1. 56 Dean Street, Chelsea and Westminster Hospital, London
Conversation 3: Chemsex: its compatibility with PrEP and ART and impact on treatment adherence
Dr Nneka Nwokolo
56 Dean Street, Chelsea and Westminster Hospital, London

2. Conflict of Interest
Dr Nwokolo has received speaker fees, honororaria and support for attendance at conferences from Gilead Sciences, Viiv, GSK, Janssen

3. What needs to be done to make PrEP as successful as possible?
Increase awareness, particularly in non-MSM groups
Correctly identify individuals who would benefit
Ensure that at-risk individuals know where to get it
Support people to take it properly (e.g. identify and manage factors that might affect adherence)

4. The sex and the drugs

5. Definition
Chemsex or ‘party ‘n play’ - use of any combination of the following psychoactive drugs or “chems” to facilitate or enhance sexual activity
Methamphetamine/MDMA
Gamma-hydroxybutyrate (GHB)/gammabutyrolactone (GBL)
Mephedrone
Poppers
Ketamine
Benzodiazepines
Erectile dysfunction agents

6. NOT the same as traditional recreational drug use
Associated with
Extended periods of sexual activity for many hours/several days in house parties or clubs
Extreme sexual practices associated with significant mucosal trauma
Multiple partners – >10 in 1 session
Stuart D and Collins S, HIV Treatment Bulletin 2015.

7. Consequences Associated with harms consequent on loss of inhibition
Disinhibition facilitates condomless, often traumatic, sexual activity with multiple partners
Linked to increasing rates of sexually transmitted infections (STIs), acute hepatitis C and HIV infections in large cities around the world
Injecting chems, “slamming” increasingly prevalent

8. Association between chems and HIV acquisition
Behaviours linked to increased risk of HIV acquisition e.g. condomless sex; multiple partners; fisting/and use of sex toys; use of HIV postexposure prophylaxis; history of previous sexually transmitted infection
Virtually no published data showing causal association
Pakianathan et al: 5x higher HIV incidence in GBM disclosing chemsex
Sewell et al Int J Drug Policy 2017; Esser &Rowley EACS 2016;

9. Chems and ART adherence
Use of chems associated with reduced adherence esp. at weekends
30% HIV+ reported poor adherence to ART – 56 Dean Street CODE clinic
Others have demonstrated similar experiences (Marquez et al AIDS Care 2009; Garin et al BMJ Open 2017)
No data that reduced adherence causes treatment failure

10. Interactions between chems and antiretrovirals
Do ARVs increase levels of chems?
No DDI PK/dose-effect relationship data
Risk of potentially toxic interactions can be only be surmised from case reports or cohort studies
ARVs and Chems… the question is do we have to worry about increased exposure of Chems in patients taking ARVs?
There are some case reports of fatalities due increased exposure of recreational substances (with MDMA, metamphetamine)
Formal studies about DDIs are lacking and therefore we do not know what the dose-effect relationship of the interactions is

11. Interactions (2)
Ritonavir and cobicistat inhibit activity of CYP2D6 and 3A4
Crystal meth, mephedrone, MDMA, ketamine, EDA, benzodiazepines, cocaine all metabolized by CYP
Increased potential for overdose

12. Interactions (3)
Most interactions between recreational drug and ARV interactions are potentially NOT toxic
Efavirenz, etravirine and nevirapine can induce drug metabolism and decrease desired effect (e.g. EDA, BDZ)
NRTIs, rilpivirine, raltegravir, dolutegravir, and maraviroc are characterized by a low potential for drug–drug interactions
The extent of the interaction is also dependent from the route of administration, the doses and frequency of use,…..etc…

14. What needs to be done to make PrEP as successful as possible?
Increase awareness, particularly in non-MSM groups
Correctly identify individuals who would benefit
Ensure that at-risk individuals know where to get it
Support people to take it properly (e.g. identify and manage factors that might affect adherence)