Increasing use of 'party drugs' in people living with HIV on antiretrovirals: a concern for patient safety

HIV and Substance Use Disorders

Over 1.2 million Americans aged 13 years and older have been diagnosed with human immunodeficiency virus (HIV). While HIV incidence has been declining since 2017, the risk of HIV acquisition and transmission persists among persons who use drugs via injection drug use and unprotected sexual intercourse associated with substance use. Untreated substance use disorder (SUD) is associated with poor adherence to HIV antiretroviral therapy, poor HIV outcomes, and increased risk for HIV acquisition. Herein, we describe the intertwined syndemic of HIV and SUD, as well as treatment strategies and evidence-based public health efforts to engage and retain persons who use drugs into care.

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.

[Epidemiology, treatment and prognosis of HIV infection in 2024: A practical review]

In recent years, the epidemiology and prognosis of HIV infection have undergone significant changes thanks to the recommendation of antiretroviral therapy (ART) for all infected persons, the development of more effective and better tolerated drugs, and preventive measures such as pre-exposure prophylaxis (PrEP). The evolution of ART, now with simple oral and injectable options, has also contributed to improvements in comprehensive HIV treatment and care. With early diagnosis and early initiation of ART, the life expectancy of people with HIV has reached the same as the general population. However, many people with HIV remain undiagnosed or are diagnosed late, and some population groups experience greater vulnerability, affecting individual and collective health. In this review we review the current epidemiology, treatment and prognosis of HIV infection.

Clinical Relevance of Drug Interactions in People Living with Human Immunodeficiency Virus on Antiretroviral Therapy-Update 2022: Systematic Review

BACKGROUND

The clinical outcomes of antiretroviral drugs may be modified through drug interactions; thus, it is important to update the drug interactions in people living with HIV (PLHIV).

AIM

To update clinically relevant drug interactions in PLHIV on antiretroviral therapy with novel drug interactions published from 2017 to 2022.

METHODS

A systematic review in Medline/PubMed database from July 2017 to December 2022 using the Mesh terms antiretroviral agents and drug interactions or herb-drug interactions or food-drug interactions. Publications with drug interactions in humans, in English or Spanish, and with full-text access were retrieved. The clinical relevance of drug interactions was grouped into five levels according to the gravity and probability of occurrence.

RESULTS

A total of 366 articles were identified, with 219 (including 87 citation lists) were included, which allowed for the identification of 471 drug interaction pairs; among them, 291 were systematically reported for the first time. In total 42 (14.4%) and 137 (47.1%) were level one and two, respectively, and 233 (80.1%) pairs were explained with the pharmacokinetic mechanism. Among these 291 pairs, protease inhibitors (PIs) and ritonavir/cobicistat-boosted PIs, as well as integrase strand transfer inhibitors (InSTIs), with 70 (24.1%) and 65 (22.3%) drug interaction pairs of levels one and two, respectively, were more frequent.

CONCLUSIONS

In PLHIV on antiretroviral therapy, we identify 291 drug interaction pairs systematically reported for the first time, with 179 (61.5%) being assessed as clinically relevant (levels one and two). The pharmacokinetic mechanism was the most frequently identified. PIs, ritonavir/cobicistat-boosted PIs, and InSTIs were the antiretroviral groups with the highest number of clinically relevant drug interaction pairs (levels one and two).

Prevalence of sexualized drug use and risk of HIV among sexually active MSM in East and South Asian countries: systematic review and meta-analysis

INTRODUCTION

Sexualized drug use (SDU), the use of psychoactive drugs in the context of sexual intercourse, has been identified as a risk factor for HIV among men who have sex with men (MSM) in Asia. Given the distinct social and cultural context of same-sex relationships and drug-using practice in Asia, we aimed to describe the prevalence of SDU in East and South Asian countries and its associations with condomless anal sex (CAI) and HIV status. Synthesizing SDU research in this region, including SDU definitions, prevalence and outcomes, provides insights to inform future research and improved programme planning, resourcing and advocacy.

METHODS

We systematically searched OVID Medline, OVID EMBASE, OVID Global Health, CINAHL, PsycINFO and SCOPUS publication databases for scientific articles published from 1990 to 2022 measuring SDU among MSM in East and South Asian countries. A narrative synthesis was utilized to describe key study attributes and findings, and meta-analyses using random pooled effect models were used to estimate SDU prevalence and its associations with CAI and HIV status. Subgroup meta-analyses, sensitivity analysis and assessment of publication bias examined potential sources of heterogeneity for the pooled SDU prevalence estimates.

RESULTS AND DISCUSSION

Of the 1788 publications screened, 49 publications met the selection criteria and 18 were suitable for meta-analyses. Findings highlight SDU definitions distinct from other regions but inconsistencies in the definition of SDU between studies that have been highlighted in research elsewhere. The pooled prevalence of recent SDU (past 12 months) was 13% (95% CI = 10-16%; I2 = 97.6) but higher when studies utilized self-administered surveys (15%; 95% CI = 12-19%; p<0.05). SDU was associated with greater odds of CAI (pooled odds ratio [OR] = 3.21; 95% CI = 1.82-5.66) and living with diagnosed HIV (OR = 4.73; 95% CI = 2.27-8.21).

CONCLUSIONS

SDU is common among MSM in East and South Asian countries, but varying SDU definitions limit between-study comparisons. Responses to SDU-related harms should consider local contexts, including specific drug types used and their relative risks.

Do ART and Chemsex Drugs Get Along? Potential Drug-Drug Interactions in a Cohort of People Living with HIV Who Engaged in Chemsex: A Retrospective Observational Study

INTRODUCTION

People living with HIV (PLWH) who engaged in chemsex are at risk of potential drug-drug interactions (pDDIs) with recreational drugs. This study aimed to characterize pDDIs between antiretroviral treatment (ART) and chemsex drugs and evaluate their association with unscheduled relevant hospital consultations.

METHODS

We conducted a single-center, retrospective, observational study in a series of gay, bisexual, and other men who have sex with men (gbMSM) living with HIV who engaged in chemsex and who attended a tertiary hospital in Barcelona, Spain, from February 2018 through August 2019. Associations between all recorded pDDIs and relevant unscheduled consultations were estimated using the incidence rate (IR) per 100 person-years of those events compared between patients with no pDDI (green flag) or moderate severity pDDI (orange flag) with patients with high severity pDDI (red flag) using the incidence rate ratio (IRR).

RESULTS

Among 172 PLWH engaged in chemsex, 249 ART regimens were prescribed: 44% based on integrase inhibitors, 30% on boosted ART, and 26% based on non-nucleoside reverse transcriptase inhibitors. The substances and recreational drugs most frequently used were erectile dysfunction agents (83%), methamphetamine (79%), GHB (77%), and alkyl nitrites (71%). Polydrug use was reported in 52%. We observed 2048 pDDIs. Of these, 23% were orange flag pDDIs; 88% related to boosted ARTs. The IR of the 285 unscheduled relevant episodes in patients with orange flag pDDIs was 64.67 (95% CI 40.07-89.28). The IRR of green flag pDDIs was 1.05 (95% CI 0.60-1.8; p = 0.876).

CONCLUSION

One in four pDDIs were of moderate severity but no significant increase in the incidence of unscheduled relevant consultations was observed. A high number of unscheduled consultations, predominantly for psychiatric events and intoxication, were observed. Beyond using non-boosted ART to minimize pDDIs, other factors related to the practice of chemsex must be addressed, in order to offer a better approach.

