Exploring influences on methamphetamine use among Black gay, bisexual and other men who have sex with men in Atlanta: A focus group study

Abstract

Background:

Methamphetamine use is a contributor to HIV risk and poor health outcomes among gay, bisexual and other men who have sex with men (GBMSM). There is a paucity of research examining methamphetamine use and its social context specifically among Black GBMSM. We therefore sought to: (1) describe trends in methamphetamine use among Black GBMSM in Atlanta, Georgia, and (2) examine the risk environment (micro-, meso- and macro-level factors operating in the political, social, physical, economic, and healthcare environments) that might elevate risk for methamphetamine use in this population.

Methods:

We conducted a qualitative study consisting of eight focus groups with 54 key informants between December 2019 and March 2020. Participants represented community-based and healthcare organizations that work closely with Black GBMSM. Our thematic analysis included an iterative, team coding approach combining deductive and inductive elements.

Results:

Participants unanimously agreed that methamphetamine use was increasingly prevalent among Black GBMSM in Atlanta, with many describing a historical arc in which methamphetamine use – previously associated with predominantly white, affluent GBMSM – was now common among younger, lower socioeconomic status Black GBMSM. At the micro-level, participants described contributors to increasing methamphetamine use including use as a sex drug, and the interrelated burdens of stress and mental illness, housing instability, geographic mobility and poverty. At the meso-level, participants described virtual and physical sex scenes including use of geosocial networking apps that facilitated the spread of methamphetamine use in the Black GBMSM community. At the macro-level, participants described how policies prioritizing other concerns (e.g., HIV, opioids) seemed to limit resources available for methamphetamine prevention and treatment programming.

Conclusion:

Multi-level environmental influences are working together to elevate risk for methamphetamine use among Black GBMSM in Atlanta, with potential to adversely impact health and well-being and undermine HIV prevention and treatment efforts.

INTRODUCTION

Methamphetamine use is an ongoing threat to individual and public health in the United States (US); approximately 1 million people in the US met criteria for methamphetamine use disorder in 2019 (Substance Abuse and Mental Health Services Administration (SAMHSA), 2020). Methamphetamines are potent synthetic stimulants, which yield short-term euphoria, wakefulness and heightening of sexual pleasure, but are also associated with a host of physical and social harms. Acutely, methamphetamine intoxication can cause behavioral changes, cardiac arrhythmias, seizures, and death (National Institute of Drug Abuse (NIDA), 2019). Among chronic users, long-term effects of methamphetamine use include neuropsychiatric problems such as impaired psychomotor function, memory deficits, depression, paranoia and psychosis (Courtney & Ray, 2014; Radfar & Rawson, 2014). Methamphetamine use also co-occurs with a range of related social harms including homelessness, food insecurity, violence, involvement in sex work, and criminal justice involvement (Nagata et al., 2020; Uhlmann et al., 2014). Approaches to reduce methamphetamine-related harms must therefore approach risk with a holistic orientation.

A significant body of research has specifically examined methamphetamine use among gay, bisexual and other men who have sex with men (GBMSM). Much of this work has been done in relation to HIV; methamphetamines are known to facilitate sexual disinhibition, and use is associated with sexual behaviours that increase risk for HIV transmission, including increased likelihood of condomless receptive anal sex, increased number of sexual partners, and higher rates of co-occurring sexually transmitted infections (Hoots, Finlayson, Nerlander, Paz-Bailey, & National, 2016; Mansergh et al., 2006). Compared to users of other drugs, men who have sex with men who injected methamphetamines were more likely to be living with HIV (Nerlander et al., 2018). For those who are living with HIV, methamphetamine use has also been associated with poorer engagement in HIV care (e.g., lower rates of retention in care and viral suppression)(Hightow-Weidman et al., 2017; Hood et al., 2018; Jin et al., 2018; Menza, Choi, LeGrand, Muessig, & Hightow-Weidman, 2018). Methamphetamine use among people living with HIV also contributes to financial strain among a population often already facing significant socio-economic inequities (Jerome, Halkitis, & Coley, 2009) and contributes to increased rates of incarceration and housing instability (Anderson-Carpenter, Fletcher, & Reback, 2017).

Black GBMSM are disproportionately impacted by the HIV epidemic; accounting for 26% of all new diagnoses despite representing less than 1% of the total US population (Centers for Disease Control and Prevention, 2018; Matthews et al., 2016). The Southern US, home to a large proportion of Black gay men, is the region of the country that currently bears the heaviest burden of HIV (Adimora, 2013; Gray et al., 2016; Prejean, Tang, & Hall, 2013; Reif et al., 2014). Elevated risk for HIV and its complications among Black GBMSM in the South can be attributed to multi-level structural barriers related to conservative cultural beliefs and policies in this region – resulting in systemic racism, homophobia, poorer access to healthcare, lower education rates, and higher rates of poverty, (Adimora, 2013; Cramer et al., 2017; Geter et al., 2016; Stopka et al., 2018).

