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Tag: Substance use

Relaunched Tweaker site tightens ties to substance-use support group

Since its inception 22 years ago, tweaker.org has been a resource for people seeking tips on using crystal meth more safely. After a design update this spring, the site is now configured to better serve the community.

In 1997, STOP AIDS Project surveyed some of San Francisco’s gay male community about issues around HIV and crystal meth was identified as a large driver for transmission. Thus, a social marketing campaign was born to address how meth affects sexual health and overall wellbeing.

The ad campaign appeared around San Francisco and tweaker.org was launched that summer, continuing for two years before its funding was canceled, leaving a static and dormant web address.

Stonewall Project, a harm reduction counseling group for gay, bisexual, queer and trans men interested in changing their relationship to drugs and alcohol, resurrected tweaker.org in 2001 as an additional outreach tool. Then, a decade after its debut, tweaker.org became part of San Francisco AIDS Foundation along with the Stonewall Project.

Jen Hecht, senior director of program strategy and evaluation at SFAF, has over 20 years of experience in public health with a focus on HIV and STIs. Now overseeing the relaunch of tweaker.org, which was updated this year to incorporate new mobile technologies and easier site navigation, Hecht spoke about the importance of access to sexual health information and the evolution of drug language.

How is tweaker.org different from other websites that offer harm reduction tips?

Jen Hecht: The fact that it’s not coming from an abstinence-only focus is huge. [The language is] non-judgemental and it’s in a tone that’s for the person who’s using. People have struggles that they’re facing and being able to learn how to really deal with them is essential.

What are the goals of tweaker.org?

The number one focus is to make sure people have access to accurate information. Secondly, and almost as important, is that people have access to communities of other users and peers, and feel that they’re not being judged. This site has been around for a lot of years and there has been a lot of activity with people supporting each other with information they’ve learned from their own experience.

Why is tweaker.org important to you?

It’s important because there are lots of people who are using and want to be able to use safely. [They] want to be able to take care of their friends, family, or partners who are using. They can be on their phone on the street and access that information. They don’t have to walk into a service provider or into a place that has a name on the front of the building that they might not feel comfortable with or be judged for. There’s any number of different scenarios where someone might not be in a position to walk into a treatment space, and that is completely fine, but they should still be able to access the information.

How have you seen drug language evolve over time?

There are terms that evolve and terms that, over time, acquire a certain stigma or negative association that we then want to move away from. While we’re based in San Francisco and a lot of the tweaker.org language is influenced by that, the website itself is accessed by people around the world. We recognize that regionally these things can be very different and that language may not be as on-point in other parts of the country or the world, but hopefully it’s at least clear.

How does tweaker.org intersect with the harm reduction values of the foundation?

We want to make sure people feel safe and welcomed into the [digital] space, and that they can get the information they want and not feel judgement.

In this new relaunch, we tightened the connection to Stonewall Project who runs tweaker.org. They have so much knowledge and expertise to share. We’re trying to make it easier for people who want to get support to be able to find it; there’s no pressure around it. The door’s open if that’s what you want, and if it’s not, here’s some information that will hopefully make using as safe, joyful and pleasurable as possible.

Try it! Access the relaunched tweaker.org from your mobile device for tips on using crystal meth more safely.

Reducing meth use improves depression in people living with HIV

Methamphetamine (meth) is a powerful stimulant that in the short-term can improve mood, energy levels and alertness—but when used long-term can lead to depression and other mental health concerns. Some people who use meth and want to make a change to their substance use opt for complete abstinence, through programs such as Crystal Meth Anonymous (CMA) with the belief that stopping substance use is the only way to “recover” from addiction. New research, published in JAIDS, is the latest in a long line of studies over many decades which shows that people struggling with substance use can experience significant improvements without abstinence.

