Back in the early 2000s crystal methamphetamine use among gay and bisexual men was considered so alarming it was dubbed the "second epidemic" after AIDS.
Nicknamed Tina or Crissy, the drug is most commonly smoked in glass pipes or snorted. It is of particular concern to health officials trying to stop the spread of HIV because meth users often lose their inhibitions, particularly during sex.
In San Francisco health officials and AIDS agencies launched a number of campaigns to turn the tide and encourage men who have sex with men not to use the drug. Former Mayor Gavin Newsom, at the urging of gay former District 8 Supervisor Bevan Dufty, created a citywide task force in 2005 to address the issue.
While the task force described meth usage in the city at a "high plateau," researchers within the health department were seeing a different picture. A 2006 study using data collected by the Stop AIDS Project published in the Journal of Drug and Alcohol Dependence found a precipitous drop in meth usage over a three-year period.
Usage of meth among HIV-negative MSM dropped from 14.7 percent in 2003 to 9 percent in 2006, while usage among HIV-positive men fell to 19.9 percent from 28 percent in late 2003.
A new report published this year in JAIDS, the Journal of Acquired Immune Deficiency Syndromes, shows that declining trend in meth usage continued through at least 2011. The study, "A New Trend in the HIV Epidemic Among Men Who Have Sex With Men, San Francisco, 2004-2011," is based on local data from the National HIV Behavioral Surveillance, which surveyed MSM in San Francisco in 2004, 2008 and 2011.
"I would say half as many men are using methamphetamines in 2011 as they were in 2004," said H. Fisher Raymond, DrPH, the lead author of the JAIDS study and director of behavioral surveillance at the San Francisco Department of Public Health.
The data also shows that over that seven-year period there was "remarkably stable HIV prevalence," with many MSM getting tested and adhering to treatment. At the same time the data indicated that sexual risk behaviors were at persistently high levels.
"Yet, encouragingly, the rate of new HIV infection seems to be decreasing," states the study. "More good news is that methamphetamine use, a noted predictor of HIV transmission, continues a previously noted downward trend among MSM."
In 2004 roughly 23 percent of the 386 MSM surveyed reported using meth in the last 12 months. By 2008 13.2 percent of the 521 MSM had used meth in the past year, and in 2011 nearly 12 percent of the 510 MSM had used the drug.
"This decline in meth use in MSM is also seen in L.A. and New York," said Raymond.
State health officials have documented that MSM in California testing positive for gonorrhea and self-reporting meth use has steadily declined since 2007, as the Bay Area Reporter reported in December. Four years ago roughly 20 percent of MSM contacted by state health officials said they had used meth in the past 12 months.
In 2011, that number had dropped to 12 percent among the 538 MSM who answered the question. Out of 84 MSM living in San Francisco County, nine men, or 11 percent, said they had used meth in the previous 12 months.
The reports by health officials do not surprise Juan Garcia, a gay man who has produced various nightlife events in San Francisco since the mid-1990s. Years ago he could easily name friends he knew using meth.
"I did lose some very close friends to that drug in the last five years," Garcia said. "It was due to overdoses or people just kind of disappear into the night that you don't see anymore."
These days Garcia said he doesn't know anyone using crystal.
"It used to be when people were doing the all-night rave parties and weekly club events that everybody kind of dabbled in it. Since the end of all the big clubs, I have not heard of or had any access or contact with anybody who does that anymore," said Garcia, who is helping to revive the formerly weekly Fag Fridays parties as a monthly event returning on April 12 at club Monarch and again May 24 at DNA Lounge.
Now that gay men's nightlife habits have changed, with bar hopping in the Castro replacing marathon dance parties on most weekend nights, there is little need to turn to meth to fuel a night out, said Garcia.
"There is nothing keeping you up and out all night long anymore," said Garcia. "I've always said that drug culture and late-night partying is always connected. When one goes so does the other."
Not everyone convinced
Not everyone is convinced that the meth epidemic among MSM is over. Dufty, who now handles homelessness issues as part of Mayor Ed Lee's administration, told the B.A.R. that he believes the drug is still a key concern among those living on the city's streets.
"I still see it as being a very significant challenge in the community," said Dufty. "I still encounter people who have lost their housing due to meth use or at times are in an abusive relationship where their partner began using meth and it spiraled them out of control."
He does credit the drop off in usage researchers are documenting to the work done by the mayoral task force, LGBT community members, and nonprofit agencies that came together to address the issue.
"I think the task force can take pride in the progress that has been achieved," he said. "I do think because of the focus and emphasis of the awareness campaign a lot was done. It had an impact."
Michael Siever, Ph.D., manager of the Stonewall Project, a harm reduction effort aimed at gay drug users begun 15 years ago and now part of the San Francisco AIDS Foundation, concedes that meth usage by MSM is not "a crisis anymore." But he contends that it remains a significant problem.
"I would say it is endemic, meaning it is kind of entrenched in the community and has been for years," said Siever, whose program provides counseling and assistance to 600 men a year. "My sense is cocaine use is probably up and, because of that, possibly meth use is down a little."
He remains skeptical of the data used to support the various reports' claims of declining meth usage, which is mainly collected from men stopped on the street asked to take part in the survey. The anti-meth messaging of years past likely makes some users of the drug less willing to admit doing so, maintains Siever.
It is a point the researchers acknowledge, noting in the JAIDS study the "possibility that participants were more likely to give socially desirable responses" such as underreporting their drug use.
"I think the meth task force conclusion is still the case. Meth use, I would say, is at a high plateau that fluctuates year to year," said Siever. "We have not seen any lessening of demand at Stonewall."
One consequence of no longer having weekly nightclubs operating is it makes it harder to find and question those MSM who may be using meth. The advent of sex hookup apps on mobile phone devices also makes it harder to survey the community, noted Siever.
"The bottom line for me is, yes, there is some lessening of use. But the reality is gay men use alcohol and other drugs at a very high rate, regardless," he said. "It is still an issue even if it does go down some."
Stonewall is currently working with Adam Carrico, Ph.D., assistant professor of nursing at the UCSF Center for AIDS Prevention Studies, to examine if its harm reduction approach to drug and alcohol use among gay and bisexual men has been effective. Called the Stonewall Treatment Evaluation Project, Carrico is using data about the program's participants over the years to see what impact it has had.
"Trends of meth use seem unchanged to us," said Carrico, who has published several papers on the effects of stimulants, such as meth and cocaine, on HIV disease progression in MSM. "We are working with people presenting for drug use treatment and are HIV positive and have had meth use problems for years."
Studies show that use of stimulants can lead to elevated HIV viral loads and cause users not to adhere to their treatment regimens. Understanding such correlations is key to seeing that HIV prevention policies such as treatment on demand are successful, said Carrico, since suppressing viral load among people living with HIV is considered key to reducing transmission of the virus.
"It is not just about getting people to stop using drugs but providing them comprehensive psychiatric care that addresses their multiple health needs," he said.
In July he will begin enrolling 230 people over four years into a study to see if providing them incentives to not use meth will be effective.
"We want to help people find rewards other than drug abuse," said Carrico.