A clinical perspective of Chemsex Dr Jake Bayley Consultant Sexual Health and HIV Barts Health NHS Trust Slides courtesy of Dr Adam Bourne, LSHTM

Use of drug in last year, British Crime Survey 2007/8 All respondents Men Straight % (n/N)   Gay/Bisexual % (n/N) Adjusted Odds Ratio* (95%CI) Cannabis 7.1 (1593/22309) 9.4 (946/10011) 18.8 (46/245) 1.73 1.22-2.43 Cocaine 2.2 (495/22374) 3.1 (311/10045) 7.4 (18/244) 1.92 1.15-3.18 Amyl nitrite 1.4 (307/22421) (142/10069) 24.4 (60/246) 23.04 16.00-33.18 Ecstasy 1.3 (299/22393) 1.8 (182/10053) 6.5 (16/245) 2.88 1.67-4.96 Amphetamine 1.1 (244/22352) (132/10039) 3.7 (9/246) 2.28 1.14-4.58 Tranquilisers 0.5 (111/22438) 0.4 (45/10076) 2.8 (7/247) 4.33 1.90-9.87 Magic mushrooms (81/22420) (50/10065) 5.14 2.27-11.66 Ketamine 0.3 (65/22437) (31/10079) 10.01 4.60-21.77 LSD 0.2 (52/22414) (31/10063) 1.6 (4/247) 4.03 1.39-11.69 Crack 0.1 (28/22428) (19/10072) 0.8 (2/247) 2.68 0.61-11.84 Heroin (26/22438) (17/10077) 2.90 0.65-12.91 Annual prevalence of drug use by sexuality in British Crime Survey 2007/8 Unpublished data from the British Crime Survey 2007/8. Data personal communication from Jacqueline Hoare (Home Office Statistics Unit); analysis by Ford Hickson (Sigma Research)

Current trends in drug use Name of drug Street names Delivery Mephedrone Meow Meow, MCAT, plant food Snorted as a powder, injected or administered rectally GHB/GBL G, Gina, liquid ecstasy Swallowed in small liquid doses Crystal meth Crystal, Ice, Tina, T Snorted as powder, smoked in glass pipe, or administered rectally Ketamine K, special K, Green Swallowed as tablet, snorted What we believe we may have seen over the past few years is a migration away from those drugs previously popular to newer psychoactive substances. We don’t yet have published national level data to reinforce this for gay men, but health practionner discourse – what they’re seeing in clinic and in services – overwhelmingly supports this switch, especially the case with mephedrone. I’ve added Ketamine to this list because while it’s not a key factor on the UK chemsex scene, I’m aware it is in other countries. Chemsex: “Sex between men that occurs under the influence of [these] drugs taken immediately preceding and/or during the sexual session”

Chemsex 'prevalence' (UK) European MSM Internet Survey (EMIS) 15,423 MSM living in England 0.7% had used crystal meth in previous 4 weeks (London 2.9%) 2.9% had used mephedrone in previous 4 weeks (London 10.2%) 1.6% had used GHB/GBL in previous 4 weeks (London 5.5%) Chemsex drug use highest among HIV positive gay men 8.6% of HIV positive men used crystal meth Vs <1% negative or untested men 13.5% of HIV positive men used GHB/GBL Vs <3% of negative or untested men (i.e. 8 crystal use 8 times higher)

Chemsex & sexual health Maintenance of safer sex behaviour Pre-determined unprotected anal intercourse Unintended sexual risk under the influence of drugs Drug use associated with increased odds of UAI during group sex Three-fold increase in odds of UAI associated with use of crystal meth A proportion of men in both studies had decided to (nearly) always have sex without condoms Generally such men had diagnosed HIV All had condomless sex with men they believed to also be positive – Serosorting STIs often seen as inevitable part of lifestyle High rates of Hepatitis C (and re-infection) but limited awareness of protective behaviours A third of men had engaged in unintentional sexual risk behaviour Drugs had myopic effect Drugs could be cognitively incapacitating

Chemsex & broader well-being Impact on mental health Anxiety attacks Acute paranoia Sexual dependency Impact on physical health Overdose Disturbed sleeping problems Injection site injuries Sexual consent concerns Bourne et al, 2015a; 2015b; Fourer et al, 2014; Knoops et al, 2015)

Conclusions – What we know The drugs most popular among MSM appears to have shifted Injection drug use has emerged as a source of concern for MSM Use of drugs in general is higher among MSM with diagnosed HIV Newly popular drugs lend themselves to use in sexual settings Chemsex is associated with a higher risk of HIV/STI transmission behaviour MSM using drugs are exposed to (and experience) a range of physical and mental health harms

“CHEMSEX” Tadgh Crozier & Louis Driver Senior Engagement Workers

WHO ARE WE? Lifeline Project – Registered charity providing national Drug & Alcohol Treatment. AFTER PARTY SERVICE – Started 2014 London based outreach service Supported and funded by the Elton John Aids Foundation One-to-one support, Harm reduction, Group work and Training. Focus on sexual health, HIV Prevention and provision Self Test HIV Kits.

