Substance Use or Alcohol Consumption and HIV-Related Sexual Behaviors Among Sexual Minority Men (SMM) in San Francisco, CA

Substance and alcohol use are often used in sexual contexts among sexual minority men (SMM) and may be associated with condomless anal sex (CAS), a proximal exposure relevant to HIV risk. This study examined the association between alcohol and substance use during sex and the frequency of insertive (ICAS) and receptive (RCAS) condomless anal sex. A secondary analysis of cross-sectional data from a respondent-driven sample (RDS) of 252 SMM in San Francisco in 2020 was conducted, and 135 participants who reported at least one CAS event with their last three sexual partners in the past six months were included in the analysis. A zero-truncated negative binomial regression model was used to estimate the rate ratio (ERR) of ICAS and RCAS. Results indicated that being drunk before or during sex was associated with a 2.6-fold increase in the number of ICAS events and a 7.2-fold increase in the number of RCAS events. Methamphetamine showed inverse associations with ICAS (ERR = 0.5) and RCAS (ERR = 0.3), while poppers were positively associated with ICAS (ERR = 2.5) and RCAS (ERR = 3). Overall, alcohol intoxication and popper use in sexual contexts were associated with higher CAS counts among SMM, supporting stigma-free harm-reduction screening and PrEP/STI prevention, while inverse associations with methamphetamine warrant cautious interpretation and event-level study in future work.