Against this background of structural disadvantage, methamphetamine use may be an emerging contributor to suboptimal HIV-related outcomes among Black GBMSM. Historically, most studies found that Black GBMSM had lower rates of methamphetamine use relative to white gay men (Garofalo, Mustanski, McKirnan, Herrick, & Donenberg, 2007; Grov, Bimbi, Nanin, & Parsons, 2006; Halkitis, Green, & Mourgues, 2005). Several media reports (Secret, 2015; Strudwick, 2020), public health initiatives (Harriman et al., 2019; The Counter Narrative Project, 2019), and preliminary studies at professional meetings (Kuo et al., 2017) have cited recent increases in methamphetamine use among Black GBMSM. However, there is a paucity of empirical, peer-reviewed published research characterizing recent trends in methamphetamine use among Black GBMSM, particularly in the Southern context. Increasing methamphetamine use among Black GBMSM is a threat to physical and social well-being; additionally, in the Southern HIV epicentres, such a trend has the potential to undermine HIV treatment and prevention initiatives, and to severely thwart efforts to end the HIV epidemic (Fauci, Redfield, Sigounas, Weahkee, & Giroir, 2019). Effective interventions to prevent methamphetamine use, reduce methamphetamine-related harms, and treat methamphetamine dependence among Black GBMSM are thus urgently needed.

In order to develop such interventions, however, we first need to better understand factors that influence risk for methamphetamine use and abuse in this population. The main objective of this study was to describe trends in methamphetamine use from the perspectives of community-based key informants in Atlanta, a Southern US city with a high HIV burden (Centers for Disease Control and Prevention (CDC), 2020), particularly among Black GBMSM (Sullivan et al., 2015), and to examine multi-level structural factors influencing these trends.

METHODS

We conducted eight focus group discussions (FGDs) of 6–8 participants each, with a total of 54 community-based key informants between December 2019 and March of 2020. Participants were recruited directly or through community-based organizations (CBOs) or health care organizations, based on either individual or organizational reputation for being knowledgeable about Black GBMSM and/or substance use services. Given the disproportionate impact of HIV on Black GBMSM in Atlanta, most of these organizations also provided HIV prevention and/or treatment services as a main or secondary focus. Members of our study team have been working with Black GBMSM in Atlanta over the past decade; we reached out to one or two main contacts at each CBO to assess interest in hosting/attending a FGD. We then asked these organizational contacts to invite colleagues to join the FGDs. Within those organizations, individuals were eligible as long as they were ≥ 18 years of age and willing to consent (verbally) to participation. At each FGD, we also asked for recommendations of other organizations to reach out to, so that the total sample was not limited to our pre-existing network of community partners.

Characteristics of each group are described further in Table 1. FGDs were held either on our university campus or on-site at participating CBOs. Two staff members, both gay-identified men of colour with master’s degrees and extensive qualitative research training and experience, conducted the FGDs using a semi-structured guide. Domains of the guide included: (1) Description of methamphetamine use among Black GBMSM in Atlanta; (2) Factors leading to initiation of methamphetamine use; (3) Consequences of methamphetamine use; (4) Perceptions of methamphetamine use; (5) Descriptions of support services; and (6) Recommendations for future work. Verbal informed consent was obtained for each participant prior to FGD initiation, and all discussions were digitally recorded and professionally transcribed for subsequent analysis. FGDs lasted an average of 75 minutes each (range 54–91 minutes). Participants were also asked to complete a brief demographic questionnaire. Honoraria of $50 USD were provided as a token of appreciation to each participant. The Emory University Institutional Review Board approved the protocol.

Table 1.

Descriptions of Focus Group Discussions (FGDs)

FGD number	Description of Key Informants	Number of participants	Location of FGD
1	Young Black gay men from research team’s community advisory board	8	University
2	Staff members at an organization offering HIV, mental health and substance use services	6	Community
3		6	Community
4	Staff members and clients at an organization providing substance use services for Black gay men	6	Community
5	Members of a community-based organization for older Black gay men living with HIV	6	Community
6	Clinical and research staff affiliated with a large HIV care center and our university	7	University
7	Members of a community-based organization for young Black gay men	7	Community
8	Staff members at an organization providing harm reduction and linkage to HIV services for people who use drugs	8	Community

All transcripts were imported into MaxQDA 20 (VERBI Software, Berlin, Germany), a qualitative data management software package. We used a thematic analysis approach to process data, develop codes, and elicit and refine themes and thematic relationships within our data (Braun & Clarke, 2006). Our analysis was guided by the risk environment framework, a well-established lens through which influences on substance use and risk can be described (Collins, Boyd, Cooper, & McNeil, 2019). The risk environment framework posits that factors at the micro (immediate), meso (institutional or network-level), and macro (societal) levels converge within four distinct environments (including social, political, economic, physical, healthcare and criminal justice environments) to influence drug-related outcomes (Cooper et al., 2012; Rhodes, 2002; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005). First, the study team read through all transcripts to develop and refine a qualitative codebook using a combined deductive and inductive approach; that is, some (deductive) codes were derived directly from areas of interest/domains of the FGD guide, while other (inductive) codes of interest arose from the data. Once the preliminary codebook was developed, two analysts coded a subset of transcripts in parallel and compared their codes. Disagreements led to further discussion and refinement of codes and code definitions until analysts were able to apply codes with little disagreement. A single analyst then coded each of the remaining transcripts. We then developed detailed analytic memos for each code, outlining dimensions and attributes as well as sub-themes and relationships to other codes. We examined quotes identified within and across coding categories to identify emerging themes. The analytic team met regularly to discuss and confirm the identification and interpretation of salient themes within the group. Finally, we organized our findings according to the constructs of the risk environment framework (e.g., into micro-, meso- and macro-level influences) for presentation below.

RESULTS

Demographic characteristics of individual participants are listed in Table 2. The majority of participants were Black, male, gay, and college-educated. We present our qualitative findings as two components: (1) Detailed descriptions of changes and trends that they observed related to methamphetamine use among Black GBMSM in Atlanta; and (2) Descriptions of factors at different levels of the risk environment (e.g., micro-, meso- and macro-level factors) that work synergistically to increase risk for methamphetamine use in this population. Of note, many of the concepts described below work at multiple levels of the risk environment; however, we still find this framing useful for organizing our findings.

Table 2.

Participant Demographics (N=52^*)

	% (N)
Age (years)
20–30	42% (22)
31–40	29% (15)
41–50	15% (8)
51+	14% (7)
Gender
Cisgender man	67% (35)
Cisgender woman	27% (14)
Transgender woman	4% (2)
Gender non-conforming person	2% (1)
Race
Black	87% (45)
White	6% (3)
Other	8% (4)
Sexual orientation
Heterosexual/straight	31% (16)
Gay/same-gender loving	56% (29)
Bisexual	8% (4)
Other	6% (3)
Education (highest completed level)
Less than high school	4% (2)
High school diploma	12% (6)
Some college	12% (6)
Associates degree/technical certification	10% (5)
Bachelor’s degree	36% (19)
Graduate degree	26% (14)

^*Demographic data missing for two participants

Changes and trends in methamphetamine use

Moving from the white gay community to the Black gay community

Participants discussed several changes that they perceived with respect to the prevalence of methamphetamine use in the Black gay community in Atlanta. Participants were virtually unanimous that methamphetamine use had increased within this community, especially over the last five years. Participants described racialized and sexualized trends in methamphetamine use that they had observed over the past decade, with the consistent refrain that methamphetamine was previously used almost exclusively by white people, but that use had now “creeped into the Black gay community.” Within gay communities, this was also a move between classes – where wealthier white GBMSM in the “party scene” were the originators of methamphetamine use that was now trickling down to lower-income Black GBMSM that were not necessarily a part of that same scene.

Some participants described this movement into the Black gay community as happening directly through individual-level inter-racial connections, including non-Black friends or sex work clients:

I feel like a lot of young Black boys, when they turn to escorting and then they go out there and they get introduced to this drug through, you know, other races and nationalities. They bring back to the community, hey, I’ve got this drug, you know, the high will last longer than X, Y, and Z…and then they try it, and it’s like, it’s like a domino effect.

(Focus Group 1)

In some cases, this introduction of methamphetamines through other races was explicitly named as abuse and exploitation (as opposed to simply being cross-racial socialization) at the hands of older, white, wealthier men.

I was going to say that unfortunately, due to the socioeconomic status of most gay Black men in the city, which is below poverty, that’s a lot of gay Black men in the city, and the entry point for methamphetamine purchase is about $100 or so. So unfortunately, because, like, doing the classes, white versus Black, white men, richer white men have access to it. So, the trend has become to basically get young Black men hooked on it so that they could be objectified by white, older men, as like a novelty…it’s just exploitation. That’s really it. And that’s unfortunate, but because of the homelessness, poverty, things like that, um, in relation to the go-get-it-ness of the drug, like have to have it, have to have it, it comes into this cycle of being basically a slave to somebody else, pretty much. Being abused, traumatized, exploited...

