that explained 73.3% of the variance. The 11 factors include fatigue, fear, fever, gastrointestinal upset, shortness of breath, sore throat, numbness, headache, rectal itch, bruising/bleeding, and body changes. Reliability for Part I of the instrument was .86 for this sample. Part II of the instrument includes 19 symptoms that did not cluster into any of the 11 factors in Part I, and Part III includes 8 gynecological symptoms. The SSC-HIVrev can be scored as a total score by summing all items or as factor scores by summing item scores for each item in a factor and dividing the sum by the number of items. Addiction Severity Index-Lite. Methamphetamine use was assessed using the Addiction Severity IndexLite (ASI), the most widely used instrument in assessing substance use and readiness for drug treatment (McClellan, 1992). The ASI is a semistructured interview containing 161 questions in seven categories that assess demographic information, medical status, employment and education, family and social background, psychiatric status, history of drug and alcohol use, and legal status. For the purpose of this study, data will be presented on methamphetamine use only. These data were determined within the

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alcohol/drugs section of the interview. Participants were asked how many times they have used alcohol/ drugs in the past 30 days, their lifetime use of alcohol/drugs in years, and their route of administration. Amphetamines were one of the ten drugs assessed.

larities in participants’ responses for the purpose of summarizing the data.

Semistructured interview. An open-ended interview guide was developed to explore whether participants used methamphetamine to manage HIV-related symptoms. Participants were referred to the SSC-HIVrev to think about a time when any of their symptoms were severe and whether methamphetamine use had triggered or been used to treat those symptoms. At the conclusion of the interview, participants were asked whether anything about methamphetamine use and living with HIV was left out yet important for health providers to know about when caring for this population.

On average, participants had been living with HIV for 10 years. Only 2 of the participants had been diagnosed with HIV less than 1 year before the interview. Almost half (45%) had been diagnosed with AIDS. The average CD4 count reported was 482 (range, 4-984), with 2 participants unable to recall their last CD4 count. All of the participants reported having a regular HIV provider; however, 2 participants did not have any appointment scheduled for the future. Less than half of the participants (40%) were prescribed ARV therapy. A total of 7 participants were told they were not ready for ARVs because their immune status was not compromised enough yet; one participant reported he was “taking a year off,” another reported being resistant to ARVs, and 3 participants had no idea why they were not on ARVs. Participants reported few HIV-related symptoms overall. The average total score for the SSC-HIVrev was 13.6 out of a possible score range of 0 to 135. For the purpose of comparison, a sample of HIVpositive patients receiving home nursing care reported a total score of 35 in another study in which the SSC-HIVrev was applied (Robinson et. al., in press). In summing the symptom factor scores, fear, fatigue and numbness were the most frequent and severe symptom factors reported. A total of 11 participants (55%) reported having used methamphetamine before they contracted HIV. On average, participants had used methamphetamine for a period of 9.8 years (range, 2-20). A total of 9 participants had not used methamphetamine in the past 30 days. Among the remaining 11, 4 used methamphetamine once a week or less, four used methamphetamine 3 to 4 times a week, and the remaining 3 participants were daily or more than once a day users. Almost half of the sample used multiple routes of administration, with snorting and intravenous (IV) administration being the most common (n ⫽ 11). A total of 9 participants reported smoking methamphetamine, and 1 participant reported using the anal route

Procedures Participants were screened by the principal investigator over the telephone as to whether they were HIV-infected and had used methamphetamine within the last 3 months. For those who met these eligibility criteria, a meeting was scheduled at a public café or coffee house of the participant’s choosing for convenience and privacy. All participants were interviewed either by the principal investigator or a research assistant experienced in addiction counseling and trained in all data determination procedures. After obtaining written consent, data determination began with the standardized instruments followed by the semistructured interview. Items on the HIV information form, ASI and SSC-HIVrev were read aloud to each participant to ensure completion of the items, and field notes were taken during the semistructured interview. At the conclusion of the interview, participants were paid $25. Data Analysis Plan The quantitative data were entered into SPSS (Statistical Package for Social Science; SPSS Inc., Chicago) and analyzed descriptively. The field notes were analyzed by the coinvestigators by entering them into a text file and looking for thematic simi-