Jeremy Prillwitz, MA, CATC
Jeremy Prillwitz, MA, CATC

I’ve been working in drug and alcohol counseling for about 8 years, and the take-home message from this study for me is that harm reduction works. A lot of people say that you have to quit meth to have any hope—but that’s just not true.

Many people are able to successfully use drugs, and many people who make changes to their substance use don’t do it with complete abstinence.

Details of the study

The study included 9,905 people living with HIV who reported the frequency that they used drugs including crack/cocaine, amphetamine-type substances (e.g., meth), illicit opioids and marijuana every six months. The researchers assessed depressive symptoms using a measurement tool called the Patient Health Questionnaire.

Most of the people in the study were men (84%) and 40% reported using a substance at the beginning of the study. A total of 1,016 reported meth use, 728 reported cocaine/crack use, 290 reported illicit opioid use and 3,277 reported marijuana use during the study. The researchers examined associations between changes in the use of individual drugs and depressive symptoms.

Over time, substance use reduction and abstinence were associated with improvements in depressive symptoms.

Changes in meth use were associated with the greatest improvements in depressive symptoms: Reducing meth also led to a significant decline in depressive symptoms (on average a decline of 1.7 points). Abstinence from meth reduced the depressive symptoms score on average 2.2 points (compared to people who continued to use).

Depressive symptoms


For other drugs, the impact of abstinence and reduced use on depression was more subtle.

Stopping marijuana decreased the average depressive symptoms score by 0.5. Reducing marijuana was associated with a decrease of 0.4.

Stopping cocaine/crack decreased the depressive symptoms score by 0.8, but reducing use did not lead to a significant decrease in depressive scores.

Stopping or reducing use of opioids was not significantly associated with a reduction in depressive symptom scores.

“Reducing [amphetamine-type drugs] was more strongly associated with alleviation of depressive symptoms, perhaps suggesting that it has greater detrimental clinical impact, including on depression, than other drugs in this population,” the researchers speculated.

The intertwined effects of meth and depression

The results of this study closely align with what I see working with clients every day.

Depression and meth use are tightly intertwined. People who experience depression are more likely to seek out meth as a way to self-medicate, and people with no history of depression are more likely to experience depression after taking meth regularly.

The reasons are pharmacological.

Meth, a stimulant, can be an incredibly effective solution to depression in the short-term. People with mental health issues often use drugs as a way to self-medicate—seeking out the particular types of drugs that solve their mental health concerns. People who are anxious are more likely to use alcohol, benzodiazepines, marijuana and other depressants; people who are depressed are more likely to seek out stimulants like meth.

A lot of people that use stimulants, in particular, have pre-existing depression. And when they discover their stimulant of choice, they feel like, “Oh my god! I finally feel normal.” Meth floods your brain with dopamine, and also prevents the re-uptake of it. In the short-term, it can blow your depression out of the water.

The problem is that it’s next to impossible to regulate meth use (or any illicit substance) in a way that mirrors the precision of pharmacological therapy. People taking meth flood their system with high doses that spike dopamine levels and lead to dramatic crashes. Drug supplies are unreliable and can be filled with adulterants. People taking frequent, high doses develop tolerance. With time, the brain loses the ability to naturally produce endogenous dopamine, which makes it even harder to stop using. The self-medication benefits from meth use stop working over the long-term.

Long-term meth use also makes people more susceptible to depression, by changing the amount of endogenous dopamine produced by the brain.

These changes mean that it can be incredibly difficult to stop using meth cold turkey. Withdrawal and post-acute withdrawal, which people experience as depression, irritability, intense fatigue and more are the effects of the body and brain adapting to the loss of dopamine.

Many people opt to reduce their use of meth, as a way to reduce the negative impacts that meth can have while lessening the withdrawal symptoms that may come from stopping use outright. And this study shows that reducing your use—even if you don’t quit altogether—can lead to significant, measurable improvements.

Reducing use and other harm reduction strategies

Reducing substance use is one way to reduce the negative impact that drugs can have on your life, but it’s not the only way.