(Focus Group 4)

Here, the participant directly drew connections between race, class, and historical abuses of Black men in the US (“being basically a slave”). The racialised power dynamic is described leading up to the initiation of methamphetamine use (where young Black men in dire financial straits get introduced to and “hooked on” methamphetamine during sexual encounters with wealthier white men) and is also perpetuated further after use begins, as (the young Black men described here do not have the resources to procure methamphetamine, and so must continue to be exploited in this manner).

It should be noted that although several participants discussed these types of direct connections between Black and white GBMSM, others clearly stated that the drug now had a hold in Black gay communities, so that Black GBMSM were now just as likely to be introduced to methamphetamines through members of their own community. That is, participants did not express that all or most of methamphetamine initiation necessarily came directly from a white person to a Black person. However, they made clear that the overall pattern was that prevalent methamphetamine use had moved from white gay communities to Black gay communities.

With meth, it could be perception, I don’t know, but it always was, the perception was that meth was a white boy drug and you know, the white kids in the suburbs were doing a lot of meth and now all of a sudden, it’s a black gay man problem. So, if that’s a trend, you know, a legitimate trend then I definitely don’t like what I see because to quote Jesse Jackson, when America gets a cold, black folks get pneumonia. So, if it is the trend that it is getting worse in with Black gay men, it’s going to explode if something is not done with meth.

(Focus Group 5)

Age disparities

For the most part, participants described younger Black GBMSM as being the most at-risk for methamphetamine use. This risk was tied to perceived higher rates of sexual activity, as well as poverty and housing-related instability among younger men relative to older men. However, some participants also described use among middle-aged Black GBMSM.

I find that it is not as equally as prevalent in older people, but it is prevalent there as well. I have a few clients who are older than young, maybe in their 40s and 50s, and they’re using meth as well.

(Focus Group 6)

Others also felt that although methamphetamine use was being introduced into the Black gay community via younger men, it would eventually disseminate to older age groups as well.

It’s not that prevalent in men who are older, but it’s still part of the process because there are men who are older who are sexually active with younger guys. So that means that, you know, you want to participate with the party mindset.

(Focus Group 4)

Methamphetamine replacing crack in Black communities

Within Black communities, participants also described a shift from crack cocaine being the predominant drug, to methamphetamines becoming increasingly popular. This shift was not restricted to GBMSM, but was also discussed in the context of drug use in Black communities more broadly.

And it’s in the hood now...I mean, it’s kind of like the market changed. They’re not smoking crack anymore, we got some crack and you need some crack. We can get you some, but they got meth on deck. It’s just like, wow, Black people are selling this now.

(Focus Group 3)

Some participants, noting these trends, expressed concern that methamphetamine use was likely to become more prevalent in the larger Black community in the future.

The straight, Black, African-American males are now surprisingly selling it, versus selling weed and selling coke. They are selling Tina [methamphetamines] because they know that this a marketable source considering the fact that Atlanta is full of gays and they are all going towards T [methamphetamines] so nobody is buying a gram of weed for $10 when they can buy a gram of T for $60. So they do the math, and of course you’re going to be making way more selling that type of drug. Um, so I think within the next five or three years, it’s going to be growing to where the straight community is now using it.

(Focus Group 3)

In contrast to the discussions of racialised power dynamics and sexual exploitation described in the Black gay community, the driving force in the wider Black community was described as being primarily economic – relating to supply, demand and profits that could be made from methamphetamines versus other drugs.

Risk Environment: Micro-level factors

Participants discussed micro-level influences on initiation of methamphetamine use among their clients/work acquaintances as well as their own personal networks. Reflecting the impact of the social environment: methamphetamine was described as being used primarily for sexual activity, as well as to cope with stress and mental illness. Many participants also discussed the impact of homelessness, geographic mobility and poverty on risk for methamphetamine initiation, reflecting intersecting physical and economic risk environments.

Use of Methamphetamine as a Sex Drug

Methamphetamine use was described as often being linked to sex, due to commonly discussed effects of sexual disinhibition as well as prolonging and heightening sexual pleasure. Use as a sex drug was described as the most common entry point through which methamphetamines were initiated in the community.

With a lot of the younger kids it’s like you know, very we don’t talk about it because it’s not a problem. It’s nonchalant, it’s I do it on the weekends, I do it when I go to the clubs, I do it when I have sex, I’m not addicted. It’s not part of my life until it is.

(Focus group 4)

Many participants also tied methamphetamine use to transactional sex – including sex work and survival sex (i.e., having sex in exchange for housing, food), particularly among younger Black GBMSM. The relationship between methamphetamine use and transactional sex was described as complex and bidirectional. Several participants discussed instances in which people were introduced to methamphetamines through clients during these transactional sex experiences, either knowingly or unknowingly.

