Chemsex and HIV infection

Mark R. Pakianathan, from the School of Hygiene and Tropical Medicine, St. George's University of London, addressed the role of Chemsex in the spread of sexually transmitted infections (STI), hepatitis C and especially HIV.

The interplay of sex, drugs, and STIs

Mark R. Pakianathan, London School of Hygiene and Tropical Medicine, St. George's University of London, London, UK, addressed the question about the role of Chemsex in the spread of sexually transmitted infections (STI), hepatitis C and especially HIV in an overview presentation at CROI 2019 in Seattle, Washington, on 6 March 2019.

Some syndemic health care models have implied that homosexuals, bisexuals and other men who have sex with men (GBMSM) have three main imbalances, namely:

These three factors can reinforce each other. For example, HIV infection can increase the risk of drug abuse, while drug abuse can increase the risk of HIV infection. A number of other factors can influence drug abuse, such as discrimination or HIV diagnosis for a GBMSM individual.

The overlap of sexual practices and drugs

Chemsex is sexual intercourse under the influence of drugs. This practice is particularly known in the gay scene. Examples of substances used in chemsex are methamphetamine, gamma-hydroxybutyric acid (GHB)/gammabutyrolactone (GBL), mephedrone (so-called bath salts) and other cathinones, cocaine, ketamine, and crystal meth. Chemsex is a social construct, Pakianathan explained, there is no case definition for it, and the substances and social circumstances in which these episodes occur vary across different countries and groups. Digital social media apps play an important role in the spread of chemsex. Apps make drug use easier as they facilitate the process of drug purchase or distribution of drugs, and the search for chemsex opportunities with interested individuals in the immediate vicinities of chemsex seekers.

Chemsex enhances the sexual experience, improves self-confidence and facilitates sexual adventures. Many men suffer, as the British Chemsex study showed, from reduced self-esteem or sexual self-confidence and hope to overcome or mask these problems with the drugs use.

Chemsex and the risk of HIV infection

As numerous studies have shown, chemsex is 2 to 4 times more common in HIV-positive homosexual men than in HIV-negative GBMSM. Up to 10% of HIV-positive GBMSM use the drugs intravenously (informally referred to as "slamming").

The risk of HIV infection increases with chemsex. The American MACS (Multicenter AIDS Cohort Study) showed over a period of 10 years (1998 to 2008) that the use of poppers, stimulants, and substances against erectile dysfunction increased the risk of HIV seroconversion in HIV-negative men.

Of 1,484 HIV-negative MSM, 23.6% used several drugs and 21.8% reported chemsex in the last 3 months. Multiple drug use and chemsex were clearly associated with riskier sexual behavior (such as sex without a condom, group sex), which favored the acquisition of STIs or HIV, as reported by the AURAH study group (Attitudes to, and Understanding of Risk of Acquisition of HIV) in 2017.

Jennifer Fulcher and colleagues found in 24 HIV-positive and HIV-negative men that chemsex with methamphetamine was associated with increased inflammation of the rectal mucosa and increased cytokine production. This could contribute to an increased risk of HIV and explain why inflammation occurs more frequently in HIV-positive individuals.

A retrospective study by Pakianathan with GBMSM of two London clinics showed that men took significantly higher risks during chemsex than during sex without drugs, e.g. they had significantly more sexual partners in the last 3 months, more group sex, they drank more alcohol, exchanged sex toys more frequently and injected drugs. In London, patients are now routinely asked about chemsex. The study also showed that STI with 70.3% was significantly more frequent in chemsex than without chemsex with 39.8%.

A French study showed an association between increased hepatitis C infections in HIV-positive and HIV-negative GBMSM with chemsex and sexual networking.

Pre-exposure prophylaxis (PrEP) has a protective effect in chemsex, but only with optimal adherence. And longer Chemsex users tend to neglect the PrEP.

Further consequences of chemsex

There are case reports of fatal interactions between antiretroviral therapy and chemsex drugs, but little is known about interactions between antivirals and specific illegal substances. However, it is known that the use of stimulants, especially amphetamines, can reduce adherence to antiretroviral therapy.

In addition, drug use during chemsex has other negative effects on the user, such as in the workplace, conflicts with the judiciary, accidental overdose, and hospitalization. In London, for example, between 2014 and 2015, an increase in deaths associated with GHB intake of over 100% was observed. "This is probably even an underestimation because the drug is rapidly metabolized and post mortem is not routinely screened for it," the British expert explained.

What to do?

Patients have told Pakianathan that they have had chemsex, once they are asked about it. By asking on the topic, suddenly he has realized that the problem "is more common than I thought," says Pakianathan. Holistic assessments should be aimed at, training in dealing with such patients makes sense, because often they do not want to talk about extreme sexual practices. Information material was developed in London to inform patients about the risks and how to minimize them.

At present, however, the origin of chemsex is not yet properly understood and better data on its psychological and social consequences are needed. It is hoped that the Australian Flux study will provide further valuable information on this subject.

Pakianathan MR. Chemsex and implications for HIV transmission and management. CROI 2019, Seattle, Washington, March 5, 209, Abstract 64.