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Drug use among men who have sex with men. Implications for harm reduction

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Numerous studies have demonstrated that men who have sex with men (MSM) experience disproportionate levels of ill-health compared to the general population, and are one of the highest risk groups for HIV in every part of the world.MSM frequently face significant stigma and discrimination from their families, communities and, in some countries, are the subject of systemic repression and persecution. Often this repression and stigmatisation can make accessing appropriate health services, where they exist, problematic.A significant concern among health professionals and advocates who work to improve the health and well-being of MSM relates to the prevalence of drug use within the population, its uses and its associated harms. The chapter begins with an overview of the range of drugs taken by MSM, followed by a description of prevalence across the world (where such data exist) and a discussion of data quality. It then assesses the reasons for drug use by MSM and the harms that may be associated with such use. The final section highlights interventions to help reduce the harms associated with drug use among MSM.
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147
Chapter 3.3
147
DRUG USE AMONG MEN
WHO HAVE SEX WITH MEN
Implications for harm
reduction
About the Author:
Dr. Adam Bourne is a Research Fellow with the Sigma Research group at the London
School of Hygiene & Tropical Medicine. His research focuses on understanding HIV risk
behaviour among men who have sex with men, as well as on health inequalities and the
broader health and well-being of people from marginalised communities.
The author would like to thank Monty Moncrieff of Antidote @ London Friend for his
valuable contribution and Dr. George Ayala for reviewing an earlier version of this chapter.
148
Introduction
Numerous studies have demonstrated that men who have
sex with men (MSM) experience disproportionate levels of
ill-health1-3 compared to the general population, and are one
of the highest risk groups for HIV in every part of the world.4,
5 MSM frequently face significant stigma and discrimination
from their families, communities and, in some countries,
are the subject of systemic repression and persecution.7
Often this repression and stigmatisation can make accessing
appropriate health services, where they exist, problematic.8, 9
A significant concern among health professionals and
advocates who work to improve the health and well-being
of MSM relates to the prevalence of drug use within the
population, its uses and its associated harms. The chapter
begins with an overview of the range of drugs taken by MSM,
followed by a description of prevalence across the world
(where such data exist) and a discussion of data quality. It then
assesses the reasons for drug use by MSM and the harms that
may be associated with such use. The final section highlights
interventions to help reduce the harms associated with drug
use among MSM.
MSM, gay, homosexual, queer?
Terminology to describe men who are attracted to, or
have sex with, other men is often carefully selected.
Some men who are attracted to, or have sex with, other
men may describe themselves as ‘gay’, while others do
not. Some might use the term ‘homosexual’ (literally
meaning they have a sexual orientation towards people
of the same sex) or ‘queer’ (referring to a sexuality that
deviates from the ‘norm’). ‘Men who have sex with men’
(MSM) refers only to the act of sexual contact between
two men and is rarely used by men themselves to
describe their sexuality. Health professionals often use
the term MSM because it relates to behaviour which,
when considering issues such as HIV, other sexually
transmitted infections (STIs) or drug use, is more
important than the identity an individual might assign
themselves. When working with this population it is
important that you establish the term with which male
clients or service users are most comfortable.
The range of drug use among MSM
Studies indicate that MSM utilise a broad range of drugs.
This chapter relates only to non-prescription drugs that
are considered illegal or otherwise ‘recreational’ in most
countries. The following is a list of drugs known to be
used by MSM, and includes street names or regional
variations.a
»Amphetamine (speed, 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 cocaine (rock, base) – essentially a super-
strength cocaine
»Crystal methamphetamine (Crystal, Tina, meth, ice,
crank) – essentially a super-strength amphetamine
»Ecstasy (E, MDMA, X, XTC)
»GHB/GBL (Gina, G, liquid ecstasy)
»Heroin (smack, skag, junk, horse)
»Ketamine (K, special K, vitamin K)
»LSD (acid, a trip)
»Mephadrone (MCAT, Meow-meow)
»Poppers (amyl, butyl, isobutyl nitrate, aromas, liquid
incense) – the formula frequently changes, but they
are chemicals from the alkyl nitrite family.
a
Prevalence of drug use among MSM
Establishing the prevalence of drug use among MSM in
different parts of the world is challenging. In a large number
of countries, homosexuality, or sex between men, is illegal,
making the collection of data relating to sexuality challenging
and complex. Even where research about MSM and drug
use has been conducted, it is often difficult, or impossible,
to compare because of inconsistent methodologies, such as
different recruitment methods, a focus on different drugs or
use in different settings or across varying time frames (e.g.
within the last month, the last three months, within the past
12 months or drug use ever in life). In addition, the use of
drugs may vary wildly not only from one region of the world
to another but from one country to the next, between cities
in the same country or even among different venues within
the same city. As is the case with other populations, drug use
among MSM in various areas can change significantly within
short spaces of time, meaning that data collected can quickly
become redundant.
The literature review that follows is written with the best data
publicly available in English.
a For a detail ed account of these d rugs commonly use d by MSM and their effe cts, see
http://www.drugfucked.tht.org.uk/.
149
Africa
There has been relatively little research in general conducted
with MSM in African nations, and only a small number of
studies that have specifically explored drug use. Much of the
research that has been conducted relates solely to injecting
drug use (IDU), with rates among MSM ranging from 3.4 to 12%
in Malawi and 8% in Namibia,10 all within the last six months,
and 14% within the last year among MSM in Zanzibar.11 Drug
use among MSM in South Africa has received more attention
than in other countries, with one study reporting that 11% of
men described having sex while under the influence of drugs
within the previous 12 months,12 and further mixed-method
research suggesting significant regional variation in drug use
across different cities in the country.13, 14 For example, crystal
methamphetamine was the most commonly used drug
among MSM in Cape Town, but dipipanone hydrochloride was
more common in Durban.
Asia
The 2010 Asian MSM Internet Sex Survey15 included 10,861
respondents recruited online from China, Singapore,
Malaysia, Taiwan, Hong Kong, Thailand, Japan, Indonesia, the
Philippines, Korea and Vietnam. Table 1 displays the levels of
reported drug use within the past six months (findings are
not publicly available at country level). Data from this survey
also indicate that drug use was significantly higher among
MSM with diagnosed HIV, particularly with respect to crystal
methamphetamine, ketamine and ecstasy. A 2009 study in
Thailand identified an association between HIV prevalence
and a history of drug use.16
Table 1: Levels of drug use among respondents in the Asian
MSM Internet Sex Survey
Stimulant drugs % Use in last 6 months
Crystal meth 4.0
Ecstasy 8.1
Cocaine 1.8
Poppers 6.1
Cannabis 3.6
GHB 2.3
Ketamine 5.3
Several other studies across the continent have explored
lifetime usage of drugs, with levels ranging from 6% in
Vietnam17 and 11.7% in Taiwan18 to nearly 65% in Japan19
(although much of this variation can be accounted for by
differences in sampling and recruitment).