They dangle it in front of their face, do you want somewhere to stay? Come over tonight for the next two days, and I get you high, and then be his whore for two days…and then they indulge and then later they can’t function. So then they start buying it, so they become the host. It’s like passed on and passed on, the cycle.

(Focus Group 2)

At the same time, people might also become addicted to methamphetamines and subsequently use sex/sex work as a way to continue obtaining methamphetamines. A few participants also discussed that methamphetamines could be used as a way to cope with the traumatic experiences around survival sex.

Yeah, and for a lot of people it’s not sexual but what happens is once they’ve experienced it and been exposed to it, then they no longer can provide the means to get it. Then they start hustling, prostituting, and then there’s a change in your usage of it. You could have started out socially and you recognized as it got in the street who does it, and who will do it with you in exchange for sex. So the graphics change. That’s not for everybody, but that’s a common way that it becomes sexually engaging for people.

(Focus Group 3)

Geographic mobility and homelessness

Several groups discussed the role of geographic mobility (i.e., moving to Atlanta) in terms of pathways into methamphetamine use. It was commonly acknowledged that Black GBMSM, especially younger Black GBMSM, often move to Atlanta seeking economic opportunity and/or freedom of sexual expression in the local Black gay scene. In many cases, young Black GBMSM were described as migrating from areas that were more rural, more conservative and less gay-friendly than Atlanta, so that this move represented their first exposure to a gay community. In this context, some participants discussed ways in which initiation into this scene, and accompanying pressure to adhere to perceived social norms, could include sexual explorations associated with methamphetamine use.

Atlanta is the Mecca... Some people come here to become a different person, because they might not have enjoyed how they were, where they were from, so they come here and build a whole new persona. It’s like oh, I’m going to become this person, and becoming someone new, you meet new friends, you do new experiences, and some people experience things and can’t get away from it... Then [methamphetamine use] just becomes a natural thing for people to do, just to be accepted. Because if you were with a group of people, and they were like, oh, we’re about to do this [use methamphetamines] …you don’t want to be black balled or whatever, so you’re like, okay, I’ll just try a little bit. And then it just comes from that. Then sex parties and stuff like, the whole underground, sex party, let’s get it, hook up, let’s link, all that, it contributes to all of that.

(Focus Group 3)

Many of these young Black GBMSM moving to Atlanta were described as lacking the financial resources or social connections to remain stably housed. In this context, a commonly described situation was one in which homeless young Black GBMSM engaged in transactional sex in exchange for a place to stay, and were introduced to methamphetamines in that context.

I’m still sticking with being homeless for the main reason [for methamphetamine use] in this area. Most of the people that come to Atlanta and end up homeless, are not from Atlanta. They move in with a friend and anybody who I’ve met who moved to Atlanta without having their own place has been put out with their stuff on the street. Every single person that I’ve met has that story and then they engage in the sex for survival and the homelessness and the drugs. So I’m sticking with that as the number one reason [for initiating methamphetamine use].

(Focus Group 8)

Psychological distress

Several participants discussed comorbid mental illness or psychological distress, and their relationship to initiation of methamphetamine use. This type of use was described as self-medication for a range of issues including low self-esteem and trauma-related symptoms.

I find that, um, a lot of gay Black men are using this drug, um, not only as a source of recreation, but as a source of medicating. Um, I believe there’s a – and I speak for myself, um, I came up into this [gay] lifestyle a hurt individual, seeking validation and seeking approval and attention, and I kind of gravitated towards the drugs so as a way of numbing everything that I didn’t like about myself, everything that didn’t feel good about myself, and changing my own perception of things.

(Focus Group 1)

Other participants discussed the relationship between mental illness and methamphetamine use in terms of the potential for methamphetamine use to exacerbate underlying mental health issues.

I think that really the problem with Black men using methamphetamine is, mental health is a serious thing that Black African-American males don’t recognize or don’t want to admit or go get treated for. That being said, in a sober mind, that mental health disorder hasn’t arose or is not noticeable, but on methamphetamine, such as meth, it increases it, and you start to see your behaviours and now you’re labelled as sketchy or you’re crazy, or you take it to the point of not smoking it, now you’re injecting it into your veins, and this is a problem because if you don’t recognize it or treat it yourself when you’re high, it’s definitely going to be a part of you where you’re going to feel like you’re ashamed of it or try to hide from it or try to numb the pain and use it more. I think that for me, that’s the problem with Black gay men using it beyond the sex, it’s the mental health that they’re just not facing to realize what they have.

(Focus Group 4)

Here, participants invoked high rates of trauma and stress among Black GBMSM, as well as barriers to seeking care to deal with these issues more directly (e.g., through clinical mental health services). Specifically, participants named homophobia and related rejection from home families and communities as common roots of trauma in the community, and they discussed how methamphetamines and other substances were used to address these types of pain.