Increasing emergency department admissions for chemsex-related intoxications in Barcelona, Spain, among people living with HIV: an observational study from 2018 to 2020

Background

Chemsex is a novel phenomenon referring to the use of drugs, including crystal methamphetamine, gammahydroxybutyric acid (GHB)/gamma-butyrolactone (GABA) and mephedrone, to facilitate, enhance, and prolong the sexual experience in men who have sex with men in large cities internationally. There is a growing concern about chemsex and fatal cases among people living with HIV on antiretroviral therapy. This study aimed to describe the clinical characteristics of chemsex-related intoxications.

Material and methods

An observational study was conducted in people living with HIV who were admitted for chemsex-related intoxications in an emergency department of a teaching hospital in Barcelona, Spain, from 2018 to 2020. Severe acute intoxications were defined according to the Poisoning Severity Score.

Results

One hundred and fifteen male patients with a median age of 35.6±7 years were included in the study:15 (13.1%) in 2018, 32 (27.8%) in 2019 and 68 (59.1%) in 2020. All patients had stable housing, 107(93.0%) were Spanish citizen and 32 (27.8%) had mental health disorders. Median CD4 lymphocyte count was 624 (500–765) cells/mm³ and 99 (86.1%) had HIV-1 RNA suppression.

Poly-drug use was observed in 51(44.3%) cases and methamphetamine in 75(65,2%) and gammahydroxibutiric acid in 68 (59.1%) were the main drugs used.

Potential drug interactions due to the inhibition of cytochrome P450 by antiviral therapy was determined in 36 (31.3%) patients. Severe intoxications cases affecting neurologic and respiratory systems were diagnosed in 12 (10.4%) patients and no patient died. CD4 cell counts ≤500 cells (O.R.:4.2; C.I.95%:1.2–14.6) and mental health disorders (O.R.: 2.9; C. I 95%: 0.8–9.9) were associated with severe acute drug intoxications in the bivariate analyses.

Conclusions

Chemsex-related intoxications are an increasing clinical problem in people living with HIV. Chemsex should be routinely screened and addressed in clinical practice, particularly for people with mental illness and low CD4 cell counts, who are at higher risk for severe intoxications.

Chemsex and antiretroviral prescribing in an HIV cohort in Brighton, UK

OBJECTIVES

Chemsex has been reported among men who have sex with men (MSM) living with HIV. There have been concerns about potentially harmful drug-drug interactions between chemsex drugs and antiretroviral therapy (ritonavir and cobicistat). We aimed to describe the prevalence and patterns of chemsex users in our HIV clinic population and to evaluate antiretroviral prescribing among chemsex users.

METHODS

We undertook a cross-sectional study of patients attending our HIV clinic between January 2019 and December 2020. We collected data on patients who disclosed recent recreational drug use including chemsex in the previous 3 months.

RESULTS

In all, 2202/2501 (88%) patients were asked about recreational drug use and 514 (23%) disclosed recreational drug use. Eighty-two (4%) of these disclosed recent chemsex; 73 (89%) used crystal methamphetamine, 51 (62%) used gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL), 55 (67%) reported poly-drug use and 63 (76%) reported injecting drug use. The chemsex users were all cis-male MSM and were significantly older (53 vs. 46 years, p < 0.0001), and more likely to have had previous syphilis (73% vs. 28%, p < 0.0001) than patients reporting non-chemsex drug use. All chemsex users were prescribed antiretrovirals and 74 (90%) had an undetectable HIV viral load; 31 (38%) patients were taking either ritonavir (N = 12) or cobicistat (N = 19) as part of their antiretroviral regimen and this was similar to other patients attending for HIV care [31/82 (38%) vs. 768/2419 (31%), p = 0.25].

CONCLUSIONS

The prevalence of chemsex users among our HIV clinic attendants is 4%, and 38% of these were prescribed either ritonavir or cobicistat. Chemsex use should be a factor in antiretroviral therapy decision-making to avoid potential harm.

Prolonged efavirenz exposure reduces peripheral oxytocin and vasopressin comparable to known drugs of addiction in male Sprague Dawley rats

Introduction

Several drugs of abuse (DOA) are capable of modulating neurohypophysial hormones, such as oxytocin (OT) and vasopressin (VP), potentially resulting in the development of psychological abnormalities, such as cognitive dysfunction, psychoses, and affective disorders. Efavirenz (EFV), widely used in Africa and globally to treat HIV, induces diverse neuropsychiatric side effects while its abuse has become a global concern. The actions of EFV may involve neurohypophysial system (NS) disruption like that of known DOA. This study investigated whether sub-chronic EFV exposure, at a previously-determined rewarding dose, alters peripheral OT and VP levels versus that of a control, ∆⁹-tetrahydrocannabinol (∆⁹-THC), methamphetamine (MA) and cocaine.

Materials and methods

To simulate the conditions under which reward-driven behavior had previously been established for EFV, male Sprague Dawley rats (n = 16/exposure) received intraperitoneal vehicle (control) or drug administration across an alternating sixteen-day dosing protocol. Control administration (saline/olive oil; 0.2 ml) occurred on odd-numbered and drug administration (EFV: 5 mg/kg, ∆⁹-THC: 0.75 mg/kg, MA: 1 mg/kg, or cocaine: 20 mg/kg) on even-numbered days followed by euthanasia, trunk blood collection and plasma extraction for neuropeptide assay. Effect of drug exposure on peripheral OT and VP levels was assessed versus controls and quantified using specific ELISA kits. Statistical significance was determined by Kruskal-Wallis ANOVA, with p < 0.05. Ethics approval: NWU-00291-17-A5.

Results

Delta-9-THC reduced OT and VP plasma levels (p < 0.0001, p = 0.0141; respectively), cocaine reduced plasma OT (p = 0.0023), while MA reduced plasma VP levels (p = 0.0001), all versus control. EFV reduced OT and VP plasma levels (p < 0.0001; OT and VP) versus control, and similar to ∆⁹-THC.

Conclusion

EFV markedly affects the NS in significantly reducing both plasma OT and VP equivalent to DOA. Importantly, EFV has distinct effects on peripheral OT and VP levels when assessed within the context of drug dependence. The data highlights a possible new mechanism underlying previously documented EFV-induced effects in rats, and whereby EFV may induce neuropsychiatric adverse effects clinically; also providing a deeper understanding of the suggested abuse-potential of EFV.

Potential drug-drug interactions in acute poisonings managed in the intensive care unit: Occurrence, risk factors and relationship to patient severity on admission

Beyond the direct toxicity resulting from each drug in the poisoned patient, additional toxicities may result from drug-drug interactions (DDIs). We aimed to determine the frequency of potential DDIs in the poisoned patient and investigate whether DDIs are associated with severity. We conducted a 1-year cohort study in a toxicological ICU. DDIs were identified using an electronic interaction-checker tool. Among our 354 ICU poisoned patients, 134 (38%) presented at least one potential DDI between acute poisoning drugs and 180 (51%) at least one potential DDI between acute poisoning and long-term treatment drugs. Using multivariate analyses, previous suicide attempt was associated with the presence of potential DDIs between acute poisoning drugs in suicide attempt patients (P = 0.014). Chronic alcoholism (P = 0.005) and tobacco smoking (P = 0.022) were associated with the presence of potential DDIs between acute poisoning and long-term treatment drugs in recreational drug users. Presence of potential DDIs between acute poisoning and long-term treatment drugs was associated with catecholamine infusion (P = 0.022) in suicidal self-exposure patients. Presence of potential pharmacodynamic DDIs between acute poisoning and long-term treatment drugs was associated with aspiration pneumonia onset in recreational drug users (P = 0.03). ICU poisoned patients present a high rate of potential DDIs that may influence the outcome.