Levels of IDU among MSM in Asia have generally been low.17,
20, 21 There are currently no data publically available on the
prevalence of drug use among MSM living in Central Asian
Republics.
Australasia
Frequent gay community surveys in Australia and New
Zealand provide a detailed picture of drug use among MSM in
these countries, as displayed in table 2.
In Australia, the proportion of men reporting any IDU in
the previous six months has remained stable at around
5–6% for the last ten years.26 While the percentage of men
using poppers has fallen slightly over the last nine years,
still in 2009 an average of 31.8% of MSM across the country
reported use within the previous six months. The Australian
surveys typically identify higher rates of all drug use in Sydney
compared to other parts of the country.
Table 2: Prevalence of drug use among MSM in Australasia within the previous 6 months
Cocaine % Poppers % Cannabis % Ecstasy % Methamphetamine % Ketamine % Source
Australia
(Sydney) 20.6 40.4 27.9 29.8 11.1 9.6 2011 Gay Community Periodic
Survey Sydney22
Australia
(Melbourne) 12.4 35.4 27.6 21.5 8.9 6.0 2011 Gay Community Periodic
Survey Melbourne23
Australia
(Adelaide) 7.1 21.9 34.6 17.2 9.5 2.1 2011 Gay Community Periodic
Survey Adelaide24
New Zealand
(Auckland) 7.3 40 37.5 21.2 7.9 5.7 2006 Gay Auckland Periodic
Sex Survey25
Chapter 3.3
150
Caribbean
Prevalence data for drug use among MSM in the Caribbean
is extremely scarce. Secondary analysis of a representative
general household survey data collected in Puerto Rico27
reported lifetime use of cannabis (63.4%), amphetamines
(20%) and heroin (20%). A quarter of MSM reported using
cannabis (24.4%) and cocaine (24.4%) in the past 12 months.
The UNAIDS-sponsored Caribbean Men for Men Internet Sex
Survey (CARIMIS) is underway at the time of writing and will
report its findings in the summer of 2012. This survey will
provide drug use data for each of the Caribbean nations and
territories and will be a useful source of information for the
development of future interventions.b
b See http://www.carimis.org
Europe
Comprehensive data on drug use among MSM was collected as
part of the European Man for Man Internet Sex Survey (EMIS).
This online survey was open for completion in 25 languages
in the summer of 2010 and recruited a total of 181,495 men.
It asked questions about use of a range of drugs within the
previous 4 weeks (as displayed in table 3). While country-level
data will become available in the near future, at present EMIS
data are reported on a European sub-regional level.
Research in the UK29 that explored drug use levels among
MSM within the previous 12 months reported levels ranging
from 39.4% for poppers, 27.7% for cannabis, 18.5% for ecstasy
and 4.7% for methamphetamine (with significant regional
variations evident and highest usage in London.)30 Drug
use among MSM in Catalonia, Spain, within the previous 12
months followed a broadly similar pattern (poppers 40.8%;
cannabis 26.0%; ecstasy 10.2% and methamphetamine
3.0%.)31
Table 3: Use of drugs among MSM across Europe within the previous four weeks
Region of residence poppers use in last 4
weeks
cannabis (or LSD) use in
last 4 weeks
Heroin/crack use in last
4 weeks
party drugs* use in last
4 weeks
West: Belgium, France, Rep.
of Ireland, the Netherlands,
the UK
28.3 13.8 0.4 10.6
North West: Denmark,
Finland, Norway, Sweden 13.8 6.2 0.3 3.1
Central-West: Austria,
Switzerland, Germany,
Luxembourg
22.0 10.1 0.2 4.9
South West: Greece, Spain,
Italy, Portugal 10.9 13.6 0.4 6.6
North East: Estonia,
Lithuania, Latvia 6.2 4.9 0.2 2.3
Central-East: Czech
Republic, Hungary, Poland,
Slovenia, Slovakia
15.2 10.2 0.3 4.9
South East (EU): Bulgaria,
Cyprus, Malta, Romania 7.9 5.9 0.3 3.0
South East (non-EU):
Bosnia & Herzegovina,
Croatia, Macedonia, Serbia,
Turkey
7.7 8.6 0.4 2.5
East: Belarus, Moldova,
Russia, Ukraine 8.3 5.2 0.3 2.4
* Party drugs include ecstasy, amphetamine, methamphetamines, mephadrone, GHB, ketamine and cocaine. Adapted from EMIS
Network.28
151
North America
There are no publically available national MSM drug use
prevalence data for the USA: prevalence is reported only at
a city or state level. This approach is appropriate in terms of
influencing local harm reduction interventions but makes
country-level comparison difficult. Table 4 provides a snapshot
of drug use prevalence in different cities, established via
multiple surveys.
Similar levels of poppers use among MSM have been observed
in Canada.35
A significant body of research has addressed
methamphetamine use among MSM in the USA. This drug
is commonly associated with euphoria, decreased sexual
inhibition and hypersexual behaviour.36, 37 Analysis of data
collected annually between 1996 and 2007 in Los Angeles
found levels of methamphetamine use within the last 12
months varying from 11% to 53%.38 A longitudinal study of
club drug using gay and bisexual men in New York found that
64.6% of their sample reported using methamphetamine
within the previous four months.39
Levels of IDU among MSM in both Canada and the USA have
typically been very low.2, 40, 41, 42
South America
Between 1999 and 2002 a series of 19 sero-epidemiological
cross-sectional surveys43 were conducted among MSM in
seven different South American nations: Argentina, Bolivia,
Colombia, Ecuador, Paraguay, Peru and Uruguay. These
surveys asked about history of drug use (ever) and analysed
such usage in light of national HIV prevalence to identify
significant associations. The surveys recruited a total of 13,847
MSM participants by opportunistic, community sampling,
although the number of participants varied considerably
between countries. Reported data from Peru appear
incomplete; therefore, Peru is not included in Table 5.
Table 4: Prevalence of drug use among MSM across the USA
City/region
(Year of data
collection)
Methamphetamine
%
Cannabis
%
Ecstasy
%
Cocaine
%
Poppers
%Study type
Time
frame of
drug use
Reference
New York
(2007) 6.2 27.9 8.38 12.03 24.46 Community survey of
MSM (n=740)
Within
the last 3
months
Carpiano et
al. (2011)32
Chicago
(2002–2003) 6 28 13 12 -
Household survey. Data
from HIV-negative MSM
(n=151)
Within
the last 6
months
Fendrich et
al. (2010)33
San Francisco
(1999–2001) 23* - - 19 37
Randomised behavioural
intervention of MSM
accessing counselling
(n=736)
Lifetime
use
Colfax et al.
