Following the initial spread of HIV among men who have sex with men (MSM) at the outset of the epidemic 25 years ago, estimates of new HIV infections among MSM in San Francisco decreased dramatically between 1988 and 1996 from as high as 8% per year in the mid 1980s to as low as 1% per year by 1996 . From 1996 to 2001, HIV incidence rose again reaching about 2.2% per year [WMcF personal communication]. Since 2001, transmission appears to have leveled off at approximately 1.5% to 2.0% per year .
Despite the leveling off in new HIV infections across MSM as a whole, new evidence suggests that many recent HIV infections are linked with the use of Methamphetamine (MA). For example, among anonymous HIV testers in San Francisco, HIV incidence among MA users was 6.3% compared to 2.1% among non-MA users . Recent research indicates that sexual behaviors known to increase risk for HIV transmission, such as unprotected anal intercourse, frequent and prolonged sexual activity and multiple sex partners are associated with MA use [4–24]. Of special concern are frequent users of MA and HIV positive men who use MA [25–27]. MA is a highly potent stimulant and can lead to frequent use, dependency and addiction; upon withdrawal, MA can cause severe psychological and physical symptoms [28, 29]. Injecting MA creates increased risk for HIV transmission from both sexual and needle sharing behaviors among MSM and their partners [30–34].
Based on a population based behavioral surveillance study conducted by the San Francisco Department of Public Health (SFDPH), the prevalence of MA use among all MSM in San Francisco is estimated at 22% (HFR, personal communication). Among HIV negative MSM, 5% reported weekly use of MA and 9% of HIV positive men used MA weekly .
MSM who use MA pose a particular challenge to HIV prevention efforts due to the difficulty in reaching this group of MSM who are often active during very late night hours [HFR, personal communication, ]. The "Party and Play" study conducted by the SFDPH sought to assess this population during 2001–2002 by recruiting study participants between midnight and 4 a.m. in San Francisco parks and streets, near bars and cafes, adult bookstores and other popular cruising hangouts. The study found high HIV prevalence (31%) and extremely high levels of recent unprotected receptive (63%) and insertive anal sex (64%). In addition, an equivalent proportion of both HIV positive and HIV negative individuals in this population reported unprotected receptive (32%) and insertive anal sex (31%) with partners whose HIV serostatus was unknown or sero-discordant. The study population also reported high levels of injection (35%) and non-injection drug use (84%) .
The SFDPH Late Night Breakfast Buffet (LNBB) reported here significantly enhanced the concept and approach of the "Party and Play" study by testing the feasibility of providing harm reduction services, including needle exchange, using a mobile van; extending the hours of outreach to 5 a.m. and following up with MSM three months later to determine prevention and other services utilization.
The goal of the LNBB was to engage MSM who were not being reached through conventionally scheduled HIV prevention programs including needle exchange programs, and to reach MSM who may not find HIV prevention interventions geared towards non-injection drug users appropriate for their needs . We chose a mobile intervention based on the success of similar studies/projects initiated by the SFDPH and literature demonstrating the effectiveness of delivering services to hard to reach populations via mobile vans [37–40]. This paper describes the results of the process evaluation of field based activities as well as the baseline results from study participants. Three month follow up and referral outcomes are reported in a separate paper.