

In a paper released Friday, researchers from UCSF and the San Francisco AIDS Foundation looked at a harm reduction program for gay and bisexual men who use methamphetamine or other stimulants. The program, called the Stonewall Project, does not require participants to abstain from using, but encourages them to consider behavior changes that can improve their health in more subtle ways.

The researchers, who studied 211 gay and bisexual men enrolled in the Stonewall Project, found that over a period of six to 12 months the men cut back on the amount of stimulant drugs they used. They also reported less severe symptoms of addiction and improved employment.

Plus, the men reported practicing safer sex while on methamphetamine. They had fewer anal sex partners and were less likely to engage in other risky behaviors like not using condoms.

"That was exciting to see, because one of the goals of harm reduction is helping people develop sex-risk reduction plans, even while they're using meth," said Adam Carrico, an assistant professor of nursing at UCSF and lead investigator of the study. "We want people to talk about all of these things they can do to be safe before they're high and in the moment."

A proven concept

Harm reduction programs have been widely accepted and used in San Francisco for more than a decade, and the Department of Public Health requires its contractors to practice harm reduction.

But it's still controversial in the addiction field, where many proponents of 12-step programs and other treatment protocols focus on drug abstinence.

The idea behind abstinence programs is that no level of drug use is acceptable, and that may apply especially to stimulants like methamphetamine, which are closely tied to extreme risk-taking behaviors.

But harm reduction advocates point out that policies such as needle-exchange programs - which became popular in the 1980s and 1990s during the peak of the HIV epidemic - prove that teaching people safer drug-use strategies, without abstinence as the goal, can have significant health benefits for individuals and the community at large.

"I have always been firmly convinced that harm reduction works, because it's realistic and practical. People do make positive changes in their life with harm reduction approaches," said Michael Siever, who founded the Stonewall Project in 1997 and was an investigator in the harm reduction study. "Now we have some pretty impressive data to show that people are making healthier choices and are able to cut down on their drug use."

HIV risk with meth

Methamphetamine in particular is strongly associated with the HIV epidemic. People taking the drug are more likely than those who are sober to engage in risky behaviors that make them vulnerable to infection.

Plus, people addicted to the drug are less likely than others to seek treatment for HIV once they're infected. And they have trouble sticking to the strict treatment regimen necessary to keep the virus under control, which hurts their health and also makes them more likely to spread the disease.

"Truly, the best way for me to make you completely safe is for you to not use meth at all," said Keith Humphreys, a Stanford addiction expert who was not involved in the San Francisco study. "However, it is also true - and this data supports it - that if you're still using some meth but you're having less unsafe sex, that also improves your health.

"There are people who say you haven't arrested the addiction if the person is still using. That's true," he said. "But that's not saying their health isn't better and their risk to other people isn't better."

The new study, which is one of the first to specifically address stimulant use and HIV harm reduction strategies, is promising for providing strong evidence that programs like the Stonewall Project can be effective, said Carrico from UCSF.

More study needed

But he noted that there are limitations to the research that need to be addressed, and that further studies need to be done to show that harm reduction programs can lead to long-term public health improvements, including fewer HIV infections.

"We did see reductions in their drug use and risk-taking behavior while they were using. From that perspective, it seems like it's possible for people to achieve some improvements," Carrico said. "But it does highlight need for more research."