(2005)34
* Includes speed and any form of methamphetamine
Table 5: Reported drug use (ever) among MSM from six South American countries
Drug used (ever) Colombia % Ecuador % Bolivia % Argentina % Uruguay % Paraguay %
Cannabis 31.2 17.4 21.4 15.4 14.8 42.4
Heroin 2.4 0.6 0.0 0.4 0.2 4.3
Cocaine 14 4.9 17.2 6.7 21.9 26.4
[Adapted from Bautista et al.]43
Chapter 3.3
152
Broad patterns of drug use among all
MSM
In reviewing this broad literature from across the globe,
several patterns in MSM drug use emerge. Firstly, most
drug use among MSM appears to be episodic, with weekly
or monthly use far higher than daily.15, 29, 44 This might
suggest that most MSM who report drug use are not drug-
dependent but instead use drugs for specific purposes (such
as when partying, socialising or when seeking or having sex).45
Episodic drug use may also reflect specific periods of stress or
uncertainty, such as an HIV diagnosis, struggles in the process
of ‘coming out’, or may occur in combination with periods of
depression or anxiety.
Secondly, MSM, or gay men, are not a homogenous group in
terms of drug use. Prevalence of use was very often higher
among further marginalised or minority groups, such as ethnic
minority gay men in the USA,46-48 and is often higher among
younger men.42, 49, 50 Use of most drugs (except cannabis)
tends to be higher among MSM living in large urban centres,
particularly those with large gay populations such as Berlin,
Sydney, London and San Francisco than it is among men in
more rural areas.26, 30
Thirdly, polydrug use (taking more than one drug during the
same session or within a fixed time frame) is common among
MSM, particularly with regards to stimulants (‘party drugs’)
such as ecstasy, cocaine, amphetamines or ketamine.34, 51
Fourthly, across the world, the prevalence of IDU, especially
heroin, was generally very low. Other than in South Africa,
reported levels of IDU in non-purposive samples rarely
exceeded 5%. Previous authors52 have suggested that the
reason insufficient attention has been paid to drug use
among MSM is specifically because levels of heroin use –
often the focus of drug harm reduction services – have been
comparatively low. In the absence of heroin-related health
concerns, and those social or community harms such as crime
which are often associated with problematic heroin use, the
harm reduction needs of gay men have not always featured
on the radar of policymakers.
Harms associated with drug use
among MSM
Harms to physical and mental health
The physical and mental health harms associated with
cocaine, heroin, ecstasy, cannabis, LSD and amphetamines are
well documented, and are likely to be similarly represented in
MSM.
Crystal methamphetamine is a super-strength amphetamine
stimulant, which results in high-energy feelings of confidence,
invincibility or impulsiveness. Continuous stimulation of the
nervous system by crystal methamphetamine has been
known to cause anxiety, depression, confusion, insomnia,
psychosis and suicidal ideation,53 and long-term use may also
result in a loss of motor control or memory.54
GHB/GBL (Gamma-butyrolactone) is a party drug that brings a
sense of euphoria. It is usually sold diluted in water, although
just an extra millilitre of GBL over a moderate dose can result in
an overdose, the effects of which are often unconsciousness,
coma or death by respiratory depression. GBL can be addictive
(although this usually only develops over longer periods
of time) and, therefore, can result in significant withdrawal
effects.
After-effects of inhaling poppers can include headaches, skin
rashes, sinus pains and burns, but only if the liquid comes
into contact with the skin. They have also been known to
cause nausea and vomiting. Inhaling poppers after taking
anti-impotence drugs, such as Viagra or Cialis, can result in a
dangerous drop in blood pressure.55 This may be more likely
to occur if also taking a protease inhibitor as part of HIV anti-
retroviral therapy (ART).
There is evidence to suggest that the use of a range of drugs,
particularly methamphetamines, GBL and ecstasy, might have
a detrimental impact on adherence to ART.56, 57
Harms to sexual health and well-being
The association between drug use (particularly
methamphetamine, ecstasy and cocaine) and sexual risk
behaviours is complex, and a comprehensive analysis of this
literature is beyond the scope of this chapter (for a review,
see Corsi et al.58 or Romanelli et al.59). It is possible to say that
there is a clear association between certain drug use and sex
that carries a risk of HIV transmission. However, it is not clear
whether this is causal or simply co-relational.
Significant attention has been paid to the role of
methamphetamine in HIV transmission risk behaviours,
particularly in the USA. This drug can cause feelings of
hypersexualisation and is commonly utilised as part of
sexual marathons (protracted periods of sexual activity)
and group sex activities.60-62 Ensuing rectal trauma facilitates
the transmission of HIV. Numerous studies have suggested
that the use of methamphetamine causes high-risk sexual
behaviour,63-65 perhaps via a myopic mechanism or the
removal of sexual inhibitions. However, other studies have
challenged this causal pathway.66, 67
Other associations with high-risk sexual behaviour have been
identified in relation to ecstasy,68 GHB/GBL69 and ketamine.70
Men who reported polydrug use in the recent past (up to
three months) are more likely to report HIV risk behaviours
than men who took only one drug.44, 47
153
Poppers cause blood vessels to dilate and also relax the
anal sphincter muscle. This can make receptive anal
intercourse more comfortable for some men. The process of
vasodilatation, and the fact that sex may be rougher or last for
longer while using poppers, means that their use during sero-
discordant anal intercourse can increase the probability of HIV
transmission by a factor of three.71, 72
Motivations for drug use
There has been relatively little research exploring the reasons
or motivations for drug use among MSM or the personal and
social context within which drug use occurs, particularly
outside North America, Western Europe and Australia.
Numerous authors52, 73 have highlighted that in most settings
the majority of venues to meet other men for social and/
or sexual interaction are those where alcohol is served and
drug use is common. Clubs and bars are the centre of most
‘gay scenes, and drug use itself is normalised within this
environment. Drugs often serve a very deliberate purpose
in helping individuals to relax, to socialise, to mitigate social
unease and to gain confidence in seeking sexual partners.74
The value of these actions and activities should not be
underestimated by those seeking to support MSM to reduce
any harm that may be associated with their drug use.
Further to this, a significant body of research indicates that
(crystal) methamphetamines are often used by MSM to
psychologically enhance sexual experience, to maintain
sexual activity over long periods of time and to facilitate
sexual desires by dissipating sexual inhibitions.75-77 Drugs may
also help MSM with diagnosed HIV, in particular, to ‘cognitively
escape’ from fear of rejection and negative self-perception
and to cope with broader emotional and physical demands of
living with HIV on a daily basis.78
The best indicator of whether drug use is problematic, or
is in danger of becoming so, is if the individual concerned
considers their use in this way. As already discussed, drug use
among MSM in general tends to be episodic in nature, but
dependency can still develop and significant harm can result.
