1. PROMOTING THE HEALTH OF MEN WHO HAVE SEX WITH MEN WORLDWIDE A training curriculum for providers

2. Module 7: Supporting Gay Men and other MSM Who Use Substances 2

3. Learning Objectives Describe the reasons for, and known patterns of, drug and alcohol use among gay men and other MSM Name the common drugs used by gay men and other MSM Increase the level of comfort discussing substance use within the clinical setting with gay men and other MSM 1 2 3 3

4. Module Overview Getting comfortable talking about drugs and alcohol The link between drug use and HIV transmission Drugs commonly used by gay men and other MSM, and their effects Approaching drug use in the clinical setting Drug and alcohol use screening tools Interventions for decreasing drug and alcohol use Potential signs of drug or alcohol abuse Gay men and other MSM who do not report problematic drug or alcohol use 1 2 3 4 5 6 7 8 4

5. Pre-reading Assignment Questions for discussion: What relevance does the drug use scenario presented in the case study have for your country or local context? Why do you think it is harder for gay men and other MSM to negotiate around safer sex? One reason may be drugs, what are others? What are strategies that you may recommend to encourage gay men and other MSM who uses drugs to connect with a healthcare provider? 1 2 3 5

6. Talking About Drugs and Alcohol Many individuals will go through life using substances either regularly or on occasion without any disruption or negative impact to their social, professional, or physical lives. It is also important to recognize that for some others, substance use can be problematic each time they use drugs and alcohol or under specific circumstances 1 2 6

7. Group Activity Substance Use Awareness 7

8. Drug and Alcohol Use Do gay men and other MSM use drugs and alcohol more than others? Several studies suggest the presence of higher rates of drug and alcohol use among severely marginalized populations There is a clear link between higher drug and alcohol use, and experiences of social discrimination Criminalization Outright rejection Isolation Denial of basic human rights 1 2 8

9. Drug and Alcohol Use Why do gay men and other MSM use drugs and alcohol? To cope with anxiety, depression, isolation, and loneliness Because drugs and alcohol may be common or appear normalized in some social venues To help individuals to relax, overcome social inhibitions, and increase confidence while seeking sexual partners To provide psychological enhancement of sexual experiences To escape from “fear of rejection” given their HIV positive status 1 2 3 4 5 9

10. Drug and Alcohol Use What are known patterns of drug use among gay men and other MSM? Episodic (i.e., weekly/monthly use is greater than daily use) Higher reported rates of drug use among gay men and other MSM who are ethnic minorities, younger, and live in urban areas Take more than one drug during the same session or within a given time frame (poly drug use) 1 2 3 10

11. Drug Use and HIV Transmission Drug and alcohol use may be linked to HIV risk, especially through the sharing of injection equipment and/or unprotected sex with a serodiscordant and viremic partner Substance use can lead to high-risk sexual behaviors through the loss of sexual inhibition while under the influence of certain drugs Use of specific substances such as cocaine or methamphetamines are associated with interruptions in antiretroviral therapy Can increase chances of HIV and STI transmission Substance use is linked to a higher likelihood of HIV transmission among MSM being treated for STIs 1 2 3 4 11

12. Commonly Used Drugs and Their Effects List of DrugsStreet Name/Regional Variation Alcohol- Amphetaminespeed, uppers, sulphate, whizz Cannabis marijuana, Mary Jane, dope, pot, spliff, hash(ish), weed, puff, grass, herb, draw, wacky backy, ganja, hemp Cocaine coke, Charlie, C, snow, blow, a toot, Bolivian/Peruvian/Colombian marching powder Crack cocainerock, base Crystal methamphetamineCrystal, Tina, meth, ice, crank EcstasyE, MDMA, X, XTC GHB/GBLGina, G, liquid ecstasy Heroinsmack, skag, junk, horse Poppersamyl, butyl, isobutyl nitrate, aromas, liquid incense 12

13. Approaching Drug Use In the clinical setting: Build rapport and confidence with the client Remind clients that any information they share, or that is documented, is confidential If information will be shared, healthcare providers must reveal to the client with whom it will be shared and under what circumstances Remember to always use a non-judgmental and non- confrontational approach when discussing drug use with clients 1 2 3 13

14. Approaching Drug Use Normalizing: “Many people find it difficult to talk about sex and drugs….” Transparency: “I need to ask you some specific questions about your drug use to better understand your health needs and provide the best possible care” Asking permission: “Would it be OK if I asked you some questions about your alcohol use?” Option of not answering question: “If you’re not comfortable answering any of these questions, you don’t have to answer them.” Offering response choices: “How often do you mix drugs together? Never? Sometimes? Always? Almost Always?” Avoid asking for judgments or opinions: “How often do you drink in a week?” or, “How many drinks do you drink in one setting?” is better than asking “Do you get drunk?” or, “Do you drink often?” Ask specific instead of general questions: “Have you ever used marijuana?” or, “Have you ever used cocaine?” is better than asking “Have you ever used street drugs?” 1 2 3 4 5 6 7 14

15. Screening Tools The best method for assessing the way forward is Identify what the client’s goals are in relationship to drugs, and Engage in an open discussion about whether or not the client’s current use aligns with where they want to be. The role of the healthcare provider is to motivate the client to articulate their personal goals and come to a clear understanding of where they stand with their goals in relationship to their current substance use 1 2 15

16. Potential Signs of Substance Abuse A tolerance to the substance Withdrawal symptoms Loss of control concerning the substance (or the inability to stop using the substance despite the desire to do so) Failed attempts to stop using the substance A preoccupation with the substance The continued use of the substance despite negative consequences 1 2 3 4 5 6 16

17. Unreported Problematic Drug Use Providing health information related to drug use from credible sources in an honest and non-judgmental manner If drug use is within the context of sex, then engage in a conversation about sexual health as well 1 2 17

18. Summary Research suggests gay men and other MSM are more likely to use drugs and alcohol when compared with adults in the general population A proportion of gay men and other MSM who use drugs and alcohol also do so for pleasure and recreation that include the use of drugs and alcohol in the sexual context or within social settings like dance clubs and bars Substance use can lead to high-risk sexual behaviors through the loss of sexual inhibition while under the influence of certain drugs Ways to handle substance use in the clinical setting include: Identify what the client’s goals are in relationship to drugs Engage in an open discussion about whether or not the client’s current use aligns with where they want to be Healthcare providers must exercise compassion, confidentiality and non- judgment while adopting harm-reduction approaches 1 2 3 4 5 18