Risk Environment: Meso-level factors

Discussions of meso-level influences primarily focused on social environments that facilitated methamphetamine use often reflected the predominant conceptualization of methamphetamines as a sex drug. Several participants referred to the concept of “party and play” or “PNP”, which was described as a well-known phrase within the gay community referring to the use of methamphetamine during sex to enhance sexual pleasure, including by prolonging sexual encounters and/or reducing inhibitions. “PNP” in turn was facilitated through virtual online platforms, as well as in-person clubs and sex parties.

Geosocial networking apps

Many participants discussed the increasingly common association of methamphetamine use with geosocial networking apps (e.g., Jack’d, Grindr) commonly used among Black and other GBMSM to socialize and meet sexual partners. The apps were discussed in every group, and seemed by far to be the biggest facilitator of methamphetamine use. Participants described well-known codes on individual profiles that would indicate interest in using methamphetamines and having sex together, such as emojis depicting snowflakes (denoting “ice”, a common euphemism for methamphetamines) or a note that an individual wanted to parTy (spelled with a capital T – alluding to Tina, another common name for methamphetamines).

Participant 1: So it’s actually very, I would say it’s very discreet. And it shows up in the form of aliases, or like for me, I remember the capitalized T. I’m a grammar person, so I’m like, why the fuck are all of the letters decapitalized and this one letter is capitalized? …One day I was just curious, and I was like, why is your T capitalized, because I’ve been seeing this like, more than just on one profile. He was like, Tina, and I was like, who is that? Who? He said that white girl, and this is how I knew I was green…He was like, crystal meth… So once I saw that, it’s like you see different profiles. You know how when you see a car for the first time, you’ve never seen it, and then after that you start seeing cars randomly? That’s kind of how it was, you just started seeing it more frequently and okay, this is what they mean by party and play, meaning that there’s some partying and some playing, going along with this drug, because the T is capitalized, yeah.

Interviewer: Any other comments about dating apps?

Participant 2: I think that’s how all of us are exposed to it. I see it all the time as well and I think that’s how most people come into contact with it…that’s how it gets out there and people see it on the dating app and, there you go.

(Focus Group 7)

Emphasizing this phenomenon, one participant in Focus Group 1, who had a personal history of methamphetamine dependence, noted that he had to delete the apps from his phone as a part of his recovery process because of the widespread prevalence of methamphetamine mentions in the various profiles.

Sex clubs and parties

In addition to methamphetamine use being facilitated by the virtual sex scene on the apps, participants also discussed widespread availability and use of methamphetamines at sex parties, clubs, and group sex events.

You have a few other people that still are partying, and those are the ones that are still partaking in [methamphetamine use]. So it’s usually people who I can say are partygoers, people who go out, like they have a good time and they enjoy sex experiences or sexual parties, group sex, and usually that’s involved in group activities, it kept you going longer.

(Focus Group 6)

Pleasurable aspects of methamphetamine use were discussed in multiple focus groups. Within these discussions, several participants described individuals who were able to use methamphetamine casually or occasionally within these settings. At times, our participants described this type of casual use with sex or “parties” as an entry point that often led to more regular use with detrimental effects for the user.

Risk Environment: Macro-level factors

At the macro-level, the healthcare and policy risk environments intersected to create communities with low knowledge and resources pertaining to treatment and prevention of methamphetamine use.

Lack of Resources -General

Poverty, at both the individual, network and community levels, was described as a major impediment to addressing methamphetamine use among Black GBMSM. Participants lamented a general lack of financial or other resources available for Black GBMSM to draw upon if they became addicted to methamphetamine.

I think that’s particularly bad because we, as Black gay men, we are less equipped, as people we are less equipped, to deal with the negative effects of drug abuse that white gays and whatnot, because they have more wealth, more education, and they are more equipped to stave off the negative effects, to get access to treatment, to get access to help. They have more job security and higher skills, higher wages, more job security, so it’s less likely you will be fired from your job if you’re addicted to drugs. So I think that with our community being disproportionately exposed to poverty, being less educated, and therefore less equipped to deal with the negative effects, we are sort of drowning.

(Focus Group 7)

As illustrated by this quote, this inability to access treatment and support for substance use was a racialised problem, explicitly contrasted with white GBMSM who were perceived as being wealthier, having a higher degree of social capital, and easier access to healthcare. Importantly, the participant unambiguously named poverty and education as exposures, as opposed to attributes of individual Black GBMSM.

Lack of Education and Prevention Specific to Methamphetamines

We asked all groups about availability of prevention programming specific to methamphetamines, and the overwhelming response from participants was that they were not familiar with any programs of this nature.

I never hear about meth like that on TV. You know, and I feel like they – I don’t feel like they want to address it that way, you know being that it is a major issue in Atlanta.