Results

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(“booty bump”). Half of the sample had previously received drug treatment ranging from 1 to 10 times. The qualitative results from the semistructured interview focused on motivations for using methamphetamine and its relationship to HIV-related symptoms. All 20 participants reported using methamphetamine for enhancement of sexual pleasure. Only 2 participants reported experiencing erectile dysfunction (“crystal dick”); however, this was not a deterrent to continued methamphetamine use. In addition to the sexual motivation for use, participants reported using methamphetamine to treat HIV-related depression, fatigue, and neuropathic pain. The following quotes illustrate how 5 different participants used methamphetamine for HIV-related depression. “I took the drug to be able to forget the HIV and forget the depression” (42-year-old Black man, 90 days abstinent from methamphetamine). “I definitely used meth for managing depression. As soon as I was diagnosed with HIV, my use skyrocketed” (37-year-old White, male IV methamphetamine user). “Using helps avoid the emotional pain of HIV” (45-year -old White man who sold methamphetamine and was an IV user). “Meth helped me accept that I had HIV and it gave me permission to forget I had HIV” (35-year-old Black man living in an HIV recovery house). “I took meth for depression, but now that I’m on psych meds, I don’t need it anymore” (43-year-old Hispanic man who smoked methamphetamine). One participant was an accountant with his own business. He reported shooting methamphetamine in the morning to “kick the fatigue” so he could get himself started. A total of 2 participants reported using methamphetamine to treat their neuropathic pain. The following quote came from a man who sewed tapestries and experienced severe finger numbness and tingling while doing so: “I use meth a lot for pain, because it helps get relief faster than going to the emergency room and waiting 2 hours or more.” Another participant reported, “I play the piano, and the pain in my fingers is so severe sometimes I can’t stand it. The meth takes that pain away.” A total of 2 participants reported that their HIVrelated diarrhea ceased when using methamphet-

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amine; however, this was seen as a byproduct, rather than a motivation for use. Within the context of discussing whether methamphetamine helped HIV-related symptoms, participants also reported negative effects. The following quotes illustrate that although there may be shortterm gains with respect to HIV-related symptoms when using methamphetamine, there are also consequences of use. “When you come down, your fatigue, nausea, body aches, and depression are 10 times worse” (41-year-old Hispanic IV methamphetamine user). “My mouth fungus would really act up with meth” (33-year-old White man who snorted methamphetamine and was diagnosed with HIV 3 months before the interview). “It intensified my anxiety. The depression goes away when I’m using, but then there’s the down period after” (47-year-old White man who snorted and smoked methamphetamine). The final question of the interview allowed participants to add anything about their methamphetamine use and living with HIV that might be of interest to those caring for this population. One participant was very emphatic about the heightened sense of sexual pleasure while masturbating when high on methamphetamine. He offered this as a motivation for safe sex. Another participant described himself as a longterm nonprogressor and attributed this success to methamphetamine use. In his words, “The meth is so toxic it inhibits the HIV. Now that I’m not using so much, my viral load has gone way up.” Another participant reported that his doctors insisted he be 3 weeks abstinent from methamphetamine use before having a blood draw for his viral load. He was told that methamphetamine causes patients to have a falsely low viral load. Because he was a heavy methamphetamine user, this abstinence was extremely difficult for him, but because he trusted his provider so much he managed to remain abstinent with wheat grass juice and ingesting a lot of caffeine. As soon as his viral load was drawn, he injected himself with methamphetamine. Finally, a 41-year-old homeless White man who had left an in-patient drug treatment program 1 week before the interview after 120 days of abstinence to use methamphetamine stated, “When I’m using, nothing else matters, not even my HIV. My recovery has to be the number one thing.”

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Discussion The results reflect a sample of people who have not yet become seriously immunocompromised, even though they have been using methamphetamine and living with an HIV diagnosis for approximately 10 years. Contrary to the literature already cited indicating that methamphetamine accelerates HIV replication and mutation, this sample remains relatively physically healthy. It is likely there are other variables influencing HIV progression in methamphetamine users that still need to be isolated to further explain this result. The participants had relatively few HIV-related symptoms at the time of their interviews. This is not altogether surprising, because of their relatively competent immune status and the fact that less than half of the participants were taking ARVs. In subsequent investigations of HIV symptoms in methamphetamine users, it would be advisable to recruit participants who are in more advanced stages of HIV disease to ensure a more symptomatic sample and to measure symptoms longitudinally, as symptoms change from day to day. The qualitative results underscore how difficult it is to accept an HIV diagnosis and live responsibly with HIV over many years. So much of HIV care focuses on monitoring the biological markers, yet methamphetamine use may represent a mark of emotional deterioration brought about by living day to day with HIV. Almost half the sample reported starting their methamphetamine use after having been diagnosed with HIV. Previous research has shown the relationship between methamphetamine use and HIV infection. The results from this study showed nearly an equal number of methamphetamine users who initiated their drug use after receiving their HIV diagnosis as a means of coping with HIV. Therefore, the challenge is not just preventing new cases of HIV because of methamphetamine use, but also keeping already infected persons from initiating use. Although the use of methamphetamine to selfmanage HIV-related depression and fatigue is not a new result, these repeated results indicate that HIVinfected persons should be screened and monitored more closely for depression and their likelihood to resort to drug use in an effort to self-medicate for emotional pain. It has been known for some time that