"Slam Sex" - Sexualized Injecting Drug Use ("SIDU") Amongst Men Who Have Sex with Men (MSM)-A Scoping Review

Sexualized injecting drug use ("SIDU") is a phenomenon associated with a wide array of high-risk injecting and sex-related practices. This scoping review establishes what is known about MSM and SIDU to assess implications for health care and policy.  Characteristics of MSM for "SIDU" may include being on anti-retroviral treatment and urban residency with drivers being challenging social taboos; a search for intimacy; convenience of administration; relationship breakdown and increased restrictions in clubs and saunas. Attraction for use appears to be enhancement or prolongation of sexual experiences/pleasure; intimacy and the facilitation of a range of potentially "unsafe" sexual activity. Traditional services are ill-equipped to address "SIDU" because of a lack of knowledge of practices, lack of associated vocabulary, and a failure to integrate sexual health with drug services. For effective responses, these issues need to be addressed.

Information-seeking behaviours in Australian sexual minority men engaged in chemsex

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Participants engaged in chemsex over long periods of time and on a regular basis.

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Most know where to seek professional help and access harm reduction information.

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Many worry about being judged by health professionals and few seek out assistance.

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Participants feel uncomfortable discussing chemsex with most health professionals.

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Information from sexual health professionals is trusted the most.

Introduction

Chemsex refers to using illicit substances to facilitate sexual experiences in men who have sex with men. Chemsex has been linked to significant negative impacts on psychological, social, and physical wellbeing. Little is known about information-seeking behaviours in this population. This study aims to provide an in-depth understanding of seeking and engaging with health information.

Methods

Self-identified Australian sexual minority men who engage in chemsex (N = 184) participated in an anonymous cross-sectional survey. Variables included chemsex engagement, knowledge, perception and use of harm-reduction information, and associated health and support services. Pearson correlation and ANOVAs were conducted. Wilcoxon-Signed-Rank and Friedman tests were applied to analyse the perceived trustworthiness of information sources.

Results

Chemsex represented a meaningful part of sexual events. Most participants knew where to access professional help and harm-reduction information but worried about being judged. Most did not feel comfortable discussing chemsex with health professionals except with sexual health doctors/counsellors. Few users discussed health risks with a professional. Information on chemsex was received through multiple sources with significant differences in perceived relevance and trustworthiness, with sexual health doctors/nurses ranked the most trustworthy information. Interest in non-traditional sources of information was low except for formal peer networks and anonymous personal expert advice.

Conclusion

Engagement with health professionals and harm-reduction information is limited in this population, despite high risk and potentially significant adverse health outcomes. Results suggest that new and combined approaches are necessary to reach this population, including peer support networks, anonymous personal advice and changing community attitudes towards chemsex.

Prevalence, beliefs and impact of drug-drug interactions between antiretroviral therapy and illicit drugs among people living with HIV in Spain

Drug use implies important challenges related to HIV management, particularly due to an increased risk of potential interactions between antiretroviral therapy (ART) and illicit drugs (pDDIs). This study analyses the prevalence and severity of pDDIs among people living with HIV (PLHIV). It also explores their awareness of pDDIs and their beliefs about the toxicity that they may cause, as well as the impact of pDDIs on selected health variables. We conducted an on-line cross-sectional survey across 33 Spanish hospitals and NGOs to collect demographics and clinical data. pDDIs were checked against the Interaction Checker developed by Liverpool University. The sample of the present study was composed of 694 PLHIV who used illicit drugs. They represented 49.5% of the 1,401 PLHIV that participated in the survey. After excluding 38 participants due to lack of information on their ART or illicit drug use, 335 (51.1%) participants consuming drugs presented with some potentially significant pDDIs between their ART and illicit drugs, with a mean of 2.1±1.7 (1–10) pDDIs per patient. The drugs most frequently involved in pDDIs were cocaine, cannabis, MDMA and nitrates ("poppers"). The prevalence of pDDIs across ART regimens was: protease inhibitors (41.7%); integrase inhibitor-boosted regimens (32.1%), and non-nucleoside reverse transcriptase inhibitors (26.3%). An awareness of pDDIs and beliefs about their potential toxicity correlated positively with intentional non-adherence (p<0.0001). Participants with pDDIs exhibited a higher prevalence of intentional non-adherence (2.19±1.04 vs. 1.93±0.94; p = 0.001). The presence of pDDIs was not associated with poorer results in the clinical variables analysed. A significant proportion of PLHIV who use drugs experience pDDIs, thereby requiring close monitoring. pDDIs should be considered in the clinical management of HIV patients. Adequate information about pDDIs and indicators about how to manage ART when PLHIV use drugs could improve ART non-adherence.

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.

We Have a Lot to Do: Lack of Sexual Protection and Information-Results of the German-Language Online Survey "Let's Talk About Chemsex"

Background: The prevalence of chemsex and sexualized substance use is increasing in several European countries, particularly among men who have sex with men. In this subgroup, illegal substance use is associated with increased sexual risk behavior, which can result in severe physical and psychological impairments. The present study examined the incidence and prevalence of chemsex in German-speaking countries. Methods: To further describe the high-risk group of Chemsex users, participants (N = 429) were asked about their psychotropic substance use, sexual and health-related behavior, health status, and socio-demographic information by using an online questionnaire. Whether Chemsex has negative effects on well-being was measured with the WHO well-being index. Of additional interest was how informed Chemsex users are about the topic and what needs are placed on the practitioners. The online questionnaire consisted of 105 items, and data was collected from March to May 2019. Thousand forty seven datasets were saved with a dropout rate of 59%, 123 completed questionnaires fulfilled the criteria for chemsex users (n =123). Results: There were no significant differences in well-being between chemsex users and non-users. All participants protected themselves against sexually transmitted diseases irregularly or not at all. The majority of chemsex users reported intermittently using illegal substances (ketamine, methamphetamine, mephedrone, γ-butyrolactone/γ-hydroxy butyric acid). They viewed their sexual and substance use behavior as problematic, but few showed motivation for behavior change. Chemsex users clearly expressed a need for more information and advice centers. Conclusion: The results provide information on chemsex users that can be used for the future development of a therapy manual and thus contribute to improving health care for this group. The prevalence of chemsex is increasing and urgently needs more research to protect clients from health impairments and stigmatization.

Evaluation of Drug Abuse by Hair Analysis and Self-Reported Use Among MSM Under PrEP: Results From a French Substudy of the ANRS-IPERGAY Trial

BACKGROUND

We used the Agence nationale de Recherches sur le sida et les hépatites virales (ANRS)-IPERGAY trial to qualitatively and quantitatively measure drug use among men who have sex with men under preexposure prophylaxis using 2 different methods, to better understand and collectively respond to risky practices.