(Focus Group 7)

Harm reduction resources were similarly described as lacking in the Atlanta community with respect to methamphetamine abuse. Effective harm reduction services were described for those who inject drugs – for methamphetamine users, however, the perception was that only a small minority progressed from smoking to injection.

Many participants attributed this lack of prevention and harm reduction to a lack of education about methamphetamine use, and contrasted the emphasis on methamphetamines with the much more dominant conversation on opioids.

Everybody is aware of – like society is geared towards awareness about opiates. There is a whole national movement, where everybody knows about the opiate epidemic, and that’s what we’re focused on right now.

(Focus Group 7)

Participants either implied or specifically named racial and gendered reasoning behind preferential attention to the opioid epidemic, stating “opiates exist in [the] Caucasian community, in the everyday housewife situation, with the doctor’s wives or the attorney’s wives. So we’ve got to address this.” (Focus Group 4)

Lack of Treatment Resources

Participants also pointed specifically to lack of substance use treatment that focused on, or at least included, methamphetamine users. A few of the participants’ organizations offered 12-step programs or other group therapy for substance use in general, including methamphetamines. As professionals providing these services, however, they often felt that specific knowledge of methamphetamine was lacking.

In most cases, even centres like [participant’s workplace], they’re not – I don’t feel adequately equipped to focus on the meth usage. The trainings and experiences go mostly into cocaine, crack cocaine, marijuana, and they mean well, but there needs to be some sort of intervention to get people educated on how to deal with meth users.

(Focus Group 4)

In other cases, substance use facilities were providing services that were specifically not geared towards methamphetamine use. Many participants cited a successful needle exchange program– however, as most people who use methamphetamine were not perceived as injecting, this was not an option for most clients. Multiple participants in different groups cited another specific facility that focused on detoxification, but because of the lack of a defined withdrawal syndrome from methamphetamine (in contrast to heroin or alcohol), clients often had difficulty getting accepted to this facility. It was commonly known in our group, that one way to get around this requirement was for would-be enrolees to consume excessive alcohol, even if what they truly wanted to detox from was the methamphetamine.

Yeah, so [facility name], you can go there if you have an opioid situation, or barbiturates, or alcohol. So what they tell people is to show up and act like, crazy, or slug a bottle of vodka before you show up, and that way you’ll get in there and you can kind of play the game and say oh, I’m an alcoholic, but get your four or five days off the street.

(Focus Group 3)

The availability of treatment facilities was contrasted with options for other substances, especially opiates, which have recently received more funding and attention. The issue of funding was quite salient across group discussions; participants noted that they had not observed funding streams specifically targeting methamphetamine use among Black GBMSM, and that services were unlikely to follow as a result.

Finally, there were a few programs that were mentioned, such as Crystal Meth Anonymous or similar 12-step programs focused specifically on methamphetamine – however, participants perceived these as being more targeted towards white GBMSM.

There is the [name of group], but it’s in Midtown. And colour shouldn’t matter, it really shouldn’t, but its primarily white. There’s a different type of support available for whites. Everybody knows the [name of group], no matter what colour, but obviously when you go over there you don’t feel a part of what’s going on because it’s so overwhelmingly Caucasian. It would be nice if there was somewhere you could go where you could see yourself represented, you know what I’m saying?

(Focus Group 4)

DISCUSSION

Our sample of community-based key informants were virtually unanimous in their agreement that methamphetamine use has recently become more pervasive among Black GBMSM in Atlanta. All levels and most types of risk environment influences (i.e., the social, economic, physical, political and healthcare risk environments) were referenced as contributors to these trends. Given the extensive disparities in HIV incidence and prevalence that already impact this population, and the well-documented associations between methamphetamine use and suboptimal HIV prevention and treatment outcomes, these new trends could have staggering implications and negative impacts on efforts to end the HIV epidemic in the US. Many of the trends and risk environment influences described in our study are similar to those described over a decade ago among diverse groups of GBMSM in other parts of the country (Garofalo et al., 2007; Halkitis et al., 2005), however, our analysis also revealed important racialised and class dynamics in the Black, Southern context. Consistent with critical race theory (Ford & Airhihenbuwa, 2010), and with critical drug literature focused on the racialisation of the US opioid epidemic (Hansen, 2017; Netherland & Hansen, 2017; Parker, Hirsch, Hansen, Branas, & Martins, 2019), we similarly demonstrate the importance of race and class as structural drivers of substance use among Black GBMSM in Atlanta. Most notably, our participants highlighted increased vulnerability among young, geographically mobile Black GBMSM, a group impacted by multiple layers of structural disadvantage including poverty, poor healthcare access, systemic racism, and homophobia.