What is CHEMSEX ? Having sex whilst using drugs Gay, bisexual, MSM Specific intention to meet, use and have sex Three main drugs: mephedrone, GHB/GBL, crystal methamphetamine

Why is it a concern? Marked change in drugs used Changing context and methods of use Increasing presentations to services – Sexual health and counselling Backdrop of rising HIV diagnoses & infections Clients not identifying as ‘that type’ of drug user (STIGMA) A move from the more traditional normalised use of recreational drugs onto harder Nps’S.

How have things have changed? Different drugs being used with different routes of administration Different harms – injecting, dependence (G), mental health (psychosis) Interventions need to include substance use, sexual behaviour & HIV prevention Interventions delivered in different settings - GUM clinics (motivational, preventative)

The drugs: Mephedrone  MIAOW, MEPH, MEOW MEOW, M-CAT, DRONE 

The drugs: GHB/GBL G, GINA, GEEBS, GBL, GBH, 

The drugs: Crystal Meth METHAMPHETAMINE, TINA, CHRISTINE, METH, ICE, GLASS, CRANK, 

‘Apps’ & ‘On-line’

What we’re seeing Sexualised drug using, multiple partners Meeting & trading of drugs through apps Private sex parties, sex on premises venues High level of current sexual risk ‘Slamming’ - Injecting (Crystal meth & Mephedrone) We have seen an increase in HIV infection as a result of Chemsex Poor adherence to HIV meds whilst using Lack of knowledge and understanding in relation to BBV’s Widespread poor self-esteem issues

What we’re hearing Concerns around consent whilst using – exploitation, rent, rape – Unconscious Slamming (injecting) on the increase as criterion for sex party admission Dealers offering needles to slamming users Filming and webcams at parties

Interventions Same principles: brief interventions, MI, CBT, SFT & relapse prevention But with cultural adaptations: e.g. relapse prevention through management of online sexual-social profiles Tackle sexual health and drug use together Delivered in LGBT-specific, or LGBT-competent locations Anecdotally 90% say ‘important’ or ‘very important’ to have LGBT specific services Breaking free – online Skype/telephone

Work in Clinics and Sauna’s People present much earlier than they would to a drug service Treatment of STIs PeP or PReP Perfect opportunity to deliver motivational & preventative interventions Chemsex Study: preference for clinic based interventions Caution! Approach works well for gay/bi men, may need to think differently for lesbian/bi women & trans people who experience different sexual health barriers

Key Messages Increase own confidence & competence of community/MSM/LGBT issues and newer drugs Be conscious of environment, language, attitude etc. Non-judgmental harm reduction advice Know where & when to refer Be aware of potential G dependence – must see a specialist service for detox advice Safer injecting – needle exchange HIV, Hep, HPV and other STI advice Monitor sexual orientation & gender identity

ANY QUESTIONS ??

RESOURCES • London Friend: http://londonfriend.org.uk/ Antidote: http://londonfriend.org.uk/antidote Out Of Your Mind report: http://londonfriend.org.uk/outofyourmind/ Antidote/Orange Nation G-Aware campaign: http://londonfriend.org.uk/get-support/g-aware/ London Friend CEO Blog : http://londonfriend.org.uk/montys-thoughts/ Chemsex Study: www.sigmaresearch.org.uk/chemsex NTA Club Drug Report: http://www.nta.nhs.uk/uploads/clubdrugsreport2012[0].pdf UK Drug Policy Commission Report: http://www.ukdpc.org.uk/publication/the-impact-drugs-different-minority- groups-lgbt- groups/ UK Drug Policy Commission Policy Briefing: http://www.ukdpc.org.uk/publication/drugs-diversity-lgbt-groups- policy- briefing/ Lesbian & Gay Foundation Part of the Picture: http://www.lgbt.foundation/potp Lancet article of crystal meth rise in London (Jan 2013): http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(13)60032-X/fulltext CNWL Club Drug Clinic: http://clubdrugclinic.cnwl.nhs.uk/ LDAN News Nov/Dec 2012 (Club Drugs & Antidote articles): http://www.ldan.org.uk/PDFs/LDANNewsDec12.pdf Engendered Penalties: http://www.pfc.org.uk/pdf/EngenderedPenalties.pdf Sexual Orientation Monitoring Guide: http://www.lgbt.foundation/som Stonewall Healthy Lives mini-site: http://www.healthylives.stonewall.org.uk/ Public Health Outcomes Framework LGBT Companion: http://www.lgbt.foundation/phof • • •

CONTACT DETAILS: Tadgh.crozier@lifeline.org.uk Tel: 07584 126 904 Louis.driver@lifeline.org.uk Tel: 07595 415 139 WWW.AFTERPARTY.ORG.UK