METHOD

We included 69 volunteers of the ANRS-IPERGAY trial. We measured drug use by 2 methods: (1) drug detection by hair analysis and (2) reported drug use by self-reported drug consumption.

RESULTS

New psychoactive substances (NPS) and conventional drugs were detected in 53 of the 69 (77%) volunteers by hair analysis and in 39 of the 69 (57%) volunteers by questionnaires. On the 219 hair segments analyzed, the most commonly used drugs were cocaine in 47 of the 69 (68%), 3,4-methylenedioxymethamphetamine/ecstasy in 31 of the 69 (45%), and NPS in 27 of the 69 (39%). On the 1061 collected questionnaires, the most commonly used drugs were cocaine in 31 of the 69 (45%), 3,4-methylenedioxymethamphetamine/ecstasy in 29 of the 69 (42%), and NPS in 16 of the 69 (23%). Hair analysis detects more conventional drugs and/or NPS use (P < 0.05). Drug use identified by hair was significantly associated with a higher number of sexual partners in the past 2 months (P ≤ 0.001), more often casual partners (P ≤ 0.001), condomless anal sex (P ≤ 0.005), hardcore sexual practices (P ≤ 0.001), a higher number of sexually transmitted infections, and chemsex (P ≤ 0.05).

CONCLUSIONS

Self-report drug use by questionnaires remains the reference tool for harm reduction at the individual level because of its feasibility and low cost. However, hair analysis is more sensitive, objectively assessing consumption, and interesting to understand uses and to be able to collectively respond to risky practices with adapted messages.

Changing Pattern of Chemsex Drug Use Among Newly Diagnosed HIV-Positive Taiwanese from 2015 to 2020 in the Era of Treat-All Policy

Chemsex drug use (CDU) is a frequent, yet neglected issue in the era of treat-all policy. We evaluated the temporal pattern of CDU, factors associated with CDU, and drug-drug interactions (DDIs) between chemsex drugs and initial antiretroviral therapy (ART) by surveying 621 Taiwanese individuals (mean age: 29.7 years; 99.2% men; 92.9% men who have sex with men) diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) from 2015 to 2020 [2015 to 2016 (period 1), 2017 to 2018 (period 2), and 2019 to 2020 (period 3)]. CDU was defined as chemsex in the past 1 year before HIV diagnosis. CDU remained prevalent across three periods (34.3-30.5%). Among CDU, methamphetamine (43.4%) was most frequently used, followed by amphetamine (40.0%) and poppers (various alkyl nitrites) (39.5%). We identified significantly increasing amphetamine use (37.0-61.5%) and decreasing ecstasy (methylenedioxy-methamphetamine) use (32.1-17.9%) in CDU across three periods. Besides, polydrug chemsex also significantly increased in CDU across three periods (23.5-43.6%), with amphetamine plus gamma-hydroxybutyrate being the most commonly used combination. CDU was associated with multiple sexual partners and a history of sexually transmitted diseases (STDs). DDIs between chemsex drugs and initial ART remained stable across three periods (10.6-7.8%), with cobicistat/elvitegravir and methamphetamine most common combination. In summary, the magnitude of CDU remained high across 2015-2020 in Taiwan, causing DDIs with initial ART agents. Strategies to reduce the frequency of high-risk sexual practices, STD transmission, and DDIs for newly diagnosed HIV-positive patients engaging in chemsex should be implemented.

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.

Complications Related to Sexualized Drug Use: What Can We Learn From Literature?

Chemsex is described as the use of specific psychoactive substances (PS) during sexual activity to sustain, enhance, disinhibit or facilitate the sexual experience. It preferentially concerns men who have sex with men (MSM). They use new synthetic substances like cathinones, methamphetamines, gamma-butyrolactone/gamma-hydroxybutyrate (GBL/GHB), ketamine, and cocaine. The prevalence of chemsex varies from 3 to 31% during lifetime. The Internet has participated significantly in the evolution of sexual behaviors, both in terms of sexual dating and the availability of new synthetic substances. The advent of geolocation applications contributed to the development of chemsex. The literature describes many complications linked to these sexual practices; the main clinical effects related to cathinones consumption were psychiatric symptoms; agitation, hallucinations, anxiety, suicidal ideation, paranoia, and confusion. Regular GBL/GHB consumption alter cognitive functions, particularly memory and emotion management. Use of these drugs in party and play is dramatically associated with high-risk sexual behaviors. The prevalence of hepatitis B, hepatitis C syphilis, and HIV is higher in men who use methamphetamine and Viagra and/or who declared they practiced slamming, chemsex, and fisting. Other sexually transmitted infections (STIs) such as gonorrhea have increased with methamphetamine and GHB/GBL use. Actually, the care of individuals who practice Chemsex in a problematic way is currently not codified, but the use of integrative and specific interventions is necessary.

An update on drug-drug interactions between antiretroviral therapies and drugs of abuse in HIV systems

INTRODUCTION

While considerable progress has been made in the fight against HIV/AIDS, to date there has not been a cure, and millions of people around the world are currently living with HIV/AIDS. People living with HIV/AIDS have substance abuse disorders at higher rates than non-infected individuals, which puts them at an increased risk of drug-drug interactions.

AREAS COVERED

Potential drug-drug interactions are reviewed for a variety of potential drugs of abuse, both licit and illicit. These drugs include alcohol, cigarettes or other nicotine delivery systems, methamphetamine, cocaine, opioids, and marijuana. Potential interactions include decreased adherence, modulation of drug transporters, or modulation of metabolic enzymes. We also review the relative incidence of the use of these drugs of abuse in People living with HIV/AIDS.

EXPERT OPINION

Despite considerable improvements in outcomes, disparities in outcomes between PLWHA who use drugs of abuse, vs those who do not still exist. It is of critical necessity to improve outcomes in these patients and to work with them to stop abusing drugs of abuse.

Cross-Sectional Study of Sexual Behavior, Alcohol Use, and Mental Health Conditions Associated With Sexually Transmitted Infections Among Deploying Shipboard US Military Personnel

INTRODUCTION

Limited comprehensive data exist on risk behavior associated with sexually transmitted infections (STI) among ship-assigned US military personnel during the predeployment time period (PDT). This study examined whether sexual risk behaviors, alcohol use, involuntary drug consumption (IDC), posttraumatic stress disorder (PTSD), and depression during the 12 months prior to deployment were associated with provider-diagnosed STIs in this population.

MATERIALS AND METHODS

Using cross-sectional data collected during 2012-2014 among sexually active personnel, multivariable regression assessed factors associated with STIs among all men (n = 1,831). Stratified analyses were conducted among men who have sex with women (MSW, n = 1,530), men who have sex with men or men and women (MSM, n = 83), and excluded those not reporting sexual partner gender (n = 218).

RESULTS

Among MSW, transactional sex (AOR 3.8, 95% CI 1.5-9.4) meeting sexual partners at work (AOR 4.3, 95% CI 2.0-9.2), IDC (AOR 6.6, 95% CI 3.0-14.5), and incomplete mental health assessments (AOR 4.4, 95% CI 1.6-12.0) were significantly associated with STIs after adjustment. Among all men, those who identified as MSM (AOR 4.6, 95% CI 1.9-11.2) and drug screen positive (AOR 3.3, 95% CI 1.3-8.6) were significantly more likely to report an STI.