Substitution strategies involve understanding what one is getting from a drug, and then trying to find other less harmful drugs or non-drug related activities to fulfill those same needs. For example, many clients find that they can use cannabis to help reduce social or sexual inhibitions instead of using meth in social or sexual situations.

You can also change how you administer or use your drugs. Some clients find that injecting is more problematic for them than smoking, snorting or booty bumping. Some people believe that once you have injected, it is difficult to revert to a different mode of administration, but people make this change frequently and successfully.

Improving your safety when you use drugs is also a harm reduction priority. Even if you do not significantly change your quantity of use, you can do things like only invite people you know for party and play in your room. Or you can always let a close friend know where you are and ask them to check in with you after a certain amount of time to ensure that you are safe.

Another key strategy is timing your meth use strategically. You can make sure to eat, pay rent and bills, and make it to a medical appointment BEFORE starting to use meth. A person with a job may set boundaries such as only using on weekends, or cutting off their use at a certain time and trying to get at least a few hours of sleep. Some people also find it helpful to set alarms for times when they need to take medications, or strategically place water, lube or other safer supplies in places they will likely be when using.

The take-away message is that many people can use meth and still maintain a quality of life that is commensurate with their values.

Want to talk to someone about drugs or alcohol?

The Stonewall Project is here to help. Stonewall offers free harm reduction counseling to gay, bi and trans men who want to assess their substance use and are thinking about making changes. For more information and to seek services, visit stonewallsf.org or call 415-487-3100.


Delaney, J.A. and colleagues. Brief Report: Reduced Use of Illicit Substances, Even Without Abstinence, Is Associated With Improved Depressive Symptoms Among People Living With HIV. JAIDS, November, 2018.


How to Booty Bump Better

Booty bumping involves mixing drugs—usually meth or cocaine­—with water and squirting it into your butt through a syringe without a needle at the end.

If you’re considering this way to use, or maybe want to learn how to do it more safely, read on for what we know about the technique, the risks and potential harms, the possible benefits, and more.

Why people booty bump

People booty bump so that they can avoid injecting, because injecting drugs can cause skin/vein damage and can be painful. If you booty bump, you won’t end up with “tracks” on your arms and may be less likely to end up with scabs, sores and other abscesses on your skin. People also may booty bump so that they can avoid snorting drugs, which can damage your nose, or avoid smoking, which can damage your lungs.

Jeremy Prillwitz, MA, CATCAlso, you’ll likely experience stronger effects of the drug if you booty bump (than if, for example, you swallow your drugs). The rectum happens to be very efficient at absorbing a high percentage of a drug into your bloodstream—which is why some medications are administered through the rectum.

Booty bumping has a very high “bioavailability” rate compared to other routes of administration. That means that a higher percentage of the drug gets into your system with booty bumping, than for example, if you smoke your drugs.

How people booty bump

Some people will simply insert the drug in their ass without mixing it in water. This is called “dabbing” or “stuffing” if the drug is wrapped in a rolling paper.

It is less physically damaging to booty bump if you first mix your drugs in water. Draw the liquid up with a clean syringe (with the needle removed).

Lube applicator
Lube applicator

Some people also use lube injectors (lube shooters or lube launchers) to booty bump, which can be even more effective than syringes because they are designed specifically for placing fluids into the rectal cavity.

Add a bit of lube to the outside of the syringe and to the inside of your butt for smoother entry and to prevent rips or tears.

Lie on your side or find a position where you can reach to insert the syringe into your butt. Gently insert the syringe into your butt and press the plunger all the way to the base (hold onto the base so you don’t lose it!) After a few minutes, carefully pull the syringe out.

Booty bumping risks


You might damage the tissue of the rectum and anus if you booty bump, especially if you do it frequently. Damage to the rectum and bleeding can increase the risk of HIV and STI transmission during anal sex (and can also be painful).

