Prevalence of drug use during sex amongst MSM in Europe: Results from a multi-site bio-behavioural survey

Exploring the Role of Social Support and Sexual Functioning: A Study of Chemsex and Sober Sex in Men Who Have Sex with Men

Research on chemsex, the intentional use of certain drugs in sexual contexts by gay men and other men who have sex with men (MSM), has been growing in recent years although, even today, much of it focuses on drug use and its consequences, rather than on the sexual and social experiences of users. This study aimed to explore the influence of social support and sexual functioning on the frequency of chemsex and sober sex. A sample of 160 MSM WAS recruited through social media and NGOs. Through regression analysis, it was found that lower perceived social support and greater number of routes of drug administration predicted a higher frequency of chemsex practice. On the other hand, higher perceived social support, higher levels of desire and arousal, and fewer routes of drug administration predicted a higher frequency of engaging in sober sex. This study provides empirical evidence that both social support and sexual functioning are key elements in chemsex and have an impact on both the frequency of chemsex and sober sex. Given the importance of these elements, we suggest that interventions should be framed holistically. Nevertheless, not all chemsex is problematic and it is a free choice in sexuality.

The Impact of Pleasure and Pain on Frequent Substance Use During Receptive Anal Intercourse

Sexualized drug use (SDU) describes use of any psychoactive substance before or during planned sexual activity to facilitate, intensify, or prolong intercourse. The impact of pain, pleasure, and other mediators on SDU is not well characterized. This study aimed to distinguish the motivations behind different classes and frequencies of substance use during receptive anal intercourse (RAI). Data were from an internet-based survey conducted between July 2022-January 2023. We measured the frequency of SDU for five substances: poppers, alcohol, marijuana, methamphetamine, and nicotine. Satisfaction with pleasurable sensations during RAI and any type of pain bother during RAI were assessed on a 5-point scale. Multivariable logistic regression was performed for 1,119 respondents. Our results showed a strong association between bothersome pain during RAI and frequent alcohol (aOR 2.1), marijuana (aOR 2.4), nicotine (aOR 3.1), and meth (aOR 5.9) use. None of the five substance classes studied was correlated with dissatisfaction with pleasure during RAI. Frequent popper use was associated with increasing lifetime RAI experience and number of sexual partners. The mechanism behind SDU during RAI is substance-specific and multifactorial. Bothersome pain during RAI is highly associated with frequent SDU. Inquiring about pain during RAI may offer avenues for intervention.

Compulsive Sexual Behavior Disorder and Problematic Pornography Use in Cisgender Sexual Minority Individuals: The Associations with Minority Stress, Social Support, and Sexualized Drug Use

Compulsive Sexual Behavior Disorder (CSBD), recently recognized in the ICD-11 as an independent disorder, has been shown to be more prevalent in sexual minorities. However, we still lack studies investigating which factors contribute to CSBD and related behaviors in this group. In our cross-sectional study, we investigated the relationships between characteristics potentially contributing to CSBD and problematic pornography use (PPU) in sexual minority individuals: sexual minority stress (internalized sexual stigma, discrimination experiences, and openness about one's sexual orientation), perceived social support, and sexualized drug use (also more prevalent in sexual minorities). We adjusted for gender, age, sexual orientation, and the frequency of sexual behaviors. Cisgender sexual minority participants (n = 198, 72.7% men, 27.3% women; Mage = 27.13, SD = 7.78) completed an online survey. We conducted a two-step linear regression. In the first step, we introduced sociodemographic variables and the frequency of sexual activities. In the second step, we placed the predictors of main interest: perceived social support, minority stress measures, and the frequency of sexualized drug use. Our results showed that social support was negatively related to CSBD, while experiences of discrimination due to sexual orientation and engagement in sexualized drug use were associated with higher CSBD symptom severity. Internalized sexual stigma related to greater PPU severity. The discussed relationships were weak to moderate in strength. Implications of current results for therapy and diagnosis of CSBD in sexual minorities are discussed. The role of minority stressors and other factors specific to sexual minorities requires further exploration to design well-suited therapeutic interventions.

The "Chemsex" Phenomenon and Its Relationship with Psychological Variables in Men Who Have Sex with Men

Chemsex is described as the use of psychoactive substances during sexual activity to sustain, enhance, disinhibit, or facilitate the sexual experience. It preferentially concerns men who have sex with men. The main objective of this study was to examine the relationship between participation in chemsex and the psychological variables impulsivity, sexual assertiveness, and hypersexuality. The sample was composed of 137 Spanish men. A total of 104 participants reported that they had engaged in chemsex, with ages ranging from 19 to 42 years (M = 31.41, SD = 4.83). A total of 33 participants reported that they had never participated in chemsex sessions. The participants were contacted and recruited at social centers, LGBT associations, and key informants. Results showed that men who participated in chemsex reported higher impulsivity, higher hypersexuality, and lower sexual assertiveness than those who have never participated in it. The frequency of participation in chemsex, as well as the number of substances consumed, was positively and significantly correlated with dimensions of impulsivity and hypersexuality. This frequency and this consumption were negatively and significantly correlated with sexual assertiveness. Findings showed significant differences in the psychological variables based on the number of consumed substances (polydrug use/consumption of one substance) and the time of consumption (before, during or before and during sex). In conclusion, the study demonstrates the existence of a clear relationship between the experience of chemsex and psychological factors such as being an impulsive person, presenting hypersexual behavior, and/or having low sexual assertiveness.

Chemsex Session Typologies and Associated Sociodemographic Factors in Sexual Minority Men: Latent Class Analysis From a Cultural Perspective Using a Cross-Sectional Survey

Background

Chemsex prevalence is still not well known, and both the lack of homogeneity and cultural component of chemsex practices are usually overlooked.

Objective

This study aims to estimate the proportion of sexual minority men (SMM) engaging in chemsex sessions, while understanding the cultural dimension of chemsex, and to analyze distinct session typologies with potential risk differences and the sociodemographic factors associated with engaging in them.

Methods

A total of 5711 SMM residing throughout Spain participated in an anonymous web-based survey that assessed chemsex session engagement and characteristics, drug use, and sociodemographic variables. We measured the association of sociodemographic factors with engaging in chemsex sessions by calculating adjusted prevalence ratios, using multivariate Poisson regression analysis. Chemsex typologies were analyzed using latent class analysis, and sociodemographic factors were associated with the different risk classes.

Results

Our results determined that 21.1% (1205/5711; 95% CI 20.0%-22.1%) of SMM engaged in chemsex sessions during their lifetime. Participating in sessions was significantly associated with being a migrant, not having a comfortable financial situation, openly living their sexuality, residing in bigger municipalities, older age, using steroids, and living with HIV (adjusted prevalence ratio: range 1.17-2.01; all P values <.05). Three typologies of sessions with different risks were identified with latent class analysis, with 23.2% of SMM engaging in sessions taking part in higher-risk ones, which was associated with younger age, using steroids, living in bigger municipalities, openly living their sexuality, and living with HIV, compared to SMM engaging in lower-risk sessions (odds ratio: range 2.75-4.99).

Conclusions

Chemsex is relatively common among SMM in Spain, but it is important to differentiate typologies of sessions with varying risks, and the proportion of SMM engaging in high-risk sessions is low. Chemsex is highly associated with sociodemographic factors. Chemsex should be prioritized in public health programs, which should consider the different forms of sessions with their varying risks and prevalence, while also considering the cultural dimension inherent to chemsex.

Chemsex Among Men Who Have Sex With Men: A Systematic Scoping Review of Research Methods

Chemsex refers to the use of psychoactive substances with sex. We carried out a systematic scoping review of methodological characteristics of chemsex research among men who have sex with men (MSM), published between 2010 and 2020. For inclusion, chemsex had to be the main focus, and studies had to specify GHB/GBL, stimulant (amphetamine, crystal meth, ecstasy/MDMA, cathinones, cocaine) and/or ketamine use with sex as a variable. From 7055 titles/abstracts, 108 studies were included, mostly cross-sectional, and from Western countries. About one-third of studies recruited exclusively from clinical settings. A majority of these recruited from sexually transmitted infection (STI) clinics. The included quantitative studies analyzed possible associations between chemsex and STI health (40%), mental health (15%), drug health (12%), sexological health (10%), and post-diagnostic HIV health (7%). Most studies included GHB/GBL and crystal meth in their operationalization of chemsex. Definitions and operationalizations of chemsex vary greatly in the literature, and researchers of chemsex among MSM should consider ways in which this variation impacts the validity of their results. More studies are needed among MSM in non-high income and non-Western countries, and examination of possible links between chemsex and post-diagnostic HIV health, sexological health, and mental health.

HIV-Related Stigma and Treatment Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men Who Use Crystal Meth in the Metropolitan Area of Mexico City

Internationally, HIV-related stigma and crystal methamphetamine (meth) use have been described as barriers to treatment adherence among gay, bisexual, and other men who have sex with men (gbMSM). Crystal meth use has been increasing among gbMSM in the Metropolitan Area of Mexico City (MAMC). Therefore, this study aimed to determine the association between HIV-related stigma and HIV treatment adherence among gbMSM who use crystal meth in the MAMC. This study was undertaken as part of an exploratory study of crystal meth use in the MAMC. The data were collected from September to December 2021 through an encrypted online survey. Participants (n = 89) were gbMSM adults living with HIV who reported crystal meth use in the past month that were recruited through an online snowball sampling. The online survey included questions about HIV treatment adherence, sexual behaviors, the Alcohol, Smoking, and Substance Involved Screening Test, and the HIV-Related Stigma Mechanisms Scale. Logistic regression analyses assessed the association between HIV-related stigma and HIV treatment adherence. The multivariate logistic regression model showed that, controlling for health insurance [adjusted odds ratio (AOR) = 0.13; 95% confidence intervals (CI)  = 0.02-0.59] and educational level (AOR = 0.16; 95% CI = 0.02-0.88), non-adherence to HIV treatment was independently associated with higher HIV-related stigma (AOR = 1.06; 95% CI = 1.01-1.12). Public health policies must include HIV-related stigma and substance use in treating gbMSM with HIV.

Psychological characteristics associated with chemsex among men who have sex with men: Internalized homophobia, conscientiousness and serostatus as predictive factors

Background

Although significant progress has been made in the rights of the LGBTQ+ community, even today this population still faces stigma and discrimination that impacts their mental health. In the case of men who have sex with men, it has been demonstrated that the use of drugs in a sexual context (chemsex) is one of the coping mechanisms and means of escape to deal with these situations.

Method

We assessed 284 native Spanish speakers' participants, 45,4 % were not engaged in sexualised drug use (n = 129) while 54,6 % were chemsex users (n = 155) using 18,7 % of them the injected via. The participants completed six questionnaires about life and sexual satisfaction, depression, anxiety, internalised homophobia and personality. Bivariate and multivariable logistic regression were performed to assess the associations between sexual behaviour-related and psychological variables. Kruskal-Wallis H test was used to analysed the impact on mental health of the administration via.

Results

Aged, unprotected sexual relationships, positive serostatus, homonegativity and conscientiousness predicted the chemsex engagement. Furthermore, we found differences regarding the administration via.

Conclusions

We conclude that mental health significantly correlates with the practice of chemsex, highlighting the importance of integrating mental health considerations into the prevention of risky sexual behaviors.

Sexual behaviours and risk with women in MSM in sub-Saharan Africa

In sub-Saharan Africa (SSA), MSM - a high HIV prevalence group - experience strong social stigma and pressure to have female partners. Accordingly, they could constitute a bridging group for HIV transmission to cisgender women. We developed a multilevel summary of MSM sexual behaviors and risk with women in various SSA regions. Following PRISMA guidelines, we conducted a mixed-method systematic review of data of sex with women in MSM in SSA. We performed meta-analyses on quantitative data (i.e. percent of recent sex and condomless sex with women) for each SSA region (when proportions reported in ≥4 studies). Pooled proportions were calculated using random-effects models. Qualitative data were analyzed using the three-step thematic synthesis methodology. The pooled proportion of MSM who had sex with women was 58% (33-83%) in East Africa (in the previous 3 months), and 27% (13-48%) in Southern Africa and 50% (95% CI 39-62%) in West Africa (in the previous 6 months); 23% (16-32%) of MSM in West Africa had condomless sex with a woman (during the most recent encounter). Approximately one quarter of MSM had recent multiple female partners. MSM reported having sex with women because of heteronormative pressure, erotic/romantic attraction, or financial needs leading to transactional sex. MSM may act as a bridging population to women in SSA, as they commonly practice sex with women and risky sexual behaviors with them. HIV programmes and community-based support for MSM should be adapted to this population to reduce this risk.

Trends in illicit drug use and their association with HIV transmission risks from behavioural surveillance of Australian gay and bisexual men

INTRODUCTION

Investigating drug trends among Australian gay and bisexual men (GBM) is crucial for understanding levels of use and the potential for harm, including HIV transmission risk.

METHOD

Using repeated, national, cross-sectional survey data collected between 2012 and 2021 (69,567 surveys), trends of recent (previous 6 months) and frequent (weekly) drug use were analysed, using logistic regression models. The last round of data from each jurisdiction (6709 surveys) was used to compare GBM who reported no use, infrequent (less than weekly) use and frequent (at least weekly) use of party drugs to investigate the association between party drug use and HIV transmission risk, using multinomial logistic regression models.

RESULTS

There was a significant upward trend in any recent drug use (from 58.4% in 2012 to 64.1% in 2021; p < 0.001). Frequent party drug use remained a minority practice over the period (consistently less than 3%). In cross-sectional analysis, frequent party drug users were more likely to report behaviours with HIV transmission risks, such as condomless anal intercourse without biomedical prevention strategies (30.0% vs. 13.1%; adjusted relative risk ratio [aRRR], 2.08; 95% CI, 1.24-3.47), weekly group sex (16.3% vs. 0.6%; aRRR, 12.36; 95% CI, 5.75-26.56) and more than 20 recent sexual partners (42.5% vs. 5.0%; aRRR, 21.44; 95% CI, 5.82-78.89), compared with GBM who did not use party drugs.

DISCUSSION AND CONCLUSION

Our findings suggest that the frequent use of party drugs remains a marker of HIV transmission risk among Australian GBM, despite the increased adoption of biomedical HIV prevention strategies over the past few years.

Substance Use and Misuse among Sexual and Gender Minority Communities Living in Former Soviet Union Countries: A Scoping Review

Objectives

We reviewed literature examining substance use among sexual and gender minorities (SGM) living in the former Soviet Union (USSR) nations.

Methods

Searches were conducted across five databases (PubMed, SocINDEX, CINAHL, PscyInfo, LGBTQ + Source) to identify peer-reviewed literature.

Results

Across 19 studies, high hazardous substance use prevalence was documented. Substance use was correlated with (a) sexual health and behaviors and (b) mental wellbeing and the use of other substances.

Conclusion

We discuss minority stress implications and challenges presented by the paucity of evidence in the literature examining substance use among SGM women and SGM living in countries unrepresented in reviewed studies.

Sexualised drug use among gay and bisexual men in New Zealand: Findings from a national cross-sectional study

INTRODUCTION

New Zealand has a unique illicit drug market, gay cultures and drug use patterns. Minimal attention has been given to how drug use shapes sexual practice, especially in the era of biomedical HIV prevention among gay and bisexual men (GBM).

METHODS

An online cross-sectional study of GBM ('Flux NZ') adapted from an Australian study was undertaken to explore connections between drug use, sexual practice, health and community. We describe drug use patterns, then identify three discrete groups determined by intensity of recent (past 6 months) sexual practice: no recent sex, recent sex and recent sexualised drug use. We examine factors associated with these groups and identify factors independently predicting sexualised drug use.

RESULTS

Of 739 participants, almost a third had engaged in group sex (29%), 17.5% were taking pre-exposure prophylaxis (PrEP), 6.5% were HIV positive. Overall, 59.5% had recently used illicit drugs (16.9% methylenedioxymethamphetamine, 6% methamphetamine, 3.3% gamma-hydroxybutyrate acid, 1.4% ketamine). Sexualised drug use was common (35.7%). Those engaged in sexualised drug use were connected to gay community and had a high uptake of biomedical HIV prevention. Independent predictors of sexualised drug use included being sexually adventurous, knowing their HIV status, having more than 10 recent sexual partners, engaging in group sex and sex at a sex-on-site venue.

DISCUSSION AND CONCLUSIONS

Many GBM engaging in sexualised drug use manage HIV transmission risks through regular testing, PrEP and HIV treatment. HIV prevention efforts should target GBM with less intensive sexual behaviour but who may be at comparatively higher risk of HIV transmission.

Sexualised drug use and chemsex in Italy: A questionnaire study based on a cohort of clients attending a STI outpatient service in Milan

BACKGROUND

Chemsex is a heterogeneous phenomenon with differences in distribution, setting, motivations and type of substances consumed between countries. The lack of data at national level of the Italian situation creates a perception of reduced need for intervention.

METHODS

Anonymous paper questionnaires were distributed to patients who had registered themselves at the STI Department IRCCS Ca' Granda Policlinico in Milan.

RESULTS

A significant association was demonstrated between use of sexualised drugs, chemsex and the following variables: (1). Number of partners: in the group of clients with more than five partners, sexualised drug users were more than twice compared with those in the group with less than five partners (35.2% vs 16.2%) p<0.0001. (2). Use of dating apps: more than one out of two persons who used drugs during sex affirmed looking for partners on internet, p = 0.0059. (3). Low condom uses with occasional partners: percentage of individuals who declared not to use condoms or devices during their sexual encounters with occasional partners is more than twice as high in the sexualised drug users group with respect to controls (44.6% vs 21.4%); p = 0.0006). (4). Use of post exposure prophylaxis (PEP): among the PEP users, more than half participants belonged to the sexualised drug users' group; p = 0.0021.

CONCLUSIONS

Sexualised drug use and chemsex are frequently practiced in Milan. This survey identified a specific population with higher-risk sexual behaviours and increased incidence of acute bacterial STIs.