For many men, drug use becomes problematic when the costs
or side-effects associated with usage impinge on their ability
to live the life they are comfortable or content with.
Harm reduction interventions to meet
the needs of MSM
Drug use interventions for MSM need to empower men with
honest information about what the possible effects (both
positive and negative) might be of taking a range of drugs.
They should seek to support men, and those around them,
to control or limit their use, or to limit the harms associated
with such use, at times when they consider their drug
use is causing harm to themselves or others. This can be
accomplished in a number of ways, ranging from provision
of educational information to psychotherapeutic support
and pharmacological interventions. Whatever the setting,
interventions should take into account each man’s personal
circumstances, acknowledging that drugs can serve a useful
purpose in their lives, particularly in terms of mitigating
psychological unease or by facilitating social or sexual
contact. Health professionals should take account of these
motivations and work with men to identify what level or type
of drug use they are comfortable with, and help to reduce
harms associated with this use.
Numerous civil society organisations in Australia, Canada,
Germany, Poland, the UK and USA have developed websites or
printed information booklets that explain the effects of drugs
commonly used by MSM, and describe ways in which any
associated harms might be mitigated. They often also include
information about the legal status of each drug, and provide
referral information for direct contact services if readers
consider their use problematic.
Provision of psycho-therapeutic services or counselling
specifically designed to address problematic drug use
among MSM varies considerably across the world and
within individual countries. They are known to currently
exist in Australia, Canada, Germany, New Zealand, Norway,
South Africa,79 Spain, Sweden, the UK and USA. A service
in Hong Kong ran between 2007 and 2009. Such therapy
includes drop-in advice, motivational interviewing, support
groups and cognitive behavioural therapy. Many of these
interventions appear grounded in evidence from evaluations
of the general population (for review, see Shearer80), although
there have been a number of evaluations of behaviour change
interventions related to methamphetamine use specifically
among MSM.81-83 In many instances, such evaluated
programmes focus on reducing harms to sexual health and
the likelihood of contracting or transmitting HIV, with mixed
success (for review, see Rajasingham et al.57). In a very small
number of settings, primarily the UK and USA, pharmacologic
interventions exist to address methamphetamine use, but
their effectiveness is still uncertain.84, 85
In Australia, and in many parts of Europe and North America,
harm reduction services are situated within the HIV prevention
sector, largely because of the association with sexual risk
behaviours and because this sector is well established with
strong links to the gay communities they serve. There is
currently no provision of any harm reduction interventions
specifically targeting MSM in Africa (except the Republic of
South Africa), Asia, the Caribbean or South America. While
MSM could access services for the general population (where
they exist), previous research has reported that they often
feel uncomfortable or unwelcome in such environments.52
Drug use among MSM is frequently associated with ‘gay scene’
social activity or with sex, and many services for the general
population may not be sufficiently knowledgeable, skilled or,
indeed, accepting to help address drug use that occurs within
these contexts.
Chapter 3.3
154
Case study:
antidote @ London friend
This organisation works exclusively with lesbian, gay,
bisexual and transgender (LGBT) people who use drugs,
the majority being gay men in their 20 and 30s, mostly
employed and financially self-supporting. In the past
three to four years the drug use profile of their clients
has shifted towards crystal meth and GHB/GBL, with
many people using them in sexual contexts. There
has been a trend to inject crystal, and for GBL use to
rapidly escalate to dependence levels (dosing around
every two hours), so the type of intervention has had to
extend to medical (mainly prescribing for GBL detox),
having been mainly psychosocial. This typically involves
administering benzodiazepines in high doses (often
> 100mg/24hrs),6 which they offer in partnership with
the NHS Club Drug Clinic, to help clients deal with
withdrawal symptoms. Dependence on GBL is an entirely
new phenomenon for members of the community, who
have used other drugs, often without major problems,
for many years.
Most service users do not fit the typical profile of
mainstream UK drug services or the typical drug
patterns presenting there. By offering a targeted service
they are able to remove many of the barriers of users not
identifying with generic support. Being an LGBT service
means that people feel less judged and more able to talk
about their full range of associated problems, which they
may feel inhibited to do in generic services, particularly
as it may involve talking about sexual behaviours they
feel ashamed of.
They work around reasons for using, dealing with
cravings and trigger situations, negotiating safer
boundaries and improving well-being overall; these are
all typical substance misuse interventions, but it is their
provision in a safe and understanding LGBT environment
which sets the service apart. c
c
Conclusions
This review has highlighted the extent of drug use among
MSM and summarised the range of harms that can be
associated with their use. Drug use is common among MSM
and is well established in gay social and sexual environments.
Given the significant harms associated with many of the drugs
that MSM use, harm reduction interventions that meet the
specific needs of MSM should be prioritised in all parts of the
world.
c See http://www.londonfriend.org.uk
Establishing the prevalence of drug use among MSM living
in Central Asian Republics, South America, the Caribbean
and Africa is a research priority. Systematic population and
local-level estimations for MSM populations are a necessary
precursor to this. There is a need for more qualitative research
in many parts of the world that explores the reasons why MSM
use drugs and the personal and social context of this use.
Harm reduction practitioners should seek to understand
variations in drug use among MSM in their local area and
tailor interventions accordingly. They should attend to
changes in such use over time, and be accepting of the social
and sexual environments in which drug use often occurs.
Harm reduction practitioners should also attend to ethnic or
sexuality variation within MSM communities, acknowledging
that further marginalised sections of the population are more
likely to use drugs and for such use to be problematic. As the
evidence base for prevalence, motivations, context and harms
associated with drug use among MSM evolves, so it would be
beneficial to develop toolkits for effective interventions for
rollout in various settings.
As long as homosexuality – or acts of sex between men – is
criminalised, and as long as MSM face stigma and persecution,
it will remain a significant challenge to develop and deliver
effective interventions to meet the complex needs that this
review identifies. Legal and policy reforms relating to MSM are
required in a large number of countries if prevention of HIV
transmission and a reduction in other harms associated with
drug use is to be realised.
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Chapter 3.3
... Sexualised drug use (SDU) is a term used to refer to sexual activities whilst under the influence of a wide range of drugs and substances, such as cannabis, amyl nitrates (poppers), and crystal methamphetamine and has been a topic of research among men who have sex with men (MSM) for some time ( Bourne, 2012 ;Leigh & Stall, 1993 ). Chemsex (sometimes referred to as 'party and play') is a particular form of SDU whereby men engage in sex with other men for long periods of time with multiple sexual partners, typically taking one or more of crystal methamphetamine, -hydroxybutyrate/ -butyrolactone (GHB/GBL), methedrone, cocaine and/or ketamine immediately before or during sex to facilitate and enhance the sexual experience ( Bourne, Reid, Hickson, Torres Rueda, & Weatherburn, 2014 ). ...
... Research investigating SDU among MSM has mostly been conducted in Western countries, and the term chemsex is typically used in a Western context , but SDU, including the sexualised use of drugs associated with chemsex, has also been observed internationally ( Bourne, 2012 ;Maxwell et al., 2019 ;Tomkins et al., 2019 ). Due to the nature of researching SDU, studies tend to be crosssectional, making causation hard to infer. ...
Article
Full-text available
Introduction: Chemsex is a specific form of sexualised drug use (SDU) that is an emerging public health issue among men who have sex with men (MSM). Although the recent focus on chemsex is a reflection of the associated harms it is important to understand SDU more broadly and its associations with risk behaviours. Additionally, some of the reasons suggested for MSM engagement in SDU are also likely to apply to women who have sex with women (WSW) and trans people. The aim of this review was to investigate SDU, including chemsex, among lesbian, gay, bisexual and trans (LGBT) people internationally in relation to sexual health outcomes (HIV status, STI diagnosis, condom use). Methods: Papers that were published between January 2010 and June 2020 reporting SDU in MSM, WSW, or trans people were identified through Medline, PsycINFO, CINAHL Plus and Web of Science. Results were synthesised using a narrative approach. Results: The search identified 2,710 publications, of which 75 were included in the final synthesis. The majority of studies measured SDU among MSM (n = 71), and four studies measured SDU among trans people. Research into SDU had been conducted in 55 countries and 32 countries had recorded the use of a chemsex drug among MSM, although the drugs used to define chemsex varied. Among studies that researched MSM, SDU was most commonly investigated in relation to condomless anal intercourse (n = 42), followed by HIV prevalence (n = 35), and then STI diagnoses (n = 27). Drug use was generally associated with sexual health outcomes, but particularly in chemsex studies. Conclusions: SDU research is lacking among WSW and trans people, despite trans women having a high HIV prevalence. Among MSM, most drugs were associated with sexual health outcomes, and therefore it is important to include both chemsex drugs and other drugs in SDU research.
... 35 ISSUE 2, AGUSTUS 2022 26 CASE REPORT berkontribusi terhadap meningkatnya risiko penularan IMS. 14 Selain itu, faktor pengaruh alkohol dan obat-obatan juga dapat menurunkan kesadaran dan kepatuhan dalam melakukan aktivitas seksual yang aman. 15 Pemeriksaan nonserologis yang berguna dalam membantu penegakan diagnosis sifilis adalah pemeriksaan histopatologi dan imunohistokimia. Kasus sifilis atipikal umumnya terjadi pada fase sekunder, di mana gejala dan tanda yang muncul sangat tidak khas atau dapat menyerupai penyakit lainnya. ...
Article
Full-text available
Pendahuluan: Pria homoseksual merupakan kelompok yang berisiko tinggi terkena infeksi menular seksual (IMS). Sifilis merupakan salah satu jenis IMS yang bersifat kronis dan sistemik. Infeksi virus human immunodeficiency virus (HIV) dan atau human papillomavirus (HPV) merupakan faktor risiko terjangkitnya infeksi sifilis, dan infeksi HIV serta koinfeksi sifilis dapat saling meningkatkan risiko IMS lainnya. Kasus: Seorang laki-laki 22 tahun, orientasi seksual sesama jenis, mengeluh bercak merah bersisik di kedua telapak tangan dan kaki, tidak gatal, rambut rontok dan benjolan di daerah genital. Pemeriksaan regio oksipital tampak adanya alopesia tanpa disertai jaringan parut, regio palmar dan plantar pedis bilateral tampak patch, plak eritem multipel sebagian hiperpigmentasi konfluens dengan skuama di atasnya, dan pada regio perineal tampak papul nodul multipel dengan permukaan licin merah pucat. Pemeriksaan acetowhite positif pada lesi papul verukosa. Hasil pemeriksaan CD4 112 sel/µl, VDRL/RPR reaktif 1:256 dan TPHA reaktif >1:5.120. Gambaran histopatologi kulit sesuai dengan gambaran sifilis kulit dan condyloma acuminata. Pada pemeriksaan imunohistokimia didapatkan gambaran Spirochaeta berwarna kecoklatan. Pasien didiagnosis dengan koinfeksi sifilis sekunder, condyloma acuminata, dan HIV. Kesimpulan: Pada kasus ini didapatkan seorang pasien homoseksual dengan koinfeksi sifilis sekunder, condyloma acuminata dan HIV. Infeksi HPV dan HIV sering ditemukan bersamaan, dan keduanya saling meningkatkan risiko infeksi menular seksual.
... The drugs used in chemsex -cathinones (including mephedrone), GHB/GBL (gamma-hydroxybutyrate/gamma-butyrolactone) and methamphetamine -are characterized by a particular action mechanism absent from drugs which have been "on the market" longer and are therefore better known. In the population using chemsex, cathinones are the most frequently used and most readily available drugs [7,8]. Mephedrone, like other synthetic cathinones, has psychoactive and sympathomimetic action similar to amphetamine, and a stronger entactogenic effect, causing increased sensory sensitivity, sexual arousal and disinhibition [9]. ...
Article
Wraz ze zwiększającym się społecznym przyzwoleniem na szukanie pomocy w zakresie zdrowia psychoseksualnego, w gabinetach specjalistycznych można zaobserwować bieżące przemiany społeczno-kulturowe oraz zrodzone z nich zjawiska. Jednym z takich relatywnie nowych fenomenów jest chemsex. To szczególna i stosowana niemal wyłącznie przez mężczyzn forma łączenia ściśle określonych substancji psychoaktywnych z aktywnością seksualną. Ze względu na podwyższone ryzyko zdrowotne, zarówno związane z używanymi środkami jak i częstym brakiem zabezpieczeń w kontaktach seksualnych, chemsex uznawany jest przez międzynarodowe instytucje zdrowia publicznego za problem zdrowotny mężczyzn mających kontakty seksualne z mężczyznami (MSM). Choć wprowadzenie w latach 90-tych kategorii MSM – głównie w kontekście HIV – miało istotne przesłanki epidemiologiczne (ważne w kontekście ryzyka jest zachowanie, a nie identyfikacja), to właśnie pomijanie tożsamości seksualnej może być jednym z brakujących ogniw w intersekcjonalnym rozumieniu i adekwatnym adresowaniu problematycznego chemsexu. Artykuł adresowany jest szczególnie do lekarzy psychiatrów, psychologów, psychoterapeutów, terapeutów uzależnień oraz seksuologów pracujących z tą grupą pacjentów.
