Don't Fool Yourself

Crystal meth just cannot stay out of the news this year. First, there was the story in February of the man in New York who contracted a new multidrug-resistant strain of HIV while engaging in a crystal-fueled sex binge. Now, with more data on methamphetamine's negative effects on the immune system and synergistic effects with HIV in the brain, its evil influence appears to extend well beyond inducing risky behavior. Everyone knows the manic 'I'm king of the world' amphetamine high gives the feeling of invulnerability and lack of inhibition that produces poor judgment leading to the failure to use condoms. Then there is the all-night energy that allows hours of multiple sexual contacts with the help of erectile dysfunction drugs. (Some think those drugs may be beneficial, since condoms stay on better on firmer penises.) But that is just the start of crystal-related problems. Crystal lowers pain thresholds and dehydrates membranes, so rough sex can lead to rectal tears. And crystal users are more likely to have syphilis or hepatitis B or C. Despite these negatives, the numbers speak for themselves. In recent surveys 10% of gay men in San Francisco and Los Angeles reported using crystal in the prior six months. The percentage is estimated to be even higher in New York. And the more you use, the greater the risk of finding out you are HIV-positive. At least 25% of occasional crystal users are HIV-positive. This number rises to 40% in chronic users. At outpatient treatment centers 60% of clients are HIV-positive, while 90% of inpatient programs' patients are HIV-positive. In fact, meth users are more likely than heroin users to be HIV-positive. Moreover, once you contract HIV, the crystal story is not over. The newest data show that crystal just keeps making things worse. From the first moment one becomes infected while on methamphetamine, a person is one strike down. Crystal has already impaired the function of cytotoxic lymphocytes, which are critical for the immune system's first response to HIV. If the immune system responds poorly, the person can end up with a higher viral set point and may need to go on medications sooner than someone not using drugs. In addition, cell cultures and animal models indicate that meth stimulates HIV replication. A study from San Diego has shown that people on anti-HIV medications while still on crystal have higher viral loads than those on meds and off crystal. Years later, crystal is still escalating the side effects of HIV. If one needs to take a statin to lower cholesterol levels, crystal increases the risk of rhabdomyolysis, its most serious side effect. Crystal also increases the risk of heart attack, kidney disease, or stroke. Most significant, however, is the tag-team effort between HIV and crystal in the brain, where meth concentrations are 10 times higher than in the rest of the body. First, meth can damage the lining of the blood vessels in the brain, allowing more HIV-infected cells to reach the brain. Then, crystal enhances the replication of HIV in certain cells, increasing the production of inflammatory substances that damage or kill brain cells. This can lead to HIV encephalitis. Studies of brain activity using newer technologies show damage in areas involved in dopamine activity in long-term crystal users. Likewise, HIV proteins have been found to be toxic to dopamine neurons. Since loss of dopamine can lead to Parkinson's-like movement disorders and loss of verbal skills--an association with HIV dementia--there is great concern that crystal can increase the risk of HIV dementia. I know there seems to be an endless drumbeat about the evils of crystal, but the numbers continue to grow, and the discovery of new areas of methamphetamine complications keeps expanding. So this story can never be told too many times. And do not fool yourself: The average age of a newly infected gay man in New York or San Francisco is about 40. Bowers is board-certified in family practice and is a senior partner with Pacific Oaks Medical Group, one of the nation's largest practices devoted to HIV care, located in Beverly Hills, Calif.