To reduce this risk, it can be helpful to alternate between booty bumping and other modes of administration such as snorting or smoking. Booty bumping frequently over a short period of time does not give the tissue enough time to heal, so it’s best if you can limit yourself to booty bumping no more than a couple of times a week—with a few days off in between.

Lube up the inside of your butt with petroleum jelly before booty bumping to prevent damage to your anal canal, and insert a Vitamin E capsule afterwards to promote healing.


Make sure all of your booty bumping equipment is thoroughly cleaned and disinfected—or else you run the risk of developing an infection.

Start with a clean surface, wash your hands with soap, and use only sterile water, syringes and other materials. Sharing a syringe causes similar risks, so make sure you have your own syringe. It is good harm reduction and usually enjoyable to booty bump with someone else, as long as you each have sanitary accoutrements.

Want to talk about the way you use drugs and alcohol?

The Stonewall Project is here to help. Stonewall offers free harm reduction counseling to gay, bi and trans men who want to assess their substance use and are thinking about making changes. For more information and to seek services, visit stonewallsf.org.

butt health cartoon logoDouchie brings butt health & happiness out of the closet so you can care for your butt in the way it deserves. Get info about everything from douching to fisting with this series on all things anal.

Check out Douchie’s Guide to Butt Health & Happiness by San Francisco AIDS Foundation.

Alcohol & HIV: What You Need to Know

“We are not here to wag fingers at bars or people who drink. We are here to provide information and resources so that everyone has the knowledge to make the best possible decisions about their health.”

—Neil Giuliano
CEO, San Francisco AIDS Foundation

On February 16, 2012, San Francisco AIDS Foundation held a public HIVision forum titled, “Alcohol & HIV: Current Thinking about Drinking.” In his introduction, foundation CEO Neil Giuliano observed that alcohol use in our community is pervasive—so much so, that “the line between drinking and drinking too much often gets blurred. And when we cross that line, many of us don’t have the tools to recognize it and know where to get help.” According to the Centers for Disease Control and Prevention (CDC), Giuliano said, one in six U.S. adults binge drinks, defined as consuming five or more drinks within two hours for men, and four or more drinks within two hours for women. Excessive alcohol use contributes to car crashes, violence, and sexually transmitted infections like HIV and is implicated in nearly 80,000 deaths per year.

San Francisco AIDs Foundation CEO Neil Giuliano with Hivision panelists“So,” asked Giuliano, “is drinking bad for us?” Not necessarily, given research showing cardiovascular benefits of moderate drinking. In addition, he said, “we want to recognize the important role that our bars and clubs—and the LGBT merchants and allies who run them—play in creating a very strong sense of community” here in San Francisco. Giuliano’s opening remarks highlighted some of the complex health and social issues surrounding alcohol use and laid the groundwork for a lively panel discussion.

Invited panelists included Susan Buchbinder, MD, director of research for the HIV Prevention Section at the San Francisco Department of Public Health and assistant clinical professor of medicine, epidemiology and biostatistics at the University of California, San Francisco (UCSF); Michael D. Siever, PhD, director of behavioral health services at San Francisco AIDS Foundation; and Chris Hastings, owner of LOOKOUT bar in San Francisco’s Castro neighborhood. The panel was moderated by E. Maxwell Davis, PhD, MSSA, assistant professor of human development and women’s studies at California State University, East Bay.

The purpose of this forum was to begin a frank dialog about the intersection of alcohol use, HIV risk, and HIV health. Following is a summary of key questions and issues that emerged during the panel and audience discussion.

To put alcohol in perspective, how is it similar to and different from other drugs?

“Alcohol affects virtually every part of the body if it’s used in excess. . . . It may be similar to some drugs, but rather than a focused or concentrated negative effect, it has a very widespread effect.”