CONCLUSIONS

Previously unreported factors significantly associated with STIs at the PDT among MSW in the adjusted analysis were meeting sexual partners at work and IDC. IDC during the PDT warrants further exploration. These results can inform tailored STI reduction interventions among shipboard personnel and similarly aged civilians undergoing similar transition/travel experiences.

Direct-acting antiviral interactions with opioids, alcohol or illicit drugs of abuse in HCV-infected patients

The hepatitis C virus (HCV) prevalence is extremely high in patients who consume and inject illicit drugs. Concerns about poor adherence and fear of interaction with drugs of abuse could constitute further disincentive for treatment initiation in these patients. We discussed the pharmacokinetics (PKs) and pharmacodynamics (PD) of currently prescribed direct antiviral agents (NSA5 inhibitors: daclatasvir, elbasvir, ledipasvir, pibrentasvir, velpatasvir; NS5B inhibitor: sofosbuvir; NS3/4A protease inhibitors: glecaprevir, grazoprevir, voxilaprevir) and most common substances of abuse (opioids: buprenorphine, fentanyl, heroin, methadone, morphine, oxycodone; stimulants: amphetamines, cathinones, cocaine; cannabinoids; ethanol). Overall, most direct-acting antivirals (DAAs) are substrates and inhibitors of the transmembrane transporter P-glycoprotein (P-gp), and several of them are metabolized by cytochrome P450 enzymes. Clinically relevant interactions are associated with P-gp and CYP3A modulators. Most substances of abuse are eliminated by Phase I and Phase II metabolizing enzymes, but none of them are either major inhibitors or inducers. PK studies did not show any relevant interactions between DAA and methadone or buprenorphine. Based on pharmacological considerations, neither efficacy loss nor adverse drug event associated with detrimental interaction are expected with opioids, stimulants, cannabinoids and ethanol. In summary, our literature review shows that the interaction potential of DAA with most opioids and illicit drugs is limited and should not be a hurdle to the initiate DAA.

Yes to Recreational Drugs and Complementary Medicines But No to Life-Saving Medications: Beliefs Underpinning Treatment Decisions Among PLHIV

Despite the life-preserving benefits of antiretroviral therapy (ART), some people living with HIV (PLHIV) delay, decline or diverge from recommended treatment while paradoxically being willing to use potentially dangerous substances, such as recreational drugs (RD) and complementary medicines (CM). During 2016 and 2017, interviews were conducted with 40 PLHIV, in Australia to understand drivers underpinning treatment decisions. While many believed ART to be effective, they expressed concerns about long-term effects, frustration over perceived lack of autonomy in treatment decisions and financial, emotional and physical burdens of HIV care. In contrast, they ascribed a sense of self-control over the use of RD and CM, along with multiple professed benefits. The perceived burden of ART emerged as a motivator for deviating from recommended treatment, while positive views towards RD and CM appear to justify use. This study may serve as guidance for the development of future strategies to address barriers to treatment uptake and adherence and subsequently health outcomes for PLHIV in Australia and elsewhere.

Delineation of chemsex patterns of men who have sex with men in association with their sexual networks and linkage to HIV prevention

BACKGROUND

Previous studies have shown that men who have sex with men (MSM) and who engage in drug use in sexualized contexts (chemsex) were more likely to be HIV positive. Their social networks and adoption of HIV prevention measures have, however, not been fully investigated. We aim to compare the sexual behavior, HIV prevention efforts and social networks of MSM by the intensity and patterns of their drug use.

METHODS

Data from respondents of a community-based, cross-sectional survey (PRiSM) conducted among MSM in Hong Kong in 2017 were collected retrospectively. Characteristics of MSM engaged and not engaged in chemsex were compared in logistic regressions, delineated by latent class analysis (LCA) and compared in multinominal logistic regression.

FINDINGS

Of 4133 respondents, 3044 were sexually active with an HIV prevalence of 6.5%. The prevalence of chemsex engagement in the preceding 6 months was 12%, after excluding use of poppers or erectile dysfunction agents (EDA) alone. Four types of drug user were identified by LCA: Minimal (mainly poppers), low-threshold (mainly poppers and EDA), medium-threshold (mainly methamphetamine, GHB, poppers and EDA) and intense (extensive use of different types of drug). Medium-threshold and intense drug users were more likely to be HIV positive, be diagnosed with sexually transmitted infections, make gay friends through mobile apps and sex parties, and intend to take pre-exposure prophylaxis (PrEP). Medium-threshold drug users had a more influential role in their social network, as shown by their higher centrality in mobile apps network.

CONCLUSION

Chemsex engagement in MSM is significantly associated with HIV infection in Hong Kong. The HIV transmission risk could however be offset by the inclination of MSM belonging to medium-threshold and intense drug users to take PrEP, should the intervention become accessible to the community. Further mobile apps could be a good channel to access MSM who are medium-threshold drug users.

Use of poppers and HIV risk behaviours among men who have sex with men in Paris, France: an observational study

The use of inhaled nitrites, or poppers, among men who have sex with men (MSM) is prevalent, yet has been associated with HIV seroconversion. We surveyed 580 MSM from a geosocial networking smartphone application in Paris, France, in 2016. Of the respondents, 46.7% reported popper use within the previous 3 months. Regression models adjusted for sociodemographic characteristics found that the use of poppers was significantly (P<0.05) associated with the following during the prior 3 months: condomless anal intercourse (adjusted relative risk (aRR) 1.27, 95% confidence interval (CI) 1.07-1.50), use of alcohol and/or drugs during sex once or twice (adjusted relative risk ratio (aRRR) 2.33, 95% CI 1.44-2.03), three to five times (aRRR 5.41, 95% CI 2.98-9.84) or six or more times (aRRR 4.09, 95% CI 2.22-7.56), participation in group sex (aRRR 3.70, 95% CI 2.33-5.90) and self-reported diagnosis with any sexually transmissible infection over the previous year (aRR 1.63, 95% CI 1.18-2.27), specifically chlamydia (aRR 2.75, 95% CI 1.29-4.29) and syphilis (aRR 2.27, 95% CI 1.29-4.29).

Chemsex case study: is it time to recommend routine screening of sexualised drug use in men who have sex with men?

This case discusses a gay male participating in sexualised drug use. It raises several important issues and strengthens the case for routine screening for sexualised drug use in men who have sex with men so that healthcare professionals can provide better-informed and higher-quality health care to this population.

Pharmacokinetic drug evaluation of ritonavir (versus cobicistat) as adjunctive therapy in the treatment of HIV

Introduction: Ritonavir and cobicistat are pharmacoenhancers used to improve the disposition of other HIV antiretrovirals. These drugs are, however, characterized by important pharmacokinetic differences.Areas covered: Here, the authors firstly update the available information on the pharmacokinetics of ritonavir and cobicistat. Subsequently, the review focuses on the description of drug-drug interactions (DDIs) involving cobicistat and comedications that might beneficiate from a shift-back to ritonavir. A MEDLINE Pubmed search for articles published from January 1995 to April 2019 was completed matching the term ritonavir or cobicistat with pharmacokinetics, DDIs, and pharmacology. Moreover, additional studies were identified from the reference list of retrieved articles.Expert opinion: Despite more than 20 years after its introduction on the market, ritonavir still represents a valid option for the treatment of selected HIV-infected patients. The large-scale switch to cobicistat may result in some unexpected DDIs not previously reported for ritonavir. Besides the issue of DDIs, additional advantage of ritonavir over cobicistat is its use in pregnancy, and its availability as single component of pharmaceutical formulations allowing the fine-tuning of antiretroviral regimens in patients with heavy polypharmacy when other unboosted-based therapeutic options cannot be used.