... Our analysis revealed that recreational drug use was closely linked to clubbing, where sex was an often expected and appreciated by-product, though not always the intention. In this way the mens' experiences did not always fit the definition of chemsex as used in previous literature where drugs are used intentionally for heightening the sexual experience [1,14,45,49]. This is an important finding that should be considered when targeting men for harm reduction efforts, as it may be that MSM who are clubbing would not consider themselves as part of the chemsex scene but are exposed to similar risks if having sex as a by-product of their clubbing. ...
Article
Full-text available
Background Recreational and sexual drug use among men who have sex with men may result in increased risk of poor health. The aim of this study was to better understand drug use and harm reduction techniques among Swedish men who have sex with men traveling to Berlin in order to improve the health of this population and inform public health strategies. Methods A qualitative study based on semi-structured interviews with 15 Swedish men aged 23–44 with experience of drug use were recruited through network sampling. Interviews were conducted in Stockholm and Berlin and analysed using content analysis. The interview guide included questions on drug use, context, health and safety. Results The participants engaged in drug use in both settings and in various contexts. Participants saw themselves as capable of finding a balance between pleasure, safety and risk with the aim to maximize positive effects while minimizing negative ones. The different risks of drug use were known, and participants relied on knowledge, harm reduction strategies and self-defined rules of intake to stay safe and healthy in a broad sense, both short term (i.e. during each session) and long term. Choice of drug and, frequency of intake, multi-use, risk of overdose, risk of HIV, purpose and context of use, how often, etc. were all part of the overall strategy. Knowledge of these methods was spread within the community and on-line rather than from counsellors or other health care providers. However, it did not always translate perfectly into practice and some had experienced overdoses and problematic use. Conclusions The findings of this study point to the need for increased adoption of harm reduction techniques in this population focusing on mitigating harm and prevention of risk of problematic use or starting injection drugs. Existing traditional services require adaptations to become more accessible and acceptable to sub-groups of drug users, including low-threshold services providing non-judgemental, evidence-based information. This will require funding of alternative providers such as STI/HIV clinics, among others, and health care providers to increase adoption of prevention strategies, specifically pre-exposure prophylaxis for HIV.
... Evidence indicates that young sexual and gender minority men (SGM men; including those who identify as gay, bisexual, queer and/or transgender) experience higher rates of cannabis use than their heterosexual and cisgender counterparts (i.e., about three times higher past-year prevalence rates) (Bourne, 2012;Branstrom & Pachankis, 2018;McCabe, Hughes, Bostwick, West & Boyd, 2009;Trocki, Drabble & Midanik, 2009). Young SGM men also experience disproportionately high rates of mental illness including depression, anxiety, substance use and trauma/stressor-related disorders (Branstrom & Pachankis, 2018;Guzman-Parra et al., 2014;Hughes, L. & McNair, 2010;Lachowsky et al., 2017;Mustanski, Garofalo & Emerson, 2010), as well as high rates of suicidal behaviours (including suicide thoughts, plans and attempts) (Lachowsky et al., 2017). ...
Article
Despite a growing body of evidence demonstrating that cannabis use is associated with mental illness among sexual and gender minority (SGM) men, little is known about the motivations, patterns and contexts that influence this relationship. Our study aimed to characterize how cannabis use features within the mental health-related experiences of young SGM men in Vancouver, Canada. From January to December 2018, semi-structured interviews were conducted with 50 SGM men ages 15 to 30 years to explore their experiences using cannabis. We draw on thematic analysis to reveal three themes regarding participants’ experiences with cannabis use and mental health. First, participants experiences emphasized the interconnectedness of cannabis use, sexual, and mental health, including using cannabis to: (i) cope with mental health symptoms during sexual encounters (e.g., anxiety, sexual trauma-related stress); and (ii) substitute or replace other substances (e.g., crystal methamphetamine, MDMA) to reduce drug-related harms in Chemsex practices (e.g., decreased ability to consent, drug-induced psychosis). Second, participants discussed the instrumental use of cannabis to alleviate and address symptoms of mental health (e.g., depression, post-traumatic experiences). Third, participants described adverse effects of cannabis use on their mental health, including feelings of paranoia that they associated with cannabis use, as well as concerns around developing cannabis dependence. Our findings reveal important implications for public health policy on how cannabis can be used to manage experiences of mental health among young SGM men, while also highlighting the need to develop harm reduction services for those who may experience mental health-related harms.
... Alkyl nitrites are a group of chemical compounds which include amyl nitrite and other volatile liquids referred to as 'poppers' (Haverkos, Kopstein, Wilson & Drotman, 1994). The use of poppers has been commonly reported among gay, bisexual and other men who have sex with men (GBM) (Bourne, 2012). In Australia, approximately twothirds of GBM report lifetime use of poppers ( Jin et al., 2018 T least one-third of GBM reporting use in the previous six months ( Jin et al., 2018;Lea et al., 2013). ...
Article
Background and aims: Gay, bisexual and other men who have sex with men (GBM) use alkyl nitrites ('poppers') at higher rates than other populations to functionally enhance sexual experiences. Their use has been associated with HIV sexual risk behaviours including receptive anal sex. We investigate the prevalence, frequency, and motivations for poppers use and their relationship with HIV risk. We also discuss the implications of the recent scheduling changes to poppers by the Australian Therapeutic Goods Administration. Methods: Data were drawn from the Following Lives Undergoing Change (Flux) study, a prospective observational study of licit and illicit drug use among GBM. Between 2014 and 2018, 3273 GBM enrolled in the study. In 2018, 1745 GBM provided data relating to frequency of and motivations for poppers use and were included in this analysis. Results: Median age was 33 years (IQR 25-46) and 801 GBM (45.9%) had used poppers in the previous six months ('recent use'). Among these men, 195 (24.3%) had used them weekly or more frequently. Most recent users (77.4%) reported using poppers for a 'buzz' during sex or to facilitate receptive anal intercourse (60.8%). The majority (57.7%) of HIV-negative men reporting recent poppers use were concurrently taking HIV pre-exposure prophylaxis. Recent poppers use was independently associated with receptive anal intercourse with casual partners (aOR 1.71; 95%CI 1.35-2.16) and chemsex (aOR 4.32; 95%CI 3.15-5.94). Poppers use was not associated with anxiety, depression, or drug-related harms. Only 15.4% of current users indicated they would stop using poppers if they were criminalised; 65.0% said they would 'find other ways' to obtain them. Conclusions: Poppers are commonly used by Australian GBM to functionally enhance sexual experiences, particularly to facilitate receptive anal intercourse. Few men experienced drug-related harms from poppers use. Regulatory changes must ensure potential harms from popper use are minimised without increasing barriers to access or perpetuating stigma.
Chapter
Substance-related and addictive disorders have played a central role throughout the four decades of the HIV epidemic. The use of opioids and other drugs by injection has been a vector for direct transmission, while the alignment of substances’ psychoactive properties, substance-related behaviors and social networks, and associated social and structural conditions contributed to unchanging, high rates of new HIV infections for many years. Recent advances in HIV prevention have made the United States’ strategic plan to end the HIV epidemic a realistic goal. Achievement of the plan’s ambitious targets depends on reaching vulnerable marginalized individuals who are either at risk for or living with HIV. Individuals who use substances have historically been difficult to engage and retain in medical care. The additional burden of HIV infection has raised the stakes and urgency to connect with vulnerable persons with addictive disorders and link them to HIV prevention efforts or HIV and addiction treatment services. This chapter begins with a brief overview of substance use as a driver of the HIV epidemic and the epidemiology of substance-related disorders and HIV. The substances that are catalysts of the epidemic include alcohol, marijuana, opioids, cocaine, crack cocaine, club drugs, methamphetamine, and novel psychoactive substances. The importance of early detection and engagement in care, and methods of identification of specific substances are discussed. The interplay between substance use and other social and behavioral factors is believed to intensify substances’ negative impact on HIV burden and outcomes. Substance-related sexual behaviors, stigma, trauma, violence, and psychiatric comorbidity are described. The substances most commonly associated with HIV are reviewed in detail, including prevalence, role in HIV acquisition, and effect on HIV disease progression. Assessment and management of substance-related disorders and corresponding drug-drug interactions between antiretrovirals and medications used to treat the disorders are discussed.
Article
Background: Sexualised drug use (SDU) has been identified as a major risk factor for HIV, as well as other mental health comorbidities among gay, bisexual and other men who have sex with men (GBMSM). While multiple studies have been conducted on the topic, few have explored the role of trauma in underpinning experiences of SDU among substance use treatment-experienced GBMSM. This qualitative study investigates life histories of trauma, and proposes a framework to better situate the factors driving SDU among treatment-experienced GBMSM. Methods: We conducted semi-structured in-depth interviews with 33 purposively-sampled GBMSM with a history of SDU, and seeking treatment for it in Singapore. Interview topics included participants' experiences and life histories of SDU, substance use, incarceration, trauma, as well as stories of resilience and ongoing recovery from SDU. Interviews were audio-recorded, transcribed, coded, and analysed using inductive thematic analysis, from which a trauma-informed framework was developed. Results: Participants firstly articulated the positive and desired aspects of SDU, such as its utility in allowing them to achieve positive emotional states, sexual enhancement, and feelings of connectedness and intimacy. Participants also described how SDU, in contrast, was used as a coping mechanism to deal with emotional and situational 'precipitants', including dealing with loneliness and a low self-esteem, sexual shame and social anxiety, as well as general stressful situations. Participants also articulated how such precipitants were underpinned by experiences of trauma, including those relating to HIV-related stigma, racism, sexual violence, death and loss, neglect, as well as internalised homophobia. Next, participants illustrated how such trauma were in turn reinforced by several 'preconditions', including the accessibility of substances, emphasis on sexual capital, and lack of access to mainstream support structures in the gay male community, alongside general sociolegal barriers to accessing care. Conclusions: This study proposes the role of trauma and the preconditions underpinning them in motivating SDU among a sample of largely substance use treatment-experienced GBMSM in Singapore. Interventions that provide support for GBMSM seeking treatment for SDU should provide trauma-informed care to address the complex barriers to treatment effectiveness.
Article
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Background Young gay, bisexual, and other men who have sex with men (YMSM) are vulnerable to the risks associated with sexualized substance use. This is a novel study in Singapore that aims to classify patterns of sexualized substance use among YMSM, and investigate its association with sexual and mental health outcomes. Methods In this cross-sectional study among 570 YMSM aged 18 to 25 years old, latent class analysis (LCA) conducted to identify classes with similar patterns of sexualized substance use, across which measures of inconsistent condom use, recent STI diagnoses, past suicide ideation and depression severity were compared. Results LCA revealed three classes of YMSM based on types of substances ever used in sexualized contexts, which we labelled as ‘substance-naive’, ‘substance-novice’, and ‘chemsex’. Substance-naive participants ( n = 404) had only ever used alcohol, while substance-novice participants ( n = 143) were primarily amyl nitrite users with a small proportion who reported using chemsex-related drugs. Chemsex participants ( n = 23) comprised individuals who had mostly used such drugs. Those in the chemsex group were more likely to report recent unprotected anal sex with casual partners (aPR = 3.28, 95%CI [1.85, 5.79]), depression severity (aβ = 3.69, 95%CI [0.87, 6.51]) and a history of suicide ideation (aPR = 1.64, 95%CI [1.33, 2.03]). Conclusions Findings of this study highlight how the use of varying substances in sexualized contexts may be classified and characterized by different sexual and mental health outcomes. Health promotion efforts should be differentiated accordingly to address the risks associated with sexualized substance use among YMSM.
Technical Report
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The Perth Gay Community Periodic Survey is a cross-sectional survey of gay and homosexually active men recruited at a range of gay community sites in Perth. The project is funded by the Western Australian Department of Health and supported by the Western Australian Centre for Health Promotion Research and the Western Australian AIDS Council. The Centre for Social Research in Health coordinates the survey with support from The Kirby Institute. The major aim of the survey is to provide data on sexual, drug use and testing practices related to the transmission of HIV and other sexually transmissible infections (STIs) among gay men. The most recent survey, the ninth in Perth, was conducted in February 2014, recruiting 681 men from gay social venues (e.g. bars), sex-onpremises venues, a sexual health clinic and Perth Pride Fair Day. The data presented in this report are based on last 5 surveys conducted between 2006 and 2014.
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The complex relationships between recreational non-injection drug use and HIV sexual risk behaviors have been documented throughout the epidemic. The purpose of this study was to (1) assess the extent of non-injection recreational drug use among gay and bisexual men frequenting gay social venues, as well as to assess recent initiation of substance use, especially “club drugs” and (2) document the interaction between drug use and risky sexual practices. Street recruitment methods were used to administer a survey to 202 gay or bisexual men recruited at ten gay social venues in New York City. The majority of participants reported substance use, and more than half reported the use of drugs other than alcohol. Participation in gay social venues such as bars, dance clubs, and bathhouses was associated with more substance use. Polydrug use, participation in gay venues, and HIV status were found to be associated with unprotected behaviors while under the influence. In multivariate analyses, the use of inhalant nitrates and alcohol were found to be the two substances that best predicted unprotected oral and analsexual behaviors.
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Poly-substance use in gay social ('club') settings is common. Recent studies suggest a link between 'club' drug use and sexual risk behaviours. In this qualitative study, we compare and contrast two 'club' drugs: crystal methamphetamine and ecstasy (MDMA). Life history interviews were conducted with 12 HIV seroconverters and 12 age-matched controls recruited from a prospective cohort study of young gay and bisexual men in Vancouver, British Columbia. Textual data concerning illicit substance use and unsafe sex were analyzed using NUDIST software. Most men related a substantial knowledge of and experience with crystal and ecstasy. Both drugs had attributes that enhanced gay socialization and were used in the same venues. Crystal was used to remain awake and increase energy. Ecstasy was used to induce euphoria and group connectedness. However, unlike ecstasy, crystal was associated with a distinct pattern of sexual arousal that frequently included unprotected (sometimes group) sex, was more likely to be used regularly by HIV-positive men, and was reportedly highly addictive and problematic. Crystal and ecstasy are used in the same social venues but differ markedly in relation to sexual risk behaviour.
Article
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Men who have sex with men (MSM) have the highest incidence of HIV infection in the United States. One of the contributing factors to HIV spread among this group is the use of crystal methamphetamine ("meth"). The objective was to review the behavioral impact of crystal meth use in HIV-infected MSM and potential treatment options. A systematic review of MEDLINE identified studies that evaluated the clinical effects of crystal meth on the HIV-infected MSM population. Search terms included HIV, methamphetamine, MSM, antiretroviral therapy, adherence, resistance, and treatment. U.S. citations in the English language in peer-reviewed journals until December 2010 were included. The primary author reviewed eligible articles, and relevant data including study design, sample, and outcomes were entered into an electronic data table. The 61 included studies highlight that HIV-infected MSM who use crystal meth are more likely to report high-risk sexual behaviors, incident sexually transmitted infections, and serodiscordant unprotected anal intercourse, compared to HIV-infected MSM who do not use crystal meth. Medication adherence in this population is notably low, which may contribute to transmission of resistant virus. No medications have proven effective in the treatment of crystal meth addiction, and the role of behavioral therapies, such as contingency management are still in question. HIV-infected MSM who abuse crystal meth have worse HIV-related health outcomes. Behavioral interventions have shown variable results in treating crystal meth addiction, and more investigation into rehabilitation options are needed. The results presented support efforts to develop and implement novel interventions to reduce crystal meth use in HIV-infected MSM.
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No approved pharmacologic treatments for methamphetamine dependence exist. Methamphetamine use is associated with high morbidity and is a major cofactor in the human immunodeficiency virus epidemic among men who have sex with men (MSM). To determine whether mirtazapine would reduce methamphetamine use among MSM who are actively using methamphetamine. Double-blind, randomized, controlled, 12-week trial of mirtazapine vs placebo conducted from September 5, 2007, to March 4, 2010. San Francisco Department of Public Health. Participants were actively using, methamphetamine-dependent, sexually active MSM seen weekly for urine sample collection and substance use counseling. Random assignment to daily oral mirtazapine (30 mg) or placebo; both arms included 30-minute weekly substance use counseling. The primary study outcome was reduction in methamphetamine-positive urine test results. Secondary outcomes were study medication adherence (by self-report and medication event monitoring systems) and sexual risk behavior. Sixty MSM were randomized, 85% of follow-up visits were completed, and 56 participants (93%) completed the final visit. In the primary intent-to-treat analysis, participants assigned to the mirtazapine group had fewer methamphetamine-positive urine test results compared with participants assigned to the placebo group (relative risk, 0.57; 95% CI, 0.35-0.93, P = .02). Urine positivity decreased from 67% (20 of 30 participants) to 63% (17 of 27) in the placebo arm and from 73% (22 of 30) to 44% (12 of 27) in the mirtazapine arm. The number needed to treat to achieve a negative weekly urine test result was 3.1. Adherence was 48.5% by medication event monitoring systems and 74.7% by self-report; adherence measures were not significantly different between arms (medication event monitoring systems, P = .82; self-report, P = .92). Most sexual risk behaviors decreased significantly more among participants taking mirtazapine compared with those taking placebo (number of male partners with whom methamphetamine was used, P = .009; number of male partners, P = .04; episodes of anal sex with serodiscordant partners, P = .003; episodes of unprotected anal sex with serodiscordant partners, P = .003; episodes of insertive anal sex with serodiscordant partners, P = .001). There were no serious adverse events related to study drug or significant differences in adverse events by arm (P ≥ .99). The addition of mirtazapine to substance use counseling decreased methamphetamine use among active users and was associated with decreases in sexual risk despite low to moderate medication adherence. Trial Registration clinicalTrials.gov Identifier NCT00497081.
Conference Paper
Gay and bisexual men in the United States experience stigma and discrimination that have the potential to negatively affect their physical and mental health. This presentation summarizes the findings of a newly completed series of systematic reviews that document health disparities experienced by gay and bisexual men. Evidence of disparities in the following areas will be summarized: mental health, violent victimization; childhood sexual abuse; alcohol, tobacco, and drug use; HIV; hepatitis; and other sexually transmitted infections. Although the health problems experienced by gay and bisexual men each have unique determinants, it is important to consider these problems within existing health disparities frameworks that have been used to understand health inequities experienced by racial/ethnic minorities and other groups. Some, if not all, of the health problems experienced by gay and bisexual men are likely influenced by cross-cutting factors that contribute to health disparities. These factors include: (1) socioeconomic status, (2) the effects of prejudice and discrimination, (3) laws and policies that affect health, health behavior, and access to health care, and (4) individual behavior and cultural norms within the gay community. These influences may combine with other sources of stigma and discrimination that are experienced by some subgroups of gay and bisexual men (such as racial/ethnic minorities, adolescents/young men, and older men), which further increases the prevention and medical needs of these particularly vulnerable subgroups. The implications of these findings for future research and public health efforts to eliminate health disparities will be discussed.
Article
OBJECTIVE: Poly-substance use in gay social ('club') settings is common. Recent studies suggest a link between 'club' drug use and sexual risk behaviours. In this qualitative study, we compare and contrast two 'club' drugs: crystal methamphetamine and ecstasy (MDMA). METHODS: Life history interviews were conducted with 12 HIV seroconverters and 12 age-matched controls recruited from a prospective cohort study of young gay and bisexual men in Vancouver, British Columbia. Textual data concerning illicit substance use and unsafe sex were analyzed using NUDIST software. RESULTS: Most men related a substantial knowledge of and experience with crystal and ecstasy. Both drugs had attributes that enhanced gay socialization and were used in the same venues. Crystal was used to remain awake and increase energy. Ecstasy was used to induce euphoria and group connectedness. However, unlike ecstasy, crystal was associated with a distinct pattern of sexual arousal that frequently included unprotected (sometimes group) sex, was more likely to be used regularly by HIV-positive men, and was reportedly highly addictive and problematic. CONCLUSION: Crystal and ecstasy are used in the same social venues but differ markedly in relation to sexual risk behaviour.