Within this context, our participants’ descriptions of the risk environment suggest several potential strategies for intervention. At the micro-level, our participants focused on homelessness, poverty, mental illness, and use as a sex drug as facilitators of methamphetamine use. The role of methamphetamine as a sex-drug is and association with sexual risk (Semple, Strathdee, Zians, & Patterson, 2010), as well as the association with mental health comorbidity (Akindipe, Wilson, & Stein, 2014), confirm findings from prior research in other studies. Additionally, our participants heavily emphasized the role of financial and housing insecurity in creating vulnerability to methamphetamine use. In particular, younger Black GBMSM moving to Atlanta from other locations might be at particularly high risk for methamphetamine initiation and its consequences. Structural interventions to provide housing and/or financial support, clinical interventions to enhance methamphetamine treatment and mental health care options more broadly, and behavioural interventions, particularly among geographically mobile populations of younger Black GBMSM, could all have a role in preventing methamphetamine use.

At the meso-level, our participants extensively discussed the interconnectedness between methamphetamine use and the sex scene, including clubs and sex parties, consistent with many prior characterizations of methamphetamine use in the gay community over the last decade and a half. However, our participants focused much more heavily on the virtual sex scene – and in particular the integral nature of geosocial networking apps to the dissemination of methamphetamine use in the community. Work in Australia has similarly described an important role for online sexual spaces in the negotiation of sex with concomitant methamphetamine use (Race, 2015). Use of geosocial networking apps is widespread among GBMSM in the US, including young Black GBMSM in the South (Duncan et al., 2018; Goedel & Duncan, 2015). Additionally, use of these apps has been associated with increased risk of sexually transmitted infections (Wang et al., 2018), higher numbers of sex partners and increased rates of condomless anal sex (Macapagal et al., 2018). Despite these associations with risk, young Black GBMSM have also reported being open to the use of geosocial networking apps for recruitment into, and delivery of, sexual health interventions (Fields et al., 2020). Our findings suggest that mobile phone-based research and intervention, including leveraging of geosocial networking app use, may be a particularly effective strategy to advance methamphetamine-related prevention and support efforts. Additional interventions should target clinicians and facilities that provide sexual health and/or HIV care to young Black GBMSM. For example, future interventions could train clinicians to screen patients presenting for sexually transmitted infections, HIV pre-exposure prophylaxis (PrEP), and/or HIV care for methamphetamine use, and to link patients to appropriate substance treatment services where indicated.

At the macro-level, participants point to a near-complete lack of public health messaging or treatment services that addresses methamphetamine use among Black GBMSM. Participants cited a need for education – targeting Black GBMSM but also clinical and public health professionals – around the clinical characteristics and consequences of methamphetamine use. The relative public health silence on methamphetamines was particularly apparent to our participants when contrasted with public health messaging and associated resources allotted for addressing the opioid and HIV epidemics. Although this disparity was a point of frustration for many of our participants, there may be opportunities for synergy with existing programs and resources that were initially meant to target HIV or opioid use. Importantly, although funding may be siloed, methamphetamine use, HIV, and opioid use share important structural drivers including but not limited to poverty, housing instability, systemic racism, and criminalization (Netherland & Hansen, 2017). Policy efforts to address these upstream influences, for example through antipoverty measures, housing relief, antiracism efforts and/or decriminalization of drug use, have potential to benefit each of these epidemics.

Limitations

Social desirability may have influenced participant responses, given the public data collection method (i.e., group discussions involving co-workers). Additionally, although our participants were very knowledgeable about the Black gay community in Atlanta, we did not intentionally recruit people with personal histories of methamphetamine use for this initial exploratory study – descriptions of drug use and its influences were therefore second-hand in most cases. Future work should incorporate more perspectives from Black GBMSM who use methamphetamines, in order to get a richer understanding of the risk environment (particularly micro-level factors). First-person accounts from people who use methamphetamine may also reveal more about pleasure and other desirable effects associated with use among Black GBMSM; we acknowledge that our sample was heavily weighted with HIV-focused public health professionals who might be more likely to focus on the negative (e.g., HIV risk-promoting) impacts of methamphetamines. Finally, we did not specifically explore relationships between methamphetamine use and PrEP utilization. Work in other contexts has suggested HIV risk mitigation with increased PrEP utilization among GBMSM who use methamphetamines (Hammoud et al., 2020; Hammoud et al., 2018), future work should examine relationships between PrEP use and methamphetamine use in Southern Black gay communities as well.

Conclusions

Increasing methamphetamine use among Black GBMSM in Atlanta has potential to exacerbate existing disparities in health and well-being among men in this community, and to impede ongoing public health efforts to end the HIV epidemic. Further epidemiological study to confirm the extent of these trends is warranted, as is intervention development to enhance prevention, treatment and harm reduction related to methamphetamine use among Black GBMSM in Atlanta.