Prevalence, characteristics, and associated risk factors of drug consumption and chemsex use among individuals attending an STI clinic (EpITs STUDY)

Sex-related drug consumption and its health-related consequences have gained relevance in the assessment of patients with sexually transmitted infections (STIs), which pose a significant challenge to public health. We aim to assess the prevalence and characteristics of drug consumption and chemsex practices, describe the associated risk factors among general individuals attending an STI clinic, and evaluate the psychological impact associated with these behaviors. We conducted an online anonymous survey offered to patients with a diagnosis of STI in a tertiary hospital in Spain. Data included sociodemographic characteristics, sexual preferences and behavior, and assessment of drug use, chemsex, and psychological and mental health symptoms. Data from 145 subjects was collected, with a higher proportion of cis-gender men (71%), and a median age of 32 years. 64 participants (44%) reported drug use in the last year, with an observed 33.8% prevalence of chemsex consumption. Drug use and chemsex were more frequent among cis-gender men, Men who have Sex with Men (MSM), people living with HIV (PLHIV), and those reporting previous group sex. Poppers and cannabis were the most frequently reported drugs, with a prevalence close to 20% for cocaine, mephedrone, extasis, and GHB. Consequences related to drug use included unpleasant physical sensations, sexual dysfunction, and impaired sexual experience after reduction or drug discontinuation. The prevalence of drug use and chemsex practices are high among patients evaluated for STIs, especially between men, MSM, and subjects practicing group sex. The study highlights the urgent need for targeted interventions on prevention and reduction of their impact on health and social well-being.

Comparison of clinical course of Mpox among HIV-negative and HIV-positive patients: A 2022 cohort of hospitalized patients in Central Europe

Mpox has become the most significant orthopoxviral infection among humans. Since May 2022, there has been a multicountry outbreak of mpox across six continents. Retrospective observational cohort study of 94 patients with probable or confirmed mpox of whom 86.2% were hospitalized in Hospital for Infectious Diseases in Warsaw, Poland between May 16 and October 30, 2022. Most patients were young (median age: 31, IQR: 25-43 years), predominantly (88.3%) Polish men who have sex with men exposed most commonly in Poland (82.7%), Spain (6.2%), or Germany (4.9%). The median observed mpox incubation period was 7 (IQR: 4-8) days with the median hospitalization time of 7 (range: 2-24, IQR: 5-11) days. History of sexually transmitted infections (STIs) was common in the group (previous syphilis or hepatitis C virus in 33.3% and 17.3%, respectively, 6.2% of early syphilis or gonorrhea). A significant proportion (n = 43, 45.7%) of mpox cases were people with human immunodeficiency virus (HIV), all except one were on stable and virologically effective (88.4% with HIV viral load <50 copies/mL) antiretroviral treatment. Chemsex was reported in 34.6% of hospitalized cases, more commonly among people with HIV (48.5% vs. 25.0%, p = 0.029). None of the mpox infected patients presented with advanced HIV infection. Despite the fact that 6.3% of cases presented with >50 skin lesions the course of the disease was self-limited with no severe cases or deaths. There were no significant clinical or laboratory differences or complication rates between patients with and without HIV coinfection. Epidemiological and clinical characteristics of mpox in Poland are similar to other countries, but there were no targeted, population oriented interventions or vaccination programs. Mpox diagnosis provided an opportunity to screen and diagnose other STIs. As Central European populations, including refugees from Ukraine, are largely unvaccinated against mpox access to preventive vaccinations and antiviral therapy should be maximized.

Prevalence of Intoxicating Substance Use Before or During Sex Among Young Adults: A Systematic Review and Meta-Analysis

Drug use before or during sex is a high-risk sexual behavior associated with adverse health risks and outcomes, such as increasing the likelihood of overdoses and of acquiring sexually-transmitted diseases. This systematic review and meta-analysis of three scientific databases examined the prevalence of the use of intoxicating substances, those tending to excite or stupefy the user on a psychoactive level, before or during sex, among young adults (18-29 years old). A total of 55 unique empirical studies met the inclusion criteria (48,145 individuals; 39% males), were assessed for risk of bias using the tools of Hoy et al. (2012), and were analyzed via a generalized linear mixed-effects model. The results produced a global mean prevalence of this sexual risk behavior of 36.98% (95% CI: 28.28%, 46.63%). Nonetheless, significant differences were identified between different intoxicating substances, with the use of alcohol (35.10%; 95% CI: 27.68%, 43.31%), marijuana (27.80%; 95% CI: 18.24%, 39.92%), and ecstasy (20.90%; 95% CI: 14.34%, 29.45%) significantly more prevalent than that of cocaine (4.32%; 95% CI: 3.64%, 5.11%), heroin (.67%; 95% CI: .09%, 4.65%), methamphetamine (7.10%; 95% CI: 4.57%, 10.88%), and GHB (6.55%; 95% CI: 4.21%, 10.05%). Moderator analyses showed that the prevalence of alcohol use before or during sex differed according to geographical sample origin, and increased as the proportion of ethnic whites in samples increased. The remaining demographic (e.g., gender, age, reference population), sexual (e.g., sexual orientation, sexual activity), health (e.g., drug consumption, STI/STD status), methodological (e.g., sampling technique), and measurement (e.g., timeframe) variables that were examined did not moderate prevalence estimates. Implications for sexual development interventions were discussed.

Substance Use and Relationship Functioning Among Young Male Couples

Research shows that, for different sex couples, individual levels of substance use are deleterious for relationship quality (e.g., satisfaction, intimate partner aggression), whereas dyadic concordance is usually protective. However, there has been no research on these effects among male couples, even though they show increased risk for substance use and certain indices of relationship distress (e.g., intimate partner aggression) compared to different sex couples. Male partners also display distinct similarity patterns and norms surrounding substance use, suggesting that there might be unique effects of substance use on relationship quality among this population. We conducted actor-partner interdependence models of substance use on relationship quality (intimate partner aggression, satisfaction) among a large sample of male dyads (N = 934 individuals, N = 467 dyads). Results suggested that there are novel actor, partner, and similarity effects that imply unique pathways to relationship well-being for male couples. These results are discussed in light of future clinical and empirical efforts. [NCT03186534 - 6/12/2017; NCT03284541 - 6/23/2017].

Risk and Protective Profile of Men Who Have Sex With Men Using Mobile Voluntary HIV Counseling and Testing: Latent Class Analysis

BACKGROUND

Mobile voluntary counseling and testing (VCT) for HIV has been carried out to improve the targeting of at-risk populations and HIV case detection for men who have sex with men (MSM). However, the HIV-positive detection rate using this screening strategy has declined in recent years. This may imply unknown changes in risk-taking and protective features jointly influencing the testing results. These changing patterns in this key population remain unexplored.

OBJECTIVE

The aim of this study was to identify the nuanced group classification of MSM who underwent mobile VCT using latent class analysis (LCA), and to compare the difference in characteristics and testing results between subgroups.

METHODS

A cross-sectional research design and purposive sampling were applied between May 21, 2019, and December 31, 2019. Participants were recruited by a well-trained research assistant through social networking platforms, including the most popular instant messenger app Line, geosocial network apps dedicated to MSM, and online communities. Mobile VCT was provided to participants at an assigned time and place. Demographic characteristics and risk-taking and protective features of the MSM were collected via online questionnaires. LCA was used to identify discrete subgroups based on four risk-taking indicators-multiple sexual partners (MSP), unprotected anal intercourse (UAI), recreational drug use within the past 3 months, and history of sexually transmitted diseases-and three protective indicators-experience of postexposure prophylaxis, preexposure prophylaxis use, and regular HIV testing.

RESULTS

Overall, 1018 participants (mean age 30.17, SD 7.29 years) were included. A three-class model provided the best fit. Classes 1, 2, and 3 corresponded to the highest risk (n=175, 17.19%), highest protection (n=121, 11.89%), and low risk and low protection (n=722, 70.92%), respectively. Compared to those of class 3, class 1 participants were more likely to have MSP and UAI within the past 3 months, to be ≥40 years of age (odds ratio [OR] 2.197, 95% CI 1.357-3.558; P=.001), to have HIV-positive results (OR 6.47, 95% CI 2.272-18.482; P<.001), and a CD4 count ≤349/μL (OR 17.50, 95% CI 1.223-250.357; P=.04). Class 2 participants were more likely to adopt biomedical preventions and have marital experience (OR 2.55, 95% CI 1.033-6.277; P=.04).

CONCLUSIONS

LCA helped derive a classification of risk-taking and protection subgroups among MSM who underwent mobile VCT. These results may inform policies for simplifying the prescreening assessment and more precisely recognizing those who have higher probabilities of risk-taking features but remain undiagnosed targets, including MSM engaging in MSP and UAI within the past 3 months and those ≥40 years old. These results could be applied to tailor HIV prevention and testing programs.

Engagement in Chemsex among Men Who Have Sex with Men (MSM) in Malaysia: Prevalence and Associated Factors from an Online National Survey

Background: Chemsex is the use of illicit drugs—particularly methamphetamine, gamma hydroxybutyrate (GHB), and gamma-butyrolactone (GBL)—to enhance sexual activity. Chemsex, which occurs primarily among communities of men who have sex with men (MSM), is associated with greater HIV risk behaviors, including multiple sex partners, group sex, condomless sex, and injection drug use. Despite evidence showing chemsex engagement among Malaysian MSM, there is a paucity of research on chemsex among MSM in Malaysia. Methods: This cross-sectional study was conducted through an online survey (August to September 2021) among 870 Malaysian MSM. Participants were recruited through targeted advertisements on social networks. We collected information regarding participants’ recent (<6 months) engagement in chemsex, demographic characteristics, psychosocial factors, pre-exposure prophylaxis (PrEP) knowledge and history, and recent sexual- and drug-related behavior. Multivariable logistic regression was used to identify factors associated with recent (<6 months) chemsex engagement. Results: Just under 1 in 10 (9.0%) of participants reported having engaged in chemsex in the previous six months. More than two-thirds of participants (69.1%) had not disclosed their sexual orientation to anyone in their family and 35.2% reported moderate to severe depressive symptoms. Multivariable analysis found that recent injection drug use (adjusted odds ratio: aOR = 6.61; 95% confidence interval: CI, 2.30−19.03), having shared pre-exposure prophylaxis (PrEP) with someone else (aOR = 5.60; 95% CI, 1.76−17.77), higher perceived HIV risk (aOR = 3.15; 95% CI, 1.25−7.93), knowing someone using PrEP (aOR = 2.93; 95% CI, 1.62−5.31), recent engagement in transactional sex (aOR = 2.38; 95% CI, 1.06−5.39), having a recent STI diagnosis (aOR = 2.36; 95% CI, 1.25−4.44), recent engagement in anal sex (aOR = 2.21; 95% CI, 1.07−4.57), and recent sexual intercourse with an HIV-positive partner (aOR = 2.09; 95% CI, 1.07−4.08) were associated with recent engagement in chemsex. Conclusions: Malaysian MSM who practice chemsex are vulnerable to several HIV risk factors, such as transactional sex, HIV-positive sexual partners, and injection drug use. There is an urgent need for programs that integrate drug, sexual health, and mental health services, with a focus on harm reduction (e.g., condoms, access to and utilization of HIV testing and PrEP services, drug knowledge, and safer drug use) tailored for MSM who practice chemsex.

Prevalence and risk factors for transactional sex among Swedish-born and foreign-born MSM in Sweden

BACKGROUND

Little is known about transactional sex (TS) (selling and buying sex) among men who have sex with men (MSM) in Sweden, especially among foreign-born MSM. This study aims to assess the prevalence and risk factors of TS (ever and in the previous five years) among MSM living in Sweden and to determine if there is a difference between Swedish-born MSM and foreign-born MSM.

METHODS

Swedish data from a multicountry online banner survey (EMIS-2017) was used (n = 4443). Multivariable regression analysis was applied to analyse the data.

RESULTS

The prevalence of ever-selling sex among all MSM participants was 13.2% and 5.9% in the previous five years. Selling sex ever and in the previous five years was higher among foreign-born MSM (16% and 8.4%, respectively) than Swedish-born MSM (12.7% and 5.4%, respectively). Among all participants, younger age (aOR:3.19, 95% CI:1.57-6.45) and really struggling to live on current income (aOR:3.37, 95% CI:2.29-4.96) increased the odds of selling sex. Being foreign-born MSM (aOR:1.33, 95% CI:1.02-1.73) and having had sex with a woman in the previous 12 months increased the odds of selling sex (aOR:1.44, 95% CI:1.00-2.07). The prevalence of ever buying sex among MSM participants in Sweden was 10.8% and 6.7% in the previous five years, with the same trend among foreign-born MSM (11.6% and 6.9%, respectively) and Swedish-born MSM (10.7% and 6.6%, respectively). Higher education and not having a current partner increased the odds of buying sex. Younger age was protective for buying sex (aOR:0.05, 95% CI:0.02-0.14). Among the foreign-born MSM, the length of stay in Sweden decreased the odds of buying sex (aOR: 0.98, 95% CI: 0.96-0.99).

CONCLUSIONS

The comparatively high prevalence of TS among MSM participants in Sweden, where buying sex is illegal, with a higher prevalence among foreign-born MSM participants, calls for sexual and reproductive health and rights interventions in this population. Increased attention, including HIV prevention programming and education, should be aimed at younger MSM, MSM struggling with their current income, and foreign-born MSM, as they are more likely to report selling sex.

Using Intervention Mapping to Develop an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Development and Usability Study

BACKGROUND

Chemsex refers to the intentional use of drugs before or during sex among men who have sex with men (MSM). Engaging in chemsex has been linked to significant negative impacts on physical, psychological, and social well-being. However, no evidence-based support tools have addressed either these harms or the care needs of MSM who engage in chemsex.

OBJECTIVE

The purpose of this paper was to describe the development of a mobile health intervention (named Budd) using the intervention mapping protocol (IMP). Budd aims to support and inform MSM who participate in chemsex, reduce the negative impacts associated with chemsex, and encourage more reasoned participation.

METHODS

The IMP consists of 6 steps to develop, implement, and evaluate evidence-based health interventions. A needs assessment was carried out between September 2, 2019, and March 31, 2020, by conducting a literature study and in-depth interviews. Change objectives were selected based on these findings, after which theory-based intervention methods were selected. The first version of the intervention was developed in December 2020 and pilot-tested between February 1, 2021, and April 30, 2021. Adjustments were made based on the findings from this study. A separate article will be dedicated to the effectiveness study, conducted between October 15, 2021, and February 24, 2022, and implementation of the intervention. The Budd app went live in April 2022.

RESULTS

Budd aims to address individual factors and support chemsex participants in applying harm reduction measures when taking drugs (drug information, drug combination tool, and notebook), preparing for participation in a chemsex session (articles on chemsex, preparation tool, and event-specific checklist), planning sufficient time after a chemsex session to recover (planning tool), seeking support for their chemsex participation (overview of existing local health care and peer support services, reflection, personal statistics, and user testimonials), taking HIV medication or pre-exposure prophylaxis in a timely manner during a chemsex session (preparation tool), and contacting emergency services in case of an emergency and giving first aid to others (emergency information and personal buddy).

CONCLUSIONS

The IMP proved to be a valuable tool in the planning and development of the Budd app. This study provides researchers and practitioners with valuable information that may help them to set up their own health interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/39678.

Evolution of Risk Behaviors, Sexually Transmitted Infections and PrEP Care Continuum in a Hospital-Based PrEP Program in Barcelona, Spain: A Descriptive Study of the First 2 Years' Experience

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is effective for HIV prevention, but the PrEP care continuum also involves improving PrEP awareness, uptake, adherence, and retention in care. Users' awareness is often compromised because of vulnerability factors and risk behaviors, such as chemsex practice or specific substance use, which could lead to risk compensation. Correct adherence and retention in care are essential to achieve the full effectiveness of PrEP. This study describes changes in users' risk behaviors and sexually transmitted infections (STIs), as well also PrEP care continuum details.

METHODS

This was a descriptive single-center retrospective study including adults at high HIV risk screened between November 2019 and June 2021 in the PrEP program of our hospital. Demographic, behavioral, STI, adherence, and retention in care variables were assessed. Data were collected from medical records and self-report questionnaires.

RESULTS

A total of 295 people were included, 94% men and 5% transgender women, with a mean age of 34 years (SD 10) and 10% sex workers. At baseline, 55% disclosed chemsex practice and 3% slamming. During follow-up, condom use for anal intercourse decreased from 41% to 13% (p ≤ 0.0001) and one HIV infection was detected; other risk behaviors and STIs remained stable. Chemsex, group sex, fluid exchange, and condomless anal intercourse were related to STI risk. Adherence was correct in 80% of users, and retention in care was 57%. Discontinuations and loss to follow-up were high, mainly affecting transgender women, sex workers, and people practicing fisting.

CONCLUSION

PrEP program implementation in our hospital was adequate, since it allowed, in a population at high HIV risk, overall users' risk behaviors and STIs to remain stable, with only one HIV diagnosis during the follow-up. We should target specific strategies to improve adherence and retention in care, as vulnerable subgroups at higher risk of loss to follow-up are identified.

Sexual uses of drug and alcohol among men who have sex with men in China: implications for HIV prevention

BACKGROUND

Sexual uses of alcohol and drugs are pervasive among men who have sex with men (MSM) and associated with increased risk of HIV infection. However, there are limited studies related to sexual uses of alcohol and drugs among MSM in China. This study aims to describe the pattern of alcohol use, drug use, and multi-drug use during sex among Chinese MSM and to examine the association between condomless anal intercourse, group sex, commercial sex and HIV infection.

METHODS

We conducted an online cross-sectional survey in China. Characteristics on social-demographic, sexual behaviors, and sexual uses of alcohol and drugs were collected. The associations with high-risk sexual behaviors and HIV infection were analyzed with multivariable logistic regression.

RESULTS

A total of 699 MSM were included in this study. About 39.5% (230/582) of men reported sexual alcohol use in the past three months and 50.8% (355/699) reported sexual drug use. Of those reporting sexual drug use, around 10.7% (38/355) reported having multi-drug use. Factors associated with both sexual uses of alcohol and drugs included: reporting more male sexual partners (alcohol: adjusted odds ratio [aOR] = 1.77; drug: aOR = 2.12), reporting condomless anal intercourse in the past three months (alcohol: aOR = 2.08; drug: aOR = 2.08), having ever engaged in group sex (alcohol: aOR = 2.04; drug: aOR = 5.22; multi-drug: aOR = 3.52) and commercial sex (alcohol: aOR = 4.43; drug: aOR = 4.22 multi-drug: aOR = 5.07). Sexual drug use was also correlated with reported HIV-positive status (drug: aOR = 2.53, 95% CI:1.31-4.90).

CONCLUSION

Sexual uses of alcohol and drugs are prevalent among Chinese MSM. Interventions to reduce the sexual use of alcohol and other drugs may be warranted among MSM in China.

Sexualized drug use among men who have sex with men in Madrid and Barcelona: The gateway to new drug use?

This original study compares the prevalences of drug use for any purpose and for sexualized drug use (SDU) among MSM. It also describes relevant characteristics of first SDU, analyzes to what extent SDU has been the first experience (the gateway) with different drugs by age and explores the correlates of SDU. Study participants included 2,919 HIV-negative MSM attending four HIV/STI diagnosis services in Madrid and Barcelona. They answered an online, self-administered questionnaire. Poisson regression models with robust variance were used. About 81.4% had ever used any drug, and 71.9% had done so in the last-12-months, while 56% had ever engaged in SDU, and 50% had done so in the last-12-months. Participants under 25 years old had the lowest prevalences of SDU, and the 25-39 age group the highest, except for Viagra, which was higher among those over age 40. The most frequently used drugs for first SDU were poppers (53.6%), cannabis (19.6%) and Viagra (12.2%). These drugs were also the most ever consumed for SDU. Among sexualized users, methamphetamine (78.3%) and Mephedrone (75.4%) were used always/most of the times for sex in the last-12-months. Around 72.2% of Mephedrone sexualized users and 69.6% of Methamphetamine vs 23.1% of ecstasy users' first consumption of these drugs involved use for sex. These drugs were provided to them free where they have sex for 66.8, 79.1, and 31.9%, respectively. On that occasion, 8.1% of Mephedrone, 6.8% of Methamphetamine and 18.4% of ecstasy users had sex only with steady partner; with 50.2, 56.2, and 26.2% respectively using a condom with any partner. SDU in the first use was associated with similar variables for recreational and chemsex drugs. The highest prevalence ratios were for having ever been penetrated by >20 men and having ever injected drugs. It can be concluded that the prevalence of SDU was more than half of the prevalence for any purpose. Thus SDU was the gateway to use for many drugs in an important proportion of users, who frequently consumed drugs that were free and had condomless anal sex with occasional and multiple partners. These circumstances were much more common for chemsex than for recreational drugs.

Chemsex users in Czechia: EMIS survey

OBJECTIVES

Chemsex is a phenomenon highly relevant to public health concerns. Our primary aim is to describe the Czech chemsex scene regarding substances used, sexual behaviour, mental health, sexual life satisfaction, internalization of homonegative attitudes, and prevalent chemsex patterns.

METHODS

The data from the European Men Who Have Sex With Men Internet Survey (EMIS) 2017 were used. The mental health of chemsex users was assessed by the Patient Health Questionnaire 4 (PHQ4), internalized homonegativity was measured using the Short Internalized Homonegativity Scale. A sample of 87 men who have sex with men (MSM) chemsex users and a comparison group of 261 MSM were selected from the total sample of 1,688 respondents. Mann-Whitney and χ² tests were used to compare groups.

RESULTS

Active chemsex users made up 5% of the sample (87 of 1,688), with an average age of 37 years. Chemsex users were more likely to engage in condomless sex with non-steady partners (χ² = 46.8, p < 0.001), and had dramatically more STIs, such as HIV (χ² = 52.9, p < 0.001), HCV (χ² = 25.9, p < 0.001), and syphilis (χ² = 41.5, p < 0.001). Chemsex users frequently injected drugs (n = 19, 20%). More than half (n = 48; 55%) of chemsex users had sober sex in the last 4 weeks. Chemsex culture was associated with riskier substance use, both in terms of mode and frequency. The mental health of chemsex users in our sample did not differ significantly from the comparison group (χ² = 0.2, p < 0.7). Chemsex users did not conceal their sexual identity more often than the comparison group, on the contrary, 69% (n = 59) of them were out to most significant others, compared to 53% (n = 134) in the comparison group (χ² = 8.8, p < 0.05). In addition, we did not find differences in the degree of internalized homonegativity (χ² = 0.9, p < 0.4). Chemsex users were clearly and significantly more satisfied with their sex life than the comparison group (Mann-Whitney U test, p < 0.001).

CONCLUSIONS

In our sample, chemsex use was not associated with a negative impact on health or wellbeing. Our results suggest that chemsex is not a homogeneous phenomenon. Many different patterns and subcultures exist, some of them are riskier, some safer than others.

The impact of discrimination on substance use disorders among sexual minorities

This paper aimed to review the literature regarding the impact of discrimination on substance use disorders among Sexual Minorities (SM), with a focus on alcohol, opioids, stimulants, polydrug use, chemsex, cannabis and tobacco, as well as inequalities in the access to health care services. It is alarmingly clear that SM report higher rates of morbidity if compared to the general population. Health care delivery inequalities have also been reported in this special population. Also, the lack of data from low- and middle-income countries on substance use among SM is a major concern. Certainly, discrimination play a key-role among leading factors to substance abuse, continued use, disorders, and lower levels of preventive and treatment interventions. However, it may be difficult to estimate the impact of discrimination because of the lack of research data and different methodologies of literature studies. Moreover, SM are differently categorized and defined and evidences may be not comparable between studies. There is an urgent need of strategic guidelines and research investments aimed at prioritizing these populations disproportionately impacted by substance use. Equity-oriented policies and programs can facilitate opportunities and decrease substance use in these vulnerable subgroups, including community- and peer-led initiatives and nonjudgmental and inclusive health services.

Sexualized Drug Use and Chemsex: Their Association with Sexual Health Among Men who have Sex with Men Living in Greece

Objectives: The study aims to investigate rates of sexualized drug use (SDU) and chemsex, a type of SDU involving specifically the use of crystal methamphetamine, mephedrone, or GHB/GBL and their association with the rates of negative sexual health outcomes among men who have sex with men (MSM) in Greece. Methods: Survey of 485 MSM in internal disease departments and community testing centers. Results: Twenty-eight percent of participants were involved in SDU and 20.4% in chemsex. HIV positive status and recent STI diagnoses were associated with SDU involvement. Conclusion: SDU and chemsex rates and their impact on health reveal the need for informed community-based services.

Methamphetamine Induces the Release of Proadhesive Extracellular Vesicles and Promotes Syncytia Formation: A Potential Role in HIV-1 Neuropathogenesis

Despite the success of combinational antiretroviral therapy (cART), the high pervasiveness of human immunodeficiency virus-1 (HIV)-associated neurocognitive disorders (HAND) poses a significant challenge for society. Methamphetamine (meth) and related amphetamine compounds, which are potent psychostimulants, are among the most commonly used illicit drugs. Intriguingly, HIV-infected individuals who are meth users have a comparatively higher rate of neuropsychological impairment and exhibit a higher viral load in the brain than infected individuals who do not abuse meth. Effectively, all cell types secrete nano-sized lipid membrane vesicles, referred to as extracellular vesicles (EVs) that can function as intercellular communication to modulate the physiology and pathology of the cells. This study shows that meth treatments on chronically HIV-infected promonocytic U1 cells induce the release of EVs that promote cellular clustering and syncytia formation, a phenomenon that facilitates HIV pathogenesis. Our analysis also revealed that meth exposure increased intercellular adhesion molecule-1 (ICAM-1) and HIV-Nef protein expression in both large (10 K) and small (100 K) EVs. Further, when meth EVs are applied to uninfected naïve monocyte-derived macrophages (MDMs), we saw a significant increase in cell clustering and syncytia formation. Furthermore, treatment of MDMs with antibodies against ICAM-1 and its receptor, lymphocyte function-associated antigen 1 (LFA1), substantially blocked syncytia formation, and consequently reduced the number of multinucleated cells. In summary, our findings reveal that meth exacerbates HIV pathogenesis in the brain through release of proadhesive EVs, promoting syncytia formation and thereby aiding in the progression of HIV infection in uninfected cells.

Prediction Model for the Risk of HIV Infection among MSM in China: Validation and Stability

The impact of psychosocial factors on increasing the risk of HIV infection among men who have sex with men (MSM) has attracted increasing attention. We aimed to develop and validate an integrated prediction model, especially incorporating emerging psychosocial variables, for predicting the risk of HIV infection among MSM. We surveyed and collected sociodemographic, psychosocial, and behavioral information from 547 MSM in China. The participants were split into a training set and a testing set in a 3:1 theoretical ratio. The prediction model was constructed by introducing the important variables selected with the least absolute shrinkage and selection operator (LASSO) regression, applying multivariate logistic regression, and visually assessing the risk of HIV infection through the nomogram. Receiver operating characteristic curves (ROC), Kolmogorov–Smirnov test, calibration plots, Hosmer–Lemeshow test and population stability index (PSI) were performed to test validity and stability of the model. Four of the 15 selected variables—unprotected anal intercourse, multiple sexual partners, involuntary subordination and drug use before sex—were included in the prediction model. The results indicated that the comprehensive prediction model we developed had relatively good predictive performance and stability in identifying MSM at high-risk for HIV infection, thus providing targeted interventions for high-risk MSM.

Comparison of Polydrug Use Prevalences and Typologies between Men Who Have Sex with Men and General Population Men, in Madrid and Barcelona

This study compares the prevalence of drug use and the typologies of polydrug use (PDU) in men who have sex with men (MSM) and general population men (GPM). Participants were men aged 16–64, living in the provinces of Madrid and Barcelona: 1720 were recruited in a GPM survey, and 2658 were HIV-negative MSM from HIV/STIs diagnosis services. Lifetime and last-year prevalence of drug use and prevalence ratios (PRs) of MSM to GPM for the different drugs were calculated using Poisson regression. Latent class analysis (LCA) was performed to identify typologies of PDU. Lifetime use of the drugs considered was higher in MSM, and even higher for drug use in the last-year: PRs for cannabis, hallucinogens and cocaine ranged from 2–5; for amphetamine, ecstasy and methamphetamine 12–16; and above 60 for ketamine, GHB/GBL, inhalants and mephedrone. In the LCA for lifetime PDU four classes arose from the GPM (No-PDU (79.6%); Conventional PDU (13.8%); Intensive conventional PDU (4.9%); Heavy PDU (1.8%)) and four among MSM (No-PDU (57.7%); Conventional PDU plus poppers (18.8%); PDU preferring chemsex drugs (6.4%); Heavy PDU (17.2%)). For PDU during the last-year, three classes arose in the GPM: No-PDU (94.7%); Conventional PDU (4.3%); Heavy PDU (0.9%). For MSM, we identified four classes: No-PDU (64.7%); Conventional PDU plus poppers (15.6%); PDU preferring chemsex drugs (6.2%); Heavy PDU (13.5%). MSM should be considered a priority group for the prevention of the use of all drugs but the heterogeneity of PDU typologies regarding users’ preference towards conventional and/or sexualised drugs needs to be taken into account.

Populations size estimations using SS-PSE among MSM in four European cities: how many MSM are living with HIV?

BACKGROUND

Although men who have sex with men (MSM) are considered at high risk for transmission of sexually transmitted infections, including HIV, there are few studies estimating the population size of MSM in Europe. We used network data from a survey of MSM in four cities to perform successive sampling-population size estimations (SS-PSE) to estimate MSM population sizes.

METHODS

Data were collected in 2013-14 in Bratislava, Bucharest, Verona and Vilnius using respondent-driven sampling (RDS). SS-PSE uses a Bayesian framework to approximate the RDS sampling structure via a successive sampling model and uses the selection order of the sample to provide information about the distribution of network sizes over the population members of MSM.

RESULTS

We estimate roughly 4600 MSM in Bratislava, 25 300 MSM in Bucharest, 7200 in Verona and 2900 in Vilnius. This represents 2.9% of the estimated adult male population in Bratislava, 2.3% in Bucharest, 2.7% in Verona and 1.5% in Vilnius. The number of MSM living with HIV would roughly be 200 in Bratislava, 4554 in Bucharest, 690 in Verona and 100 in Vilnius.

CONCLUSIONS

Benefits of this method are that no additional information from an RDS survey needs to be collected, that the sizes can be calculated ex post facto a survey and that there is a software programme that can run the SS-PSE models. However, this method relies on having reliable priors. Although many countries are estimating the sizes of their vulnerable populations, European countries have yet to incorporate similar and novel methods.

Absence of drug-drug interactions between γ-hydroxybutyric acid (GHB) and cobicistat

OBJECTIVES

Potential interactions between CYP3A4 inhibitors and γ-hydroxybutyric acid (GHB) have been suggested as a possible explanation for cases of GHB overdose in recent years among people living with HIV engaged in chemsex. Our objective was to assess the effect of cobicistat on the pharmacokinetics of GHB.

METHODS

Fifteen healthy adults were enrolled in this randomized, double-blind, placebo-controlled, two-arm, crossover clinical trial. Participants underwent two 5 day treatment periods with at least a 1 week washout period between them. In each treatment period, participants received cobicistat (150 mg q24h orally) or matched placebo. On day 5 of each treatment period, participants were given a single oral dose of GHB (25 mg/kg). Plasma concentrations of GHB, subjective effects, blood pressure, heart rate and oxygen saturation were monitored for 5 h after dosing. GHB pharmacokinetic and pharmacodynamic parameters were calculated for each participant during each study period by non-compartmental analysis and were compared using linear mixed-effects models. The study was registered at https://www.clinicaltrialsregister.eu (Eudra-CT number 2019-002122-71) and at https://clinicaltrials.gov (NCT04322214).

RESULTS

Ten participants completed the two study periods. No drug-related adverse events that necessitated subject withdrawal or medical intervention occurred during the study. Compared with placebo, none of the primary pharmacokinetic parameters of GHB was substantially changed by the administration of GHB with cobicistat. Similarly, no differences regarding subjective or physiological effects were observed when GHB was administered alone or with cobicistat.

CONCLUSIONS

Neither pharmacokinetic nor pharmacodynamic drug-drug interactions between cobicistat and GHB were identified in this study.

Sexualized drug use and specialist service experience among MSM attending urban and rural sexual health clinics in England and Scotland

Background: To date, evidence on whether sexualized drug use (SDU) and chemsex occur less frequently in rural compared to urban areas in Britain has been conflicting. This study aimed to better measure and understand whether attending urban versus rural sexual health clinics in the United Kingdom was associated with a difference in men who have sex with men's (MSM) experience of SDU or their access to SDU support. Methods: Men from 29 sexual health services across England and Scotland were recruited by self-completing a waiting room survey. Results: A total of 2655 men (864 MSM) took part. There was no statistically significant difference in recent SDU or chemsex identified in MSM attending rural compared to urban clinics. Gamma-Hydroxybutyrate/Gamma-Butyrolactone (GHB/GBL) was the most commonly reported chemsex drug used in a sexual setting, with equal prevalence of use in urban and rural MSM attendees. Distance travelled for SDU was not significantly different for rural compared to urban MSM. Rural MSM reported a higher rate of unmet need for SDU specific services, although this difference was not statistically significant. Conclusion: Within this sample of MSM, there were no significant differences in sexualized drug use behaviours between those attending rural compared to urban sexual health settings.

Sexualized drug injection among men who have sex with men in Madrid and Barcelona as the first episode of drug injecting

BACKGROUND

We estimate the prevalence of drug injection, the variables associated with having ever injected and the proportion of ever injectors whose first drug injection was for having sex; we describe the first drug injection episode, analyze the drugs most frequently injected and estimate the prevalence of risky injecting behaviors.

METHODS

The participants were 3387 MSM without a previous HIV diagnosis attending four HIV/STI diagnosis services in Madrid and Barcelona. Lifetime prevalence and prevalence ratios (PRs) by different factors were calculated using Poisson regression models with robust variance. We compared the characteristics of first drug injection episode, lifetime injection and risky injecting behaviors of those whose first injection was for sex (FIS) with those whose was not (non-FIS).

RESULTS

Lifetime prevalence of injection was 2.1% (CI 1.7-2.7). In the multivariate analysis, it was strongly associated with having been penetrated by more than five men in the last 12 months (aPR = 10.4; CI 2.5-43.4) and having met most of their partners at private parties (aPR = 7.5; CI 4.5-12.3), and less strongly with other factors. Of those who had ever injected drugs, 81.9% injected for sex the first time they injected drugs (FIS). At first injection, FIS participants had a mean age of 31 years, 62.7% used mephedrone and 32.2% methamphetamine on that occasion. Of this FIS group 39.0% had ever shared drugs or equipment and 82.6% had always shared for sex. Some 30.8% of non-FIS reported having also injected drugs for sex later on.

CONCLUSIONS

Only two out of a hundred had ever injected, most to have sex and with frequent drug or injecting equipment sharing. Injecting for sex is the most common first episode of drug injection and is the most efficient risky behavior for the transmission of HIV, hepatitis B or C and other blood-borne infections. MSM participating in private parties should be considered a priority group for prevention policies.

Sexual consent and chemsex: a quantitative study on sexualised drug use and non-consensual sex among men who have sex with men in Amsterdam, the Netherlands

Background

Chemsex (drug use to enhance sex) has emerged among men who have sex with men (MSM). Non-consensual sex (NCS) is hypothesised to occur frequently under the influence of chemsex, however data are scarce. In this cross-sectional study, it was aimed to assess whether NCS is associated with chemsex.

Methods

We offered a survey about chemsex in the past 6 months (crystal methamphetamine, mephedrone and/or gamma-hydroxybutyrate/gamma-butyrolacton use) and NCS (sexual experiences beyond one’s limits or unpleasant sexual experiences) in the past 5 years to Amsterdam-located gay dating platform users. Associations were assessed using χ² test, Fisher’s exact test and multivariable logistic regression.

Results

Of 891 participants, 30.6% (273 of 891) engaged in chemsex; 21.2% engaging and 16.7% not engaging in chemsex reported any NCS experiences (p=0.109).

Among MSM who reported any NCS experiences, chemsex engagers reported being touched against one’s will less often compared with non-engagers (22.4% vs 39.8%; p=0.036). Yet, chemsex engagers reported passing out and not remembering what happened during drug use more often (41.4% vs 8.7%; p<0.001). The level of suffering from NCS experiences did not differ between chemsex engagers and non-engagers (p=0.539); and was rated by most participants with no suffering at all or low suffering (77.1%). In the multivariable regression analyses, chemsex engagement in the past 6 months was associated with NCS (adjusted OR 1.46; 95% CI 1.01 to 2.11).

Conclusions

A substantial proportion of MSM (regardless of chemsex engagement) reported NCS in the past 5 years. In multivariate logistic regression analysis, chemsex engagement was associated with an NCS experience. Among participants who reported NCS, suffering related to NCS however, did not differ between chemsex engagers and non-engagers. Sexual healthcare professionals need to address chemsex and NCS during consultations involving MSM and refer men for specialised help if deemed necessary.

Being in the Closet. Correlates of Outness Among MSM in 13 European Cities

Data for MSM continue to show a high risk of acquiring HIV-STIs. Within this population, outness seems to have an impact on both risk-taking and on health seeking behaviors. The objective of this study was to assess the relationship between socio-demographic, behavioral characteristics, testing behaviors, and outness level among MSM using data from a multi-center bio-behavioral cross-sectional study carried out in 13 EU cities. A multilevel analysis was conducted to identify factors associated with being open ("out") versus not being open ("in"). A total of 4,901 MSM were enrolled in the study and were classified as "out" in 71% of the cases. MSM "out" were more likely to report HIV testing and being reached by HIV prevention programs compared to MSM who were "in." The results confirm the key role of outness in relation to different healthy and risky behavior, ranging from testing to party-drug use.

Use of multiple recreational drugs is associated with new HIV infections among men who have sex with men in China: a multicenter cross-sectional survey

Background

There is limited information about the types of recreational drugs used by men who have sex with men (MSM) in China or the consequent impact on sexual health and human immunodeficiency virus (HIV) acquisition.

Methods

We recruited MSM from seven cities in China between 2012 and 2013 using multiple approaches including advertisements on gay websites, collaborating with local MSM community-based organizations, peer referrals, and venues such as gay bars and bathrooms visited by MSM. We divided participants into four subgroups based on the number of recreational drugs (RDs) used in the previous 6 months. We defined use of multiple RDs as use of ≥2 types of RDs. Demographics and HIV-related high-risk behaviors were collected, and blood samples were tested for recent HIV infection by the HIV-1 subtypes B, E, and D immunoglobulin G capture enzyme immunoassay (BED-CEIA). We used multivariable logistic regression adjusted for sociodemographics to determine the adjusted odds ratios (aORs) and associated 95% confidence intervals (CIs) of the subgroups of RD use for recent or established HIV infection.

Results

A total of 4496 Chinese MSM participated; 28.4% used RDs, and 5% used multiple types of RDs. The prevalence of each RD use was as follows: poppers (25.9%), ecstasy (2.4%), ketamine (1.2%), amphetamine (0.6%), tramadol (0.4%), methamphetamine (3.8%), and codeine (1.9%). Users of multiple RDs commonly used poppers combined with one or more other types of RDs. Multiple RD users were likely to be aged 26–30 years (vs. 18–25 and > 30 years), live in non-local cities (vs. local cities), never married (vs. married), have a high monthly income (vs. no income and 1–599 USD), use versatile positions during anal intercourse (vs. top or bottom), and have inadequate HIV-related prevention knowledge (vs. adequate). As the number of RDs used in the previous 6 months increased, the prevalence of HIV-related high-risk behaviors increased (P < 0.05 for all). The odds of recent HIV infection were higher among those who used one type (aOR = 2.2, 95% CI: 1.5–3.0) or two types of RD (aOR=2.3, 95% CI: 1.0-5.2) in the previous 6 months compared to the odds among those who did not use RDs.

Conclusion

The level and pattern of multiple RD use among Chinese MSM were different from high-income countries. MSM who used more RDs are more likely to engage in high-risk sexual behaviors, and these behaviors may be associated with increases in new HIV infections.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10223-y.

Psychological and Interpersonal Factors Associated with Sexualized Drug Use Among Men Who Have Sex with Men: A Mixed-Methods Systematic Review

Chemsex-the use of specific drugs during planned sexual activity to sustain or enhance sexual functioning (Bourne et al., 2015)-is widely reported as a major public health issue among gay, bisexual, and other men who have sex with men (GBM) in Western countries. Considering current evidence surrounding Chemsex, we conducted a mixed-methods systematic review regarding psychological and interpersonal factors associated with Chemsex behaviors among GBM. Publications covering Chemsex and psychological or social variables were eligible. Theoretical papers and studies solely presenting physical health outcomes were excluded. 35 English papers published between January 2008 and June 2019 were identified through PubMed, Scopus, and PsycINFO. We performed a parallel-results convergent synthesis (Hong, Pluye, Bujold, & Wassef, 2017) on results extracted from qualitative and quantitative studies comprising the final corpus. Qualitative data suggest that six mechanisms promote Chemsex-related behaviors: dealing with painful emotions or stressful events; normalization and risk minimization of sexualized drug use; giving into interpersonal pressure or fulfilling desire for community belonging; increasing intimacy or connectedness; enhancing sexual performance and functioning; lessening interpersonal and sexual inhibitions. In quantitative reports, six variable categories emerged: sexual control and self-efficacy; sexual functioning; mental health; attitudes toward substance use; life stressors and internalized stressors; and identification with sexual identities or scenes. This review summarizes key psychological and interpersonal correlates of Chemsex among GBM. Further research is needed to replicate current findings and explore new hypotheses across multiple GBM sociodemographic groups and cultural contexts, following best practices in sampling for hard-to-reach populations.

Association of Sexualized Drug Use Patterns with HIV/STI Transmission Risk in an Internet Sample of Men Who Have Sex with Men from Seven European Countries

We estimated the prevalence of overall sexualized drug use (SDU) and of chemsex in particular, assessed patterns of drug use, and identified subpopulations of men who have sex with men (MSM) where SDU and chemsex are more frequent. Using data from an online survey of 9407 MSM recruited during 2016 in 7 European countries, we calculated the proportion of participants who reported SDU and chemsex (mephedrone, methamphetamine, and/or GHB/GBL) in the last 12 months. We grouped the different drug-use combinations in patterns and described sexual risk behaviors, sexually transmitted infections (STI), and HIV seropositivity for each one of them. Factors associated with SDU and chemsex were assessed with two logistic regression models. SDU was reported by 17.7% and chemsex by 5.2%. Risk indicators increased through the different SDU patterns but were higher within those including chemsex drugs. In the multivariate analysis, chemsex was independently associated with living in Slovenia. Both SDU and chemsex were independently associated with living in Spain; being < 50 years old; living in cities of > 500,000 inhabitants; being open about their sex life; reporting transactional sex; condomless anal intercourse; having received an STI diagnosis and with being HIV positive or having been tested ≤ 12 months ago. Magnitude of associations was higher in the chemsex model. One in five participants reported SDU, but prevalence of chemsex was notably lower. However, the risk profiles and higher prevalence of HIV/STIs among those involved in chemsex suggest the existence of a subpopulation of MSM that could be playing a relevant role in the HIV and STI epidemics, especially in very large cities of some countries.

Service provision and barriers to care for men who have sex with men engaging in chemsex and sexualised drug use in England

BACKGROUND

Chemsex and sexualised drug use (SDU) among men who have sex with men (MSM) has become a public health issue because of its associated sexual risks. Some MSM engaging in SDU require further help and support, but it is not clear if this need is being met. This research seeks to understand MSM and service provider (SP) perspectives of the current standard of service provision for MSM engaging in SDU.

METHOD

Semi-structured interviews were conducted with 13 MSM and 16 SPs in England (January-December 2019). MSM who reported taking one of ten substances for sex in the past 12 months were recruited from a mailing list or a community organisation providing chemsex support. Potential SP participants were recruited via an email sent from their local healthcare NHS Trust. Data for MSM and SPs were analysed separately using thematic analysis.

RESULTS

MSM participants had a median age of 34 years (range 23-66).The majority of SPs recruited were genitourinary medicine (GUM) consultants. We found that the main reason for engagement in SDU was because of the enhanced sexual experience. Most MSM recruited were satisfied with their sexual health service provision, but barriers to care were highlighted by both MSM and SPs. Four themes relating to barriers to care were identified: accessibility of sexual health services, funding of services, SP's attitudes towards MSM who engage in SDU, and services outside sexual healthcare.

CONCLUSION

SPs appeared to have adopted a harm reduction approach to MSM engaging in SDU, but for MSM wanting further help and assistance in relation to their SDU additional barriers to care existed. Training healthcare providers outside of sexual health services regarding chemsex and SDU may reduce some of these barriers, but funding for sexual health services needs to be improved to maintain and further develop services.

Process evaluation of a bio-behavioural HIV research combined with prevention among GBMSM in 13 European countries

Comparative European data using Second Generation Surveillance System (SGSS) are scarce among gay, bisexual and other men who have sex with men. This study evaluated the implementation of Sialon II, a bio-behavioural HIV research combined with targeted HIV prevention in 13 European cities conducted in collaboration with community partners. A mixed-methods process evaluation assessed the project's coverage, outputs, quality, challenges and opportunities for improvement. Data collected through structured questionnaire from 71 data collectors from community-based organisations and semi-structured interviews with 17 managers of participating gay venues were analysed. Overall implementation was successful, achieving 4901 valid behavioural questionnaires and obtaining 4716 biological samples. Challenges in conducting bio-behavioural research in gay venues related to strict research protocols and unfavourable characteristics of venues. Formative research, collaboration with community gay venues, and offering HIV prevention emerged as facilitators. Community researchers' training was crucial for fidelity to research protocols, increased trust amongst communities and enabled data collectors to effectively address practical problems in the field. Scientifically sound SGSS with community participation is feasible and allows for including 'hard-to-reach' populations. Prevention benefits include awareness raising, capacity building and sexual health promotion in gay venues. The findings are beneficial for epidemiological research among other HIV key populations.

Estimating the percentage of European MSM eligible for PrEP: insights from a bio-behavioural survey in thirteen cities

OBJECTIVES

This paper aims to estimate the percentage of European men who have sex with men (MSM) who may benefit from pre-exposure prophylaxis (PrEP), applying the three most widely used HIV risk indices for MSM (MSM Risk Index, Menza score, San Diego Early Test (SDET) score) and drawing on a large-scale multisite bio-behavioural survey (Sialon II).

METHODS

The Sialon II study was a bio-behavioural survey among MSM implemented in 13 European cities using either time-location sampling or respondent-driven sampling. Biological and behavioural data from 4901 MSM were collected. Only behavioural data of HIV-negative individuals were considered. Three widely used risk indices to assess HIV acquisition risk among MSM were used to estimate individual HIV risk scores and PrEP eligibility criteria.

RESULTS

4219 HIV-negative MSM were considered. Regardless the HIV risk score used and the city, percentages of MSM eligible for PrEP were found to range between 5.19% and 73.84%. Overall, the MSM Risk Index and the Menza score yielded broadly similar percentages, whereas the SDET Index provided estimates constantly lower across all cities. Although all the three scores correlated positively (r>0.6), their concordance was highly variable (0.01<CCC<0.62).

CONCLUSION

Our findings showed the impact of different scoring systems on the estimation of the percentage of MSM who may benefit from PrEP in European cities. Although our primary aim was not to compare the performance of different HIV risk scores, data show that a considerable percentage of MSM in each city should be offered PrEP in order to reduce HIV infections. As PrEP is highly effective at preventing HIV among MSM, our findings provide useful, practical guidance for stakeholders in implementing PrEP at city level to tackle HIV infections in Europe.

Links between chemsex and reduced mental health among Norwegian MSM and other men: results from a cross-sectional clinic survey

BACKGROUND

The use of specific drugs to facilitate, enhance or prolong sexual sessions is referred to as 'chemsex'. The popularity of the behavior seems to be growing, but there is a paucity of information on the mental health aspects associated with chemsex and no data on chemsex from Nordic countries. We investigated the link between chemsex and mental health among men who have sex with men (MSM) and other men in Norway.

METHODS

We recruited participants from a walk-in sexually transmitted infections (STI) clinic. Participants completed a piloted, anonymous self-administered survey. It consisted of questions about men's sociodemographic characteristics, mental health, sexual behaviors, substance use, and chemsex. The outcome we investigated was reduced mental health, measured with the validated Hopkins Symptom Check List. We obtained descriptive statistics and performed univariate and multivariate logistic regression analyses.

RESULTS

1013 (96%) of the surveys were complete and could be analysed. The mean age of the sample was 33, 51% were MSM, and 21.7% had reduced mental health. More MSM than other men engaged in chemsex in the past year (17% vs 12%). The most frequently reported chemsex drugs were cocaine and gamma hydroxybutyrate/gamma butyrolactone (GHB/GBL). Men engaged in chemsex primarily to enhance sexual pleasure and excitement, and about half reported almost never or never using condoms for chemsex. In univariate analyses, significant predictors of reduced mental health was chemsex (Odds Ratio [OR] = 1.82), being unemployed (OR = 3.54), and having sex with only women (OR = 0.58). In multivariate analyses, two variables remained significantly associated with reduced mental health: chemsex (adjusted OR = 2.18, 95%CI = 1.25-3.78) and being unemployed (adjusted OR = 4.10, 95%CI = 2.13-7.87).

CONCLUSIONS

In our sample of men from an STI clinic in Norway, about 14% self-reported engaging in chemsex in the past year and about a fifth of the men had reduced mental health. Men who engaged in chemsex, which more MSM engaged in than other men, had two times greater odds of reduced mental health. These findings suggest that mental health assistance should be among the interventions offered to men engaging in chemsex.

Review of sexualized drug use associated with sexually transmitted and blood-borne infections in gay, bisexual and other men who have sex with men

PURPOSE

The aim of the present study was to quantify associations between sexualized drug use (SDU) and sexually-transmitted and blood-borne infection (STBBI) diagnoses in gay, bisexual and other men who have sex with men (GBMSM) with defined temporal proximity between SDU exposure and STBBI diagnoses.

METHODS

In May 2018 and June 2019, we searched the literature for primary studies that quantified the association between STBBI and SDU among GBMSM. A random-effects model was used to meta-analyze the data and estimate the association between SDU and STBBIs.

RESULTS

Nineteen studies met the inclusion criteria and fourteen studies were included in the meta-analyses. SDU was associated with higher odds of bacterial STI diagnoses, higher odds of HCV diagnoses, and higher odds of HIV diagnoses. Associations between SDU and diagnoses of bacterial STIs or HCV remained after adjustment for behavioral and sociodemographic factors.

CONCLUSIONS

Robust and consistent associations between SDU and STBBI identified in this review add to the evidence suggesting SDU is a potential contributor to bacterial STIs and HCV or a proxy indicator for other risk factors.

First case report of tDCS efficacy in severe chemsex addiction

Chemsex is an escalating public health issue among men who have sex with men, with potentially severe somatic and psychiatric consequences. Given the limited knowledge and lack of treatment recommendations available in this area, we proposed the use of noninvasive brain stimulation in order to reduce problematic chemsex behavior. This is the first open-label case report of a positive effect of transcranial direct current stimulation (tDCS) in a patient who was complaining of severe chemsex addiction. Total disappearance of chemsex behavior occurred after 5 days of daily sessions of right prefrontal cortex stimulation and did not return after 8 months of follow-up. The strengthening of dorsolateral prefrontal cortex activity may have modulated limbic pathways and reduced incentive salience and craving of both sexual addiction and concomitant illicit drug use.


Interest in Taking HIV Pre-exposure Prophylaxis Is Associated with Behavioral Risk Indicators and Self-Perceived HIV Risk Among Men Who Have Sex with Men Attending HIV Testing Venues in Sweden

This study explored factors associated with interest in taking PrEP among men who have sex with men (MSM) attending HIV testing venues in Sweden. Data from 658 HIV-negative respondents, surveyed by a questionnaire at six sites, were analyzed descriptively and by univariable and multivariable logistic regression. A total of 453 (68.8%) of the respondents expressed interest in taking PrEP. Reporting self-perceived risk of HIV acquisition as moderate or high, reporting ≥ 5 partners for condomless anal intercourse during the past year, and reporting hard drug use during the past year were independently associated with interest in taking PrEP. However, an aggregated variable of self-reported rectal gonorrhea, rectal chlamydia, or syphilis infection during the past year was not associated with interest in taking PrEP. Overall, Swedish MSM were well-informed regarding PrEP, and interest in taking PrEP was positively associated with sexual risk indicators.

Attitude and beliefs about the social environment associated with chemsex among MSM visiting STI clinics in the Netherlands: An observational study

BACKGROUND

Drug use during sex, 'chemsex', is common among men who have sex with men (MSM) and related to sexual and mental health harms. This study assessed associations between chemsex and a wide range of determinants among MSM visiting STI clinics to increase understanding of characteristics and beliefs of MSM practicing chemsex.

METHODS

In 2018, 785 MSM were recruited at nine Dutch STI clinics; 368 (47%) fully completed the online questionnaire. All participants reported to have had sex in the past six months. Chemsex was defined as using cocaine, crystal meth, designer drugs, GHB/GBL, ketamine, speed or XTC/MDMA during sex in the past six months. Associations between chemsex and psychosocial determinants, socio-demographics, sexual behaviour and using tobacco or alcohol were assessed by multivariable logistic regression analyses.

RESULTS

Chemsex was reported by 44% of MSM (161/368) and was not associated with socio-demographics. Independent determinants were 'believing that the majority of friends/sex partners use drugs during sex' (descriptive norm) (aOR: 1.95, 95%CI: 1.43-2.65), 'believing that sex is more fun when using drugs' (attitude) (aOR: 2.06, 95%CI: 1.50-2.84), using tobacco (aOR: 2.65, 95%CI: 1.32-5.32), multiple sex partners (aOR: 2.69, 95%CI: 1.21-6.00), group sex (aOR: 4.65, 95%CI: 1.54-14.05) and using online dating platforms (aOR: 2.73, 95%CI: 1.13-6.62).

CONCLUSION

MSM are likely to find themselves in distinct social networks where it is the norm to use drugs when having sex and pleasure is linked to chemsex. Health services should acknowledge the social influence and pleasurable experiences to increase acceptability of strategies aimed at minimizing the possible harms of chemsex.

Identifying and managing infectious disease syndemics in patients with HIV

PURPOSE OF REVIEW

We will present recent articles focusing on HIV synergistic interactions with other sexually transmitted infections, tuberculosis, and hepatitis, as well as recent advances in the study of social and behavioral determinants that facilitate this clustering of infectious disease. For each synergistic interaction, we highlight evidence-based interventions that clinicians and policymakers should consider to tackle HIV and infectious disease syndemics.

RECENT FINDINGS

Significant advances in understanding the behavioral and structural determinants of HIV and other infectious disease synergisms have been made in the past years. Intervention strategies based on these new models have also been developed. It is now well understood that treating infectious disease syndemics will require a multidisciplinary and multipronged approach.

SUMMARY

HIV is synergistic with multiple other infectious diseases because the risk behaviors that lead to HIV acquisition may be similar to the other infections. The influence of HIV on the other infection may be due to immunosuppression associated with disease progression resulting in increased susceptibility (e.g., HIV and tuberculosis), especially when patients are not virologically suppressed using antiretroviral therapy. In reverse, another infectious disease may, when not treated, influence HIV disease progression. Social/structural determinants like homelessness, mass incarceration, and structural discrimination precipitate psychiatric comorbidity, substance use, and risky sex behavior which lead to the spread and co-occurrence of infectious disease.