—Susan Buchbinder

Alcohol is an intoxicant and central nervous system depressant like many other substances of abuse, but it is legal, readily available, and widely socially accepted. Like other drugs, alcohol alters the way we think about, perceive, and react to things, but as Dr. Susan Buchbinder noted, excessive alcohol use has broader effects throughout the body. Buchbinder also explained that alcohol can alter the way medications are metabolized in the body, which may reduce their effectiveness or cause unwanted side effects.

Unlike some more addictive substances, there is “a spectrum of people who are more susceptible or less susceptible to becoming addicted to [alcohol],” Buchbinder observed. “It’s not necessarily a very addictive substance, but for some people, it probably is.” Dr. Michael Siever emphasized that although not everyone who drinks becomes addicted to alcohol, it is a drug. “One of the phrases that a lot of us in the substance-abuse field use pretty frequently is ‘alcohol and other drugs,’ the emphasis on ‘other.’ . . . When you ask people what drugs they do, they generally are not going to talk about alcohol.”

And yet, Siever continued, overuse of alcohol can have consequences as deadly as any other form of substance abuse. “There are regularly stories about . . . ‘hazing’ events where people are encouraged to down a fifth of vodka in one gulp. That can kill you. So it’s a serious drug, but we don’t think of it that way.”

Buchbinder agreed. “I would say that we see many, many more diseases that are related to alcohol use, deaths related to alcohol use, and hospitalizations related to alcohol use than probably all of the other drugs put together”—most likely, she said, because more people drink alcohol than use other drugs and because alcohol affects every organ in the body when overused. “If you’ve already got disease in an organ—the brain, the liver, the heart, the kidneys—alcohol can make that worse.”

“Frankly,” added Siever, “alcohol is much harder on your body than heroin!” Siever acknowledged research indicating the health benefits of moderate drinking, but cautioned that “it’s pretty easy to tip over into the territory where it’s really not a positive effect on your body.”

Given alcohol’s wide social acceptance, how do we define and recognize problematic alcohol use?

“Obviously, it’s about when your drinking is starting to cause problems. That’s easy to say, but the problem is we don’t always recognize when our drinking is causing problems.”

—Michael Siever

According to Siever, drinking is widely considered a cultural “norm”—a view that obscures the real range of ways people use (or don’t use) alcohol. “We tend to think either [your drinking] is fine or you’re an alcoholic, and there’s nothing in between. That’s a major problem in terms of how we think and talk about it.” Rather, there is a continuum of alcohol consumption, from total abstinence and non-problematic use to problematic overconsumption, alcohol dependence, and alcoholism.

Siever mentioned a CDC survey showing that only 50% of American adults drink regularly—although, he noted, the survey “defined a ‘regular drinker’ as someone who drinks 12 or more drinks a year, so that’s a pretty hazy definition.” To moderator Dr. E. Maxwell Davis, this definition further demonstrated how alcohol is viewed differently from other drugs: “If I tell someone that I use crack casually, they probably automatically tell me I have a problem, right? . . . There’s no level of socially acceptable use for a lot of other substances.”

Chris Hastings offered two perspectives on problematic alcohol consumption. “As a member of the community and as a friend, I would say problem drinking is something that’s going to negatively impact someone’s life; it’s going to cause them to make decisions that maybe they wouldn’t otherwise. Maybe that’s on the scale of an evening, or it could be bigger—something that’s going to affect their job or [relationships].” As the owner of a local bar, he has another take: A sign of problem drinking could be “someone just being loud and rude and annoying the patrons around them, or it could be something more serious so that they hurt themselves. There’s a pretty big spectrum of what could be considered a problem.” At his bar, Hastings takes these warning signs seriously: “I think it’s really important for me and my staff to recognize and see those things before they become big problems.”

Siever added that “drinking can cause problems in a lot of different ways, whether it’s physical health or mental health or becoming belligerent or unpleasant. There are also people who quietly drink and it’s not so obvious, but it’s causing problems for them also.” Continuing to do something despite the negative consequences is key to some definitions of addiction, Siever explained. “If you’re having negative consequences yet you continue to do the same thing, that’s a problem.”

Buchbinder identified specific signs of problem drinking, including driving while alcohol-impaired. Drinking among young adolescents is also problematic, she said, as is heavy alcohol use by people over age 65. Among older adults, overconsumption is “going to be a problem particularly, because they are going to be more susceptible to infections [and] to cancers.”

In a clinical setting, Buchbinder said, doctors start asking patients about their alcohol use “when we do blood work and we see a particular pattern of liver dysfunction; we know that that’s from alcohol.” She also described the “CAGE” score, a mnemonic device to remind clinicians to ask patients a series of questions about their alcohol use: Have you ever felt like you need to cut down on your drinking; have you annoyed people with your drinking; do you ever feel guilty about your drinking; and do you ever need an eye opener—that is, do you need a drink in the morning to be able to function? “If people say ‘yes’ to any of those questions, then that’s a trigger to start to ask more questions.”

How does alcohol use affect the health of people living with HIV?

“Probably the biggest issue is that when people are drinking too much, they’re not taking their meds.”

—Susan Buchbinder

Susan BuchbinderBuchbinder emphasized that people with HIV don’t necessarily need to abstain from alcohol unless they have a comorbid condition, such as hepatitis C or other liver disease, that would be worsened by alcohol use. But, she continued, “HIV and alcohol act synergistically, so that there’s more brain tissue disruption. There’s a new understanding of how HIV causes disease by causing these inflammatory reactions, and alcohol also increases that.”

In addition to the risk of increased inflammation—and the resulting higher risk for neurological and cardiovascular problems—alcohol use may interfere with HIV-positive people’s ability to adhere to their antiretroviral treatment regimen. “In talking with colleagues, they say that they can get most of their patients down to an undetectable viral load, including sometimes their meth users, their crack users, their injection drug users, but not their alcoholics,” related Buchbinder. “It’s just so destructive to the rhythm of people’s days that it’s really challenging to help people to use meds effectively. If you aren’t using them effectively, you may be developing resistance, and you may be eliminating your future options.”

Alcohol use can also have negative consequences for mental health, Siever noted. Not everyone who turns to alcohol during times of stress or sadness realizes it is, in fact, a depressant. “For those of us living with HIV, depression is one of the things that we struggle with,” he explained. “Drinking, although initially or in the moment seems like it’s helping, probably isn’t helping—and in some ways it probably makes [depression] worse. That’s another way that it interacts with HIV disease.” Siever also noted that, “along with depression, isolation is a real issue for a lot of people—in general, but also for people with HIV. It’s a well-known fact that for people who have problematic drinking or other drug issues, over time, isolation tends to be a result of that.”

Drawing from her own research on HIV and alcohol, moderator Davis mentioned that heavy alcohol use can interfere with important self-care behaviors. “I remember people saying [in interviews], ’It’s not so much what I do if I’m drinking a lot, it’s what I don’t do. I don’t go have coffee with my good friend who is supportive of me, I don’t go to the gym, I don’t do my laundry and such. . . . I don’t do the things that I need to do to live successfully with this disease, because there are times when my drinking is getting problematic.’”

Buchbinder also brought up the challenges of aging with HIV in relation to alcohol. “A lot of the negative impacts of alcohol may accumulate over time, so what might not seem problematic now could be problematic later on,” she observed. As people with HIV live longer, “we might be dealing with the consequences of alcohol at a later time when it’s had an opportunity to cause more disease.” Siever offered his own perspective: “For a lot of us who’ve been living with HIV for a long time, there’s this whole history and accumulation of all the things we did when we thought we were about to die. . . . What impact did that have? What’s our relationship with alcohol and other drugs now? It’s a complicated trajectory over the last 30 years.”

The San Francisco Department of Public Health has identified alcohol as a driver of new HIV infections. In what ways does alcohol contribute to HIV transmission and acquisition risk?

“There’s a lot of data to suggest people are not as safe when they’re under the influence of alcohol. It’s probably partner choice, it’s probably what you’re doing—it may even be how you’re doing it. It’s a combination of all of those things.”

—Susan Buchbinder

Buchbinder explained that the Department of Public Health defines a “driver” of HIV infection as something that is both independently related to HIV acquisition (all other things being equal, that particular factor, in this case alcohol, increases the risk of becoming HIV infected) and is common (that is, at least 10% of the population has that particular risk factor). “Alcohol meets both of those requirements,” she said.

“In terms of becoming HIV infected,” she continued, “it’s probably about what you choose to do sexually” while under the influence. “It’s not clear that [alcohol] is really affecting biologically what’s happening to you; it’s more likely that it’s affecting your judgment, your sexual practices, your choice of partners at the time, those kinds of things.” Added Siever, “in the context of HIV transmission, you don’t have to be an alcoholic or addicted to a drug to have done enough so that you’re not thinking very carefully about what you do.”

Not surprisingly, the disinhibiting effect of alcohol contributes to its role in HIV transmission and acquisition: “We tend to be disinhibited and not think about the consequences of our actions or take responsibility for our actions when we’re a little toasted,” Siever remarked. “And in this culture, it’s also sort of an absolution—like ‘Oh, I was drunk’ is going to absolve you of any responsibility for what you do. I think there are lots of complications about how we think about drinking that make it really problematic in terms of public health.”

Also, Buchbinder noted, if heavy alcohol use prevents people from taking their antiretroviral regimens effectively, there can be potential consequences for both their own health and that of their sex partners. Current research indicates that HIV treatment doubles as HIV prevention by reducing viral load: Less virus in the body means lower likelihood of passing it on through unprotected sex.

Indeed, getting HIV-positive people into medical care and on appropriate treatment is now considered a public health strategy for HIV prevention. “Alcohol probably is the leading risk factor for lack of adherence,” said Buchbinder, “and that will fuel the epidemic—and, more unfortunately, yield an epidemic that has a lot of resistant HIV so that people who are getting newly infected don’t have treatment options either.” To combat this problem, she suggested developing better systems of support for people who are struggling with alcohol and medication adherence. “People should be able to choose whether or not they go on meds,” she stated, “but if they’ve chosen to go on meds, then we want to be sure we have those support structures in place.”

Even after discussing the potential dangers of drinking in the context of HIV health and HIV risk, the panelists agreed that alcohol and bars have an important function in San Francisco. Said Siever, “I’m old enough to remember when gay bars were really the only place you could go to meet other gay people.” Buchbinder added, “that’s the challenge of alcohol, because a little bit of it may be a good thing for some people, right? We don’t want to shut down people’s social interaction.” Hastings agreed, noting that bars have offered “a place where people could come and feel safe when there weren’t other places to go. For a very long time, that was built into what it means to be a part of our community.” And, he continued, “it’s really important for bars to still take on that role. That’s something I try really hard to have LOOKOUT do: really be a part of the fabric of the community that we’re in.”

Can we create effective interventions without addressing the complex relationships between problematic alcohol use and other psychosocial factors like HIV stigma, homophobia, and lack of social support?

“In interviews, folks would tell me, ‘In my family, in my world, on my block, it is so totally unacceptable to be gay, it’s totally unacceptable for me to have HIV—so frankly, I’d rather they think I’ve become an alcoholic.’”

—E. Maxwell Davis

E Maxwell Davis at podiumLike HIV infection, alcohol use and abuse occur in a social context and are driven by a wide range of psychosocial factors, including homophobia and stigma. Siever explained that unease with sexuality and sexual relationships can increase the appeal of using alcohol before engaging with potential partners. “We all think we’re very liberated,” he joked, “but we all struggle with that stuff.” He recalled a conversation with a group of gay men coping with substance-use issues: “I said, ‘How many of you have ever had sex with anyone not under the influence of anything—stone-cold sober?’ And not one of them ever had.”

Buchbinder added, “it’s really clear that the epidemic is driven by a number of upstream issues—stigma, homophobia, poverty, all kinds of things. We definitely do need to address those…but I don’t think those are going to be simple solutions.” Siever suggested harm reduction, a counseling and treatment model that addresses the negative consequences of substance use without requiring a commitment to abstinence from alcohol or other drugs. “Even if you have a problem in terms of your alcohol consumption,” said Siever, “abstinence isn’t necessarily the only answer.”

Stigma around alcohol dependence can prevent people from seeking help, he added: “I think there’s a reluctance to talk very honestly about some of these issues for fear of being labeled as an alcoholic.” Siever highlighted The Stonewall Project, a family of counseling, treatment, and support programs (and part of San Francisco AIDS Foundation) that offers “services people can access regardless of where they’re at with their alcohol use and to what extent they think they do or don’t have a problem with drinking.” He explained, “you don’t have to have already decided or know that you’ve got a problem to be able to come and talk with someone.”

Hastings offered a different take on the psychosocial factors implicated in alcohol use and its interaction with HIV. “I feel like it is possible to address those issues, but I don’t feel like it’s necessary,” he said. Rather, “we should be looking at [having] an impact on decision-making, and the point at which people are making those poor decisions. I feel like that’s a simpler approach to take rather than trying to dissect how complicated and how intertwined alcohol is into our culture, especially in the gay community.” Hastings’ is one of a handful of bars in the Castro and South of Market area participating in the PACE study, short for “Pacing Alcohol Consumption Experiment,” conducted by UCSF and Stop AIDS Project (part of San Francisco AIDS Foundation). Patrons exiting bars opt to take a five-minute survey and use a breathalyzer to gauge their blood alcohol level, and can complete a follow-up online survey about what they did after leaving the bar. The researchers hope to shed light on patterns of alcohol use and related activities, as well as community norms around drinking.

What strengths can we capitalize on in order to address the interaction of problematic alcohol use and HIV/AIDS in our community?

“I think the biggest strength that I’ve seen in the community since I’ve taken over the business is how people band together . . . and how strongly we support each other.”

—Chris Hastings

The discussion ended on a forward-looking note as the panelists turned to the strengths our community can draw on to deal with challenges around alcohol and HIV. Hastings called for greater community awareness of the role of alcohol in San Francisco’s HIV epidemic. “Unfortunately, people don’t at this time see us in being in a crisis mode with this,” he said. In a similar vein, Buchbinder recalled the early AIDS crisis in San Francisco, when people took care of those in need and educated and supported each other in preventing the spread of the disease. “Nothing that we’ve ever done to try to prevent HIV even comes close to what the community did to reduce the rates of infection of HIV,” she said. “I don’t think we could ever hope for a vaccine that would be as effective as the community was.” (She was quick to add, “Hopefully we’ll get a vaccine!”)

Buchbinder also highlighted a need for “expanding that community so that it isn’t just necessarily geographically limited to the Castro.” HIV and alcohol collide in other San Francisco neighborhoods hard-hit by the epidemic; for example, as observed by one audience member, a self-described AIDS survivor, “where I stay, in the Tenderloin, we have four liquor stores to every block.”

To Siever, the word “community” is sometimes overused: “I’ve often complained about how easily we use the word ‘community’ and go around as if it means something, and it doesn’t always.” But, he continued, “part of the meaning of that word to me is that . . . we do take care of each other and look out for each other. I think that does happen a lot, and that is one of our strengths, but it doesn’t always happen.” He emphasized the role of individuals: “If one of our friends is drinking too much, . . . it’s part of being a community and part of being a friend to say something to them.” Concluded Siever, “we’re all in this together.”