Recreational drug and excessive alcohol use among HIV-infected men who have sex with men in Central Israel

Background

HIV-infected men who have sex with men (MSM) who use recreational drugs (RD) or excessive alcohol (EA) may be involved in risky sexual behaviours, including unprotected anal intercourse (UAI). This study describes the prevalence RD/EA-use among HIV-infected MSM, and compares those who used RD/EA with those who did not.

Methods

This cross-sectional study included HIV-infected MSM who were recruited in a convenient sample from two AIDS-treatment centres and events for HIV-infected MSM in Israel in 2016. Participants completed anonymous questionnaires including RD/EA-use and their sexual behaviours. RD/EA-use was defined as consumption of any psychoactive stimulants or dissociative anaesthetics, or an uptake of alcohol until drunkenness before or during sex.

Results

Of all 276 HIV-infected MSM, 202 (73.2%) used RD/EA. Those who used RD/EA were younger, reported earlier sexual debut, had more sexual partners, were more likely to perform UAI with casual partners, more commonly involved in paid sex, used psychiatric medications and more likely to be unsatisfied with their health-status compared to those who did not use RD/EA. HIV-infected MSM who used RD/EA reported a lower CD4-count and higher viral-load than those who did not. In a multivariate analysis, being younger, reported earlier sexual debut and been prescribed psychiatric drugs were associated with RD/EA-use among HIV-infected MSM.

Conclusions

A large proportion of HIV-infected MSM used RD/EA and also engaged in risky sexual behaviours. A subset of HIV-infected MSM can benefit from mental support during their routine treatment at the AIDS treatment centres and should also receive harm reduction intervention by their providers in order to minimize potential risks pertaining to RD/EA-use.

Mephedrone and chemsex: when it stops being a party and becomes a fatal problem

Chemsex is the use of psychoactive substances, mainly gamma-hydroxybutyrate, 4-methylmethcathinone (mephedrone), and methamphetamines to facilitate and enhance the experience of sexual intercourse. The toxicity of these drugs may be problematic and lead to a fatal outcome in some patients. We present the case of a 26-year-old man living with human immunodeficiency virus whose frequent use of mephedrone caused his death.

Recreational drugs and STI diagnoses among patients attending an STI/HIV reference clinic in Rome, Italy

BACKGROUND

An observational study was conducted to assess recreational drug use in association with recent STIs among clients of an STI/HIV reference centre in Rome, Italy.

METHODS

Attendees self-compiled a questionnaire concerning sexual behaviours and drug use, including the nine drugs used for sex (amphetamines, poppers, cocaine, ketamine, erectile dysfunction agent (EDA), steroids and the three chemsex drugs, ie, chems: γ-hydroxybutyric acid/γ-butyrolactone, crystal and Mcat).

RESULTS

Overall, 703 patients participated, with men who have sex with men (MSM) accounting for 50.4% of the total and 73.2% of HIV-positive patients. Apart from condylomatosis, whose prevalence was higher among females (38.8%) and non-MSM (45.8%) than MSM (14.4%), STIs were more frequent among MSM, particularly syphilis (14.1%), gonorrhoea (4.8%), urethritis (3.4%) and hepatitis A (6.5%). Recreational drug use was significantly more frequent among MSM (39.8% vs 17.6% in females and 22.7% in non-MSM). A total of 26.3% of MSM used at least one of the nine drugs and 5.1% at least one of the three chems. Cocaine (13.3%) and poppers (13.0%) were the most used sex drugs in MSM.The use of any of the nine drugs was associated with being MSM (adjusted OR (AOR): 1.94, 95% CI 1.05 to 3.58), sex with partner contacted online (1.99, 95% CI 1.14 to 3.45), group sex (4.08, 95% CI 2.40 to 6.93) and STI in the last year (1.65, 95% CI 1.05 to 2.61). Use of any of the nine chems among MSM was associated with condomless sex (2.24, 95% CI 1.21 to 4.14), group sex (2.08, 95% CI 1.01 to 4.31) and STI diagnosis in the last year (4.08, 95% CI 2.32 to 7.19).

CONCLUSIONS

Our data suggest that recreational drug use is quite common among MSM in Italy. No evidence of association with STI was found among non-MSM and females, where only cannabis and cocaine use was reported. The use of chems is still limited, but cocaine, poppers and EDA are widely used among MSM. Recreational drug use appears associated with high-risk sexual behaviours and a higher risk of STI.

Missed opportunities of HIV pre-exposure prophylaxis in France: a retrospective analysis in the French DAT'AIDS cohort

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) was implemented in France in November 2015 based on individual-level risk factors for HIV infection. We evaluated the proportion of missed opportunities for PrEP among newly HIV-diagnosed people entering the Dat'AIDS cohort in 2016.

METHODS

Multicenter retrospective analysis in 15 French HIV clinical centers of patients with a new diagnosis of HIV infection. Among them we differentiated patients according to the estimated date of infection: those occurring in the PrEP area (a previous negative HIV test in the last 12 months or those with an incomplete HIV-1 western blot (WB) with no HIV-1 anti-Pol-antibody at time of HIV diagnosis) and those in the pre-PrEP area (older infections). Epidemiological, biological and clinical data at HIV diagnosis were collected. Clinicians retrospectively identified potential eligibility for PrEP based on individual-level risk factors for HIV infection among those infected in the PrEP area.

RESULTS

Among 966 patients with a new HIV diagnosis, 225 (23.3%) were infected in the PrEP area and 121 (53.8%) had complete data allowing evaluation of PrEP eligibility. Among them, 110 (91%) would have been eligible for PrEP, median age 31 years, with 68 (75.6%) born in France and 10 (11.1%) in Central/West Africa, with more than one previous STI in 19 (15.7%). The main eligibility criteria for PrEP were being a man who had sex with men or transgender 91 (82.7%) with at least one of the following criteria: unprotected anal sex with ≥2 partners in the last 6 months: 67 (60.9%); bacterial sexually transmitted infection in the last 12 months: 33 (30%); Use of psychoactive substances in a sexual context (chemsex): 16 (14.5%). PrEP was indicated for other HIV risk factors in 25 (22.7%).

CONCLUSION

With 91% (110/121) of patients infected in the PrEP area eligible for PrEP, this study highlights the high potential of PrEP in avoiding new infection in France but also shows a persistent delay in HIV testing. Thus, an important limit on PrEP implementation in France could be insufficient screening and care access.

A review of the influence of functional group modifications to the core scaffold of synthetic cathinones on drug pharmacokinetics

RATIONALE

The synthetic cathinones are a class of designer drugs of abuse that share a common core scaffold. The pharmacokinetic profiles of the synthetic cathinones vary based on the substitutions to the core scaffold.

OBJECTIVES

To provide a summary of the literature regarding the pharmacokinetic characteristics of the synthetic cathinones, with a focus on the impact of the structural modifications to the pharmacokinetics.

RESULTS

In many, but not all, instances the pharmacokinetic characteristics of the synthetic cathinones can be reasonably predicted based on the substitutions to the core scaffold. Mephedrone and methylone are chemically alike and have similar T_max and t_1/2 in male rats. MDPV, a structurally distinct synthetic cathinone from mephedrone and methylone, has a lower T_max and t_1/2. Increasing the length of the alkyl chain on the α position of methylone, to produce pentylone, results in increased plasma concentrations and longer t_1/2. Metabolism of the synthetic cathinones is reasonably predictable based on the chemical structure, and several phase I metabolites retain pharmacodynamic activity. CYP2D6 is implicated in the metabolism of all of the synthetic cathinones, and other P450s (CYP1A2, CYP2B6, and CYP2C19) are known to contribute variably to the metabolism of specific synthetic cathinones.

CONCLUSIONS

Continued research will lead to a better understanding of the pharmacokinetic changes associated with structural modifications to the cathinone scaffold, and potentially in the long range, enhanced overdose and addiction therapy. Additionally, the areas of polydrug use and pharmacogenetics have been largely overlooked with regard to synthetic cathinones.

Reasons for delayed antiretroviral therapy (ART) initiation in the era of early ART initiation guidelines: a retrospective service evaluation

Following changes in national antiretroviral therapy (ART) guidelines removing the CD4 threshold for initiation of ART, we evaluated the time to ART initiation and reasons for delayed or non-initiation. A retrospective notes review of 292 newly diagnosed HIV-positive individuals attending two London clinics between August 2015 and December 2016 was performed. Two hundred and fifty-four of 292 (87%) individuals started ART. Median time to ART initiation was 29 days (range: 0-514). Thirty of 292 (13%) did not start ART. Rates of virological suppression at six months were similar regardless of time to ART initiation. People who inject drugs (16.7% vs. 3.6%) (p = 0.009), having a higher median baseline CD4 cell count (500 vs. 388 cells/mm³, p = 0.001), and having gastrointestinal/liver co-morbidities (23% vs. 9%, p = 0.001) were associated with delayed ART initiation. The cohort not on ART had a higher median baseline CD4 cell count (500 vs. 388 cells/mm³, p < 0.001). Documented reasons for delayed or ART non-initiation included patient's choice, prolonged adjustment periods, and difficulty leaving work. We conclude that delayed or non-initiation of ART was associated with injecting drug use and prolonged adjustment to a new HIV diagnosis. Clinician factors may include lack of urgency with higher baseline CD4 cell counts. Improved linkage to care and drug services pathways may encourage timely ART initiation.

Drug use among men who have sex with men in Ireland: Prevalence and associated factors from a national online survey

BACKGROUND

Little is known about the prevalence and determinants of drug use among men who have sex with men (MSM) in Ireland. The aims of this study were to measure the prevalence of recreational drug use among MSM in a national sample, and to identify sub-groups of MSM who may benefit from targeted preventive interventions.

METHODS

The MSM Internet Survey Ireland (MISI) 2015 was a community-recruited, nationally-promoted, self-completed online survey for MSM. MISI 2015 included standardised questions on recreational drugs, poppers, and drugs associated with chemsex (i.e. crystal methamphetamine, GBL/GHB, mephedrone, ketamine). Multivariable-adjusted logistic regression was used to identify factors associated with use of these substances.

RESULTS

In the previous year, 36% of MSM used recreational drugs, 33% used poppers, and 7% used drugs associated with chemsex. Five percent were diagnosed HIV-positive. Recreational drug users were significantly younger than non-users (median = 27 vs. 32 years; p < 0.001); popper users were significantly older than non-users (median = 34 vs. 28 years; p < 0.001). The odds of recreational drug use were higher among MSM diagnosed HIV-positive (vs. never tested; AOR 2.27, 95%CI 1.39-3.70). Use of poppers, and use of drugs associated with chemsex, were also higher among MSM diagnosed HIV-positive (vs. never tested; AOR 3.77, 95%CI 2.41-5.90, and AOR 5.87, 95%CI 3.08-11.18 respectively).

CONCLUSIONS

The prevalence of recreational drug use is higher among MSM than in the general population in Ireland, and it is particularly high among MSM diagnosed HIV-positive. Targeted harm reduction messages and preventive interventions are warranted to complement population-based approaches to reducing drug use in this population.

Poppers and PrEP: Use of Pre-exposure Prophylaxis Among Men Who Have Sex with Men Who Use Inhaled Nitrites

Men who have sex with men (MSM) commonly use inhaled nitrites, or poppers, though their use is a risk factor HIV seroconversion. Pre-exposure prophylaxis, or PrEP, is effective for HIV prevention, but is not widely used, and little is known regarding PrEP use and acceptability among MSM who use inhaled nitrites. We surveyed 580 MSM in Paris, France in 2016 about popper use, sexual behaviors including condomless anal intercourse (CAI), serosorting, and sexual positioning, PrEP use, PrEP candidacy, and interest in alternate PrEP delivery modalities. We included 444 HIV negative participants for the current study. 46.2% reported popper use in the prior 3 months. Using multivariate adjusted logistic regression, we found that popper users were more likely than non-users to consider themselves candidates for PrEP [adjusted relative risk ratio (aRRR) = 2.73; 95% CI 1.54-4.83], but they were not more likely to be current (aRRR = 1.54; 95% CI 0.71-3.33) or past (aRRR = 1.37; 95% CI 0.44-4.28) PrEP users. Mediation analyses indicated that increased CAI and serosorting partly explained the relationship between popper use and PrEP candidacy. There was considerable interest in alternate proposed PrEP delivery modalities, particularly long-acting injectable PrEP [adjusted risk ratio (aRR) = 1.43; 95% CI 1.15-1.79].

Drug-Drug Interactions Potential of Direct-Acting Antivirals for the treatment of Chronic Hepatitis C Virus infection

The advent of direct-acting antiviral agents (DAAs) has transformed the hepatitis C virus (HCV) therapeutic landscape in terms of efficacy and safety, with a cure rate of more than 90%. However, an important potential for drug-drug interactions (DDIs) is expected with these combinations, particularly in patients with other comorbidities (e.g. HIV co-infection, cardiovascular diseases). Each DAA can be a substrate, an inhibitor and/or an inducer of metabolic enzymes and drug efflux transporters. DAAs can act as both victims and perpetrators of DDIs and can sometimes increase the risk and/or intensity of side effects or limit the efficacy of treatment. Therefore, knowledge and management of DDIs with DAAs should be considered a key issue of HCV therapy. This review describes the pharmacokinetic profile of currently used and recommended DAA regimens and summarizes available data regarding DDIs to optimize HCV treatment in clinical practice.

Epidemiology and Elimination of HCV-Related Liver Disease

Hepatitis C virus (HCV) infection, defined by active carriage of HCV RNA, affects nearly 1.0% of the worldwide population. The main risk factors include unsafe injection drug use and iatrogenic infections. Chronic HCV infection can promote liver damage, cirrhosis and hepatocellular carcinoma (HCC) in affected individuals. The advent of new second-generation, direct-acting antiviral (DAA) agents allow a virological cure in more than 90% of treated patients, and therefore prevent HCV-related complications. Recently, concerns have been raised regarding the safety of DAA-regimens in cirrhotic patients with respect to the occurrence and the recurrence of HCC. Here, we review the current available data on HCV epidemiology, the beneficial effects of therapy, and discuss the recent controversy with respect to the potential link with liver cancer. We also highlight the challenges that have to be overcome to achieve the ambitious World Health Organization objective of HCV eradication by 2030.

The pharmacological interactions between direct-acting antivirals for the treatment of chronic hepatitis c and psychotropic drugs

INTRODUCTION

Most direct-acting antivirals (DAAs) and psychotropic drugs are metabolized by or induct/inhibit CYP enzymes and drug transporters. Although they are frequently coadministered, the drug-drug interactions (DDIs) have been little studied. Therefore, the aim of this review is to describe the interactions between the approved DAA or combination regimens and the main psychoactive substances, including legal and illegal drugs of abuse. Areas covered: We performed a literature search on PubMed database on drug interactions with the currently available antivirals for hepatitis C and a review of the information on pharmacokinetics, metabolism, and drug interactions from www.hep-druginteractions.org and from all the Summary of Product Characteristics (SmPC). This review covers the DDI between the DAA regimens approved, such as simeprevir and sofosbuvir, paritaprevir, glecaprevir, voxilaprevir, ombitasvir, ledipasvir, daclatasvir and sofosbuvir, elbasvir and grazoprevir, sofosbuvir and velpatasvir, glecaprevir/pibrentasvir, sofosbuvir and velpatasvir, and main psychotropic agents. Expert Commentary: DAA regimens based on sofosbuvir combination usually have less DDI than protease inhibitor-based regimens. Among protease inhibitors regimens, new combinations, such as glecaprevir/elbasvir and grazoprevir/elbasvir, seemed to have less DDI than the combination POrD (paritaprevir/ombitasvir/ritonavir/dasabuvir). However, the analysis of each interaction is theoretical and further interaction studies would be necessary to confirm actual effect.

A New Era of HIV Risk: It's Not What You Know, It's Who You Know (and How Infectious)

HIV is transmitted in social and sexual relationships, and HIV transmission risks, as well as protective actions, are evolving as HIV epidemics unfold. The current focus of HIV prevention is centered on antiretroviral medications used to reduce HIV infectiousness in persons already infected with HIV [treatment as prevention (TasP)]. The same medications used to treat infected persons can also be used by uninfected persons as pre-exposure prophylaxis (PrEP) to reduce the infectivity of HIV. Both PrEP and TasP are effective when adherence is high and individuals do not have co-occurring sexually transmitted infections. HIV prevention is most effective and efficient when delivered within sexual networks with high HIV prevalence. Specific network characteristics are recognized as important facilitators of HIV transmission; these characteristics include the degree of similarity among network members (homophily), gender role norms, and belief systems. Since 2011, HIV risk has been redefined based on infectiousness and infectivity, ushering in a new era of HIV prevention with the potential to end HIV epidemics.

Psychoactive substances, alcohol and tobacco consumption in HIV-infected outpatients

OBJECTIVES

To assess the alcohol consumption, tobacco addiction and psychoactive substance use (PSU) of people living with HIV (PLHIV).

DESIGN

Cross-sectional study in an HIV outpatient unit.

METHODS

Autoquestionnaire systematically proposed to all patients during their usual clinical care visit during a 6-months period, for alcohol (AUDIT test), tobacco (Short Fagerstrom Test) and PSU (ASSIST V3.0 test).

RESULTS

Of 1334 distributed questionnaires, 1018 PLHIV responded: 76.8% were men [528 patients were MSM), and the median age was 49 years (interquartile range: 42-46). A prevalence of excessive alcohol drinking was found in 22% [95% confidence interval (CI) 19.5-24.7%] and 44.6% (CI 41.5-47.7%) were current smokers, with high dependence in 29.1% (CI 24.9-33.7%). The prevalence of PSU was 37.8% (CI 34.8-41%) in the past 3 months: cannabis 27.7%, poppers 16.4%, cocaine 8.9%, psychotropic medications 7.1%, gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL) 4.7%, stimulants 3.1%, synthetic cathinones 2.7%, hallucinogens 1.5%. In the past 3 months, PSU was more prevalent in MSM than in non-MSM patients (46 versus 30%, P < 0.001). MSM consumed significantly more inhaled solvents (poppers) 31.0 versus 1.1%, GHB/GBL 7.8 versus 0.8%, stimulants 5.0 versus 1.1%, synthetic cathinones 4.9 versus 0.3%, and hallucinogens 2.3 versus 0.5%.

CONCLUSION

Given the high prevalence of PSU and other addictions (alcohol and smoking) among PLHIV, and particularly among MSM, a systematic screening of PSU and other addictions should be part of routine clinical care.

Chemsex and new HIV diagnosis in gay, bisexual and other men who have sex with men attending sexual health clinics

OBJECTIVES

The aim of the study was to analyse associations between chemsex and new HIV and sexually transmitted infection (STI) diagnoses among gay, bisexual and other men who have sex with men (GBMSM) accessing sexual health clinics.

METHODS

A retrospective case note review was carried out for all GBMSM attending two London sexual health clinics between 1 June 2014 and 31 July 2015.

RESULTS

Chemsex status was documented for 1734 of 1840 patients. Overall, 27.1% (n = 463) disclosed current recreational drug use, of whom 286 (16.5%) disclosed chemsex participation and 74 of 409 (18.1%) injected drugs. GBMSM who were already HIV positive were more likely to disclose chemsex participation [adjusted odds ratio (AOR) 2.55; 95% confidence interval (CI) 1.89-3.44; P < 0.001]. Those disclosing chemsex participation had higher odds of being newly diagnosed with HIV infection (AOR 5.06; 95% CI 2.56-10.02; P < 0.001), acute bacterial STIs (AOR 3.94; 95% CI 3.00-5.17; P < 0.001), rectal STIs (AOR 4.45; 95% CI 3.37-6.06; P < 0.001) and hepatitis C (AOR 9.16; 95% CI 2.31-36.27; P = 0.002). HIV-negative chemsex participants were also more likely to have accessed post-exposure prophylaxis for HIV in the study period and to report sex with a discordant HIV- or hepatitis C virus-infected partner (P < 0.001).

CONCLUSIONS

Chemsex disclosure in sexual health settings is associated with higher rates of STI diagnoses, including HIV infection and hepatitis C. GBMSM attending sexual health services should therefore be assessed for chemsex participation and disclosure should prompt health promotion, harm minimization and wellbeing interventions.

Tobacco, illicit drugs use and risk of cardiovascular disease in patients living with HIV

PURPOSE OF REVIEW

There is a strong link between HIV, smoking and illicit drugs. This association could be clinically relevant as it may potentiate the risk of cardiovascular diseases (CVD). The purpose of this review is to bring readers up to date on issues concerning the cardiovascular risk associated with tobacco and illicit drugs in patients living with HIV (PLHIV), examining the studies related to this topic published in the last year.

RECENT FINDINGS

There is a strong association between smoking and atherosclerotic disease in PLHIV, reducing life expectancy secondary to CVD by up to 6 years. Illicit drugs were associated with increased risk of atherosclerotic problems but to a lesser extent than smoking. A significant association of drugs such as cocaine with subclinical coronary atherosclerosis been demonstrated. The relation of marijuana, heroin and amphetamines with atherosclerosis generates more controversy. However, those drugs are associated with cardiovascular morbidity, independently of smoking and other traditional risk factors.

SUMMARY

Tobacco and illