Conversation 4: Community Perspectives on Chemsex Paul Steinberg London HIV Prevention Programme

No conflicts of interest to declare. Conflict of Interest No conflicts of interest to declare.

What needs to be done to make PrEP as successful as possible? Policy Budget Awareness and Education Availability Access for Communities Uptake and Adherence Combination prevention

6.6% How common is chemsex in England? Use of chemsex drugs (crystal, GHB/GBL or mephedrone) within previous 4 weeks: For all respondents across all of England: 6.6% (n=979/15,360) 6.6% Hickson, et al (2016) State of play: Findings from the 2014 Gay Men’s Sex Survey, Sigma Research

21.9% How common is chemsex in England? Use of chemsex drugs (crystal, GHB/GBL or mephedrone) within previous 4 weeks: For HIV positive respondents across all of England: 21.9% 21.9% Hickson et al, 2016

How common is chemsex in London? Use of chemsex drugs (crystal, GHB/GBL or mephedrone) within previous 4 weeks: For respondents living in London: 14.3% 14.3% Hickson et al, 2016

How common is chemsex in London? Use of chemsex drugs (crystal, GHB/GBL or mephedrone) within previous 4 weeks: For HIV positive respondents living in London: 32.7% 32.7% Hickson et al, 2016

An emerging evidence base… Positive Voices (Pufall et al, 2016) 387 sexually active MSM respondents, 29% had engaged in chemsex in previous year MSM involved in chemsex had significantly higher odds of: Engaging in condomless intercourse (91 v. 62%) Diagnosis with an STI (71 v. 39%) Higher mean number of casual sex partners (30 v. 9.5%) Increasing polydrug use associated with increasing prevalence of condomless sex among HIV positive MSM (Daskalopoulou et al, 2014) Higher rates of recent STI diagnosis among MSM engaging in chemsex than those who do not (Kurka et al, 2015; Gilbart et al, 2015) Association between self-aware “high risk” + PrEP + chemsex: - 12% ‘recreational drug use’ in last 3 months (GUMCAD 2016) - 54% engaged in chemsex in last 3 months (PROUD, 2015-16) Do It London Outreach Q14 data (Jan-March 2017, total n4095): 49% tested in last 6 months; 5% already use PrEP; 65% condomless AI previous 12 months (49% with with casual partner); 31% recent GHB/GBL use; 30% recent crystal meth use; 26% mephedrone use Chemsex is increasingly associated with higher risk of STIs (and HIV) transmission – for clinicians, community activists, media & policymakers

14 July 2017

The context of chemsex COUNTRY: France FOCUS: Chemsex in men under 30 living in Paris and Lyon KEY CONTEXTUAL FINDINGS: Chemsex as a context for seeking love and searching emotional bonds with other men ‘Slamming’ initiation followed breakup or beginning of relationship with IDU partner Complicated interplay of emotional and relational rationales for drug use Amaro R. Taking Chances for Love? Reflections on Love, Risk, and Harm Reduction in a Gay Slamming Subculture. Contemporary Drug Problems 43: 216-227, 2016.

The context of chemsex COUNTRY: Netherlands FOCUS: Crystal meth use and slamming KEY CONTEXTUAL FINDINGS: Sense of freedom acquired by disinhibiting effect of “Tina” Reduction in embarrassment and insecurity about sexual performance and attractiveness Problems relating to crystal meth use and chemsex are noticed most by professionals who provide other forms of care to MSM (i.e. HIV and sexual health services) Knoops L et al. Tina & slamming: MSM, crystal meth and intravenous drug use in a sexual setting. Amsterdam, Mainline, Soa Aids Netherlands, 2015

EMIS 2010 & Qualitative Research 2014 15,423 MSM living in England 5,009 in London 1,142 in Lambeth, Southwark or Lewisham 603 in Lambeth 357 in Southwark 182 in Lewisham www.lambeth.gov.uk/chemsex Published March 2014

The role of drugs in relation to risk 4 main groups Pre-determined condomless intercourse A quarter of men had decided to (nearly) always have sex without condoms All were HIV positive All had condomless sex with men they believed to also be positive Chemsex played minor role in action around STI risk, but did play major role in facilitating sex with more men and for longer

Unintended sexual risk under the influence of drugs A third of men had engaged in unintentional sexual risk behaviour Drugs had myopic effect Drugs could be cognitively incapacitating “I try to have protected sex, but the thing is that when you’re in a euphoric state, things happen. You might not be totally aware of what actually people are doing [to you] because you are that fucked.” [Aged 50, last tested HIV negative]

Strict maintenance of safer sex behaviour Using drugs to rationalise risk taking Only the case for a very small number of men Drugs enabled them to push transgressive boundaries Strict maintenance of safer sex behaviour Nearly a quarter of men had strict rules about condom use Used chemsex drugs but little evidence of risky sex “You actually knew what was going to happen. You did it on purpose […] It’s not necessarily that the drugs make you not care, it’s that you’re using them as an excuse so you can go off into this separate little bubble and say that’s not really me.” [Aged 32, last tested HIV negative] Fieldwork conducted in early 2014 – before increased availability of PrEP via private purchase

Perceived harms associated with chemsex Harms to physical health (including overdosing; sexual assault) Harms to mental health Acute irritability Paranoia Anxiety Insomnia Psychosis Time, work and opportunity costs Harms to the gay community commonly perceived to be widespread, visible and easily accessible in London (apps) > Growing community response – facilitated by social media – and service provision is catching up locally

Community responses

Voluntary sector responses

Clinical responses

Number of HIV diagnoses in GUM clinic attendees by quarter and sexual orientation, England 2012-2016 Delpech, et al, Recent trends in HIV diagnoses and HIV testing among MSM attending GUM clinics in England – Public Health England

Gaps in the evidence on chemsex Is prevalence rising? Are behaviours changing? (…EMIS 2017) What role in ongoing and new STI epidemics in MSM? What is the association with mental health – as driver and impact? What works to reduce the harms of chemsex? Are traditional drugs services suitable for MSM/chemsex? Are community/service responses effective? Need to evaluate interventions over time Chemsex in the PrEP era – where do we go from here in sexual health promotion for MSM?

“Why is it that we don’t seem to, as gay men, value our lives that much? Why are we upping the dose, why are we just necking so many drugs, just escape to make us feel like porn stars who, ironically, can’t get hard-ons. There must be something in it. I could have died several times over the last year and yet I still continue. It’s not good.” [Aged 40, last tested HIV negative]

What needs to be done to make PrEP as successful as possible? Policy & Budget High Court Ruling (Aug 2016) NHS England 10,000 participant trial (Dec 2016) Availability Private purchase; PROUD/Discover Access SH clinics (IMPACT Trial – Aug 2017?) Awareness & Education Clinicians and Communities Uptake & Adherence Broad eligibility criteria… …beyond 2020? Ongoing combination prevention – recognise the complex psychological, social and cultural factors of people’s sexual lives and relationships

Acknowledgements Special thanks to Dr Adam Bourne, formerly of Sigma Research, now at La Trobe University, Melbourne Thanks to colleagues at Sigma Research, Association of Directors of Public Health London, Lambeth Council Thanks to study parcipitants in Lambeth, Southwark & Lewisham Paul Steinberg London HIV Prevention Programme Tel: +44 020 7926 0480 PSteinberg@lambeth.gov.uk @Paul_Steinberg www.doitlondon.org @doitldn