depression goes underdiagnosed in HIV-infected persons; however, the social consequence of underdiagnosis has not been fully considered (Asch et al., 2003). Frank discussions about methamphetamine use as an ineffective coping measure and the possibility of becoming reinfected with a drug resistant viral strain need to occur as a routine component of HIV care. The result that participants used methamphetamine to treat their neuropathic pain has not previously been reported and deserves further study. Methamphetamine can be legally prescribed for specific conditions such as narcolepsy, and perhaps under careful supervision with appropriate controls, the validity of this result could be further examined. The fact that methamphetamine helped with HIV-related diarrhea also deserves further study. It may be that methamphetamine has a constipating effect; however, it could also be that diarrhea diminishes because typically people do not eat or drink very much during periods of methamphetamine use. The exploratory results provide some interesting perspectives from the participants on their use. Although it would not be advisable to recommend methamphetamine use to anyone regardless of its enhancement of masturbation, this may provide a safe, harm-reduction intervention for current users or those at high risk of using. Safe sex while high on methamphetamine does not seem to be an attainable outcome unless sex is without a partner. The rich insights gained from this study must be tempered with cautious acknowledgement of the study limitations. The data gathered from this small sample cannot be generalized to reflect the experience of all HIV-infected methamphetamine users. One critical omission was the inability to recruit women into the study. Their experiences are likely to differ from the experience of these 20 men. The accuracy of self-report data could also have compromised the validity of the results. It would be advantageous in subsequent studies to measure CD4 counts and viral load and to test for methamphetamine use through urine screening.

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Implications for Practice

Conclusion

Nurses caring for HIV-infected methamphetamine users are caring for a population with two chronic illnesses. HIV care cannot be effectively provided without integration of treatment for addiction. Drug treatment for methamphetamine users has been shown to decrease the incidence of unsafe sexual practices and improve adherence to ARVs (Reback et al., 2003; Reback, Larkins, & Shoptaw, 2004). The denial HIV-infected persons are living under, such as believing that methamphetamine is protective and toxic to HIV, is a barrier to seeking drug treatment. HIV providers must confront these misperceptions and do everything possible to facilitate entry into drug treatment. Myths have been perpetuated by the popular media about methamphetamine addiction being unresponsive to drug treatment. Yet studies indicate that success rates after treatment for methamphetamine abuse mirror those of other stimulant use such as cocaine (Frawley & Smith, 1992; Rawson et al., 2002). As one participant reported, HIV care is a secondary concern to an active drug user. This does not suggest that HIV care should be delayed or withheld until after drug treatment, however. Drug treatment, as shown in this sample, is a lifelong journey and often involves multiple treatment admissions, many without success. HIV care therefore cannot be put on hold until the patient is completely abstinent, because this day may never come. The two chronic illnesses need to be addressed in tandem with equal zeal given to successfully manage both diseases. Whether methamphetamine artificially lowers viral load readings needs to be shown empirically. This practice has not been reported in the literature, and long-term abstinence before blood work may be impossible for some patients to achieve. Patients with a long history of methamphetamine use may suffer serious cognitive deficits. What may be interpreted as noncompliance may reflect the patient’s inability to remember information conveyed in an office visit or an inability to problem-solve secondary to the brain damage caused by methamphetamine. It may be beneficial to use pictures in patient teaching materials and to keep instructions at the simplest level possible.

The methamphetamine epidemic is growing and is perhaps the worst thing to have happened to the HIV epidemic to date. Clinicians working in HIV care are challenged to meet the needs of this population and will be caring for them into the distant future. More research is needed to examine how methamphetamine use affects the progression and day-to-day experience of living with HIV. Nurses with expertise in HIV care need to collaborate with colleagues who are expert in addiction science to more fully integrate treatment protocols from both areas of study. Integrated treatment strategies will then need to be evaluated to determine whether this approach improves patient outcomes.

Acknowledgment This study was supported through postdoctoral fellowship NINR T32 NR 07077.

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