Sex, drugs, and HIV: let’s avoid panic
The Lancet HIV, UK
Martin Holt a
In The Lancet HIV, Marina Daskalopoulou and colleagues1 report data from the cross-sectional ASTRA study showing high rates of drug use and condomless sex in HIV-diagnosed men who have sex with men (MSM) in the UK.1 The results are newsworthy in view of the rising number of HIV infections in British MSM and the perception that transmission is being driven by the growing popularity of so-called chemsex (the use of drugs such as crystal methamphetamine for extended periods of sex, sometimes with multiple partners).2, 3
Concerns about MSM’s sex and drug practices recur with depressing regularity. Throughout the HIV epidemic we have seen panic about gay and bisexual men having sex without condoms, about high levels of drug use, and about the role of new technology such as the internet or mobile phones in driving these practices. There have been flurries of research and commentary about internet sex-seeking, crystal methamphetamine use, circuit parties (large dance events), and barebacking (ie, condomless sex), to name a few.4 All have been implicated in heightened risks for HIV and adverse health effects. This implication is perfectly understandable—it is the business of public health to identify new threats to health and to respond to prevent harm. But in the surge of analysis and debate we often lose sight of the fact that most of the participants in these sex and drug practices do not experience harm and are not a threat to others. Sensational headlines put an issue on the agenda,3, 5 but then we are left with harder questions, such as what is the scale of the problem, and what is an appropriate response?
As Daskalopoulou and colleagues acknowledge, a high rate of recreational drug use in HIV-positive MSM is not a novel finding.1, 6 Drug use might make people feel uncomfortable, and is often illegal, but these factors do not make it a public health problem in itself.7 Measures of drug-related harm and dependence can help us identify and understand the effect of harmful drug use.8 Unfortunately, these data were not collected in the ASTRA study, which makes assessment of the scale of the problem difficult. Findings from studies in gay and bisexual men in London showed that few men who engaged in chemsex felt that their drug use was problematic.2 Most people successfully managed their drug use and found it enjoyable. Of course, in large cities such as London, only a small proportion of people need experience harm for the issue to alarm the community and to stretch existing services, which emphasises the importance of identifying those who need assistance, rather than assuming widespread harm.
Another area of concern raised by Daskalopoulou and colleagues is the potential for HIV transmission.1 Their analysis is welcome in that it differentiates between condomless sex with little to no chance of HIV transmission (ie, sex between HIV-positive partners or sex when the HIV-positive partner has an undetectable viral load) and situations in which the risk of transmission is high (ie, when the partners are serodiscordant and the HIV-positive partner might be infectious).1 Only (7%) of the 2248 MSM included in the analysis reported such high-HIV-risk sex. This finding is heartening, and suggests that most HIV-positive MSM take care to prevent HIV transmission. Only a small proportion, it seems, need assistance in negotiating sex, drugs, and HIV treatment.
In Australia, use of crystal methamphetamine in gay men surged in the early 2000s. At its peak in 2006, nearly one in five gay men in the largest cities reported some use of the drug.9 As in the present situation in the UK, many voiced serious concern that use of crystal methamphetamine could lead to health problems, unsafe sex, and HIV infections. However, the link between the drug and HIV was far from clear; research findings indicated that although its use had increased, rates of condomless sex had stabilised or fallen.10 Gay community members, however, gave voice to harrowing stories about the problems people experienced if they became dependent on crystal methamphetamine. The subsequent response, therefore, focused on disseminating harm reduction information about how to use the drug more safely, as well as promoting gay-friendly drug counselling and treatment programmes. Similar recommendations have been made in London.2 A culturally appropriate evidence-based response is needed to help reduce harm in the UK without further sensationalising the issue.
I declare no competing interests.
1 Daskalopoulou M, Rodger A, Phillips AN, et al. Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV 2014. published online Sept 8. http://dx.doi.org/10/.1016/S2352-3018(14)70001-3.
2 Bourne A, Reid D, Hickson F, Torres Rueda S, Weatherburn P. The Chemsex Study: drug use in sexual settings among gay and bisexual men in Lambeth, Southwark & Lewisham. London: Sigma Research, London School of Hygiene & Tropical Medicine, 2014.
3 Kirby T, Thornber-Dunwell M. High-risk drug practices tighten grip on London gay scene. Lancet 2013; 381: 101-102. Full Text | PDF(161KB) | PubMed
4 Elford J. Changing patterns of sexual behaviour in the era of highly active antiretroviral therapy. Curr Opin Infect Dis 2006; 19: 26-32. PubMed
5 Kirby T, Thornber-Dunwell M. New HIV diagnoses in London’s gay men continue to soar. Lancet 2013; 382: 295. Full Text | PDF(145KB) | PubMed
6 Stall R, Purcell DW. Intertwining epidemics: a review of research on substance use among men who have sex with men and its connection to the AIDS epidemic. AIDS Behav 2000; 4: 181-192. PubMed
7 Holt M, Treloar C. Pleasure and drugs. Int J Drug Policy 2008; 19: 349-352. PubMed
8 Nutt D, King LA, Saulsbury W, Blakemore C. Development of a rational scale to assess the harm of drugs of potential misuse. Lancet 2007; 369: 1047-1053. Summary | Full Text | PDF(124KB) | PubMed
9 Lea T, Prestage G, Mao L, Zablotska I, De Wit J, Holt M. Trends in drug use among gay and bisexual men in Sydney, Melbourne and Queensland, Australia. Drug Alcohol Rev 2013; 32: 39-46. PubMed
10 Rawstorne P, Digiusto E, Worth H, Zablotska I. Associations between crystal methamphetamine use and potentially unsafe sexual activity among gay men in Australia. Arch Sex Behav 2007; 36: 646-654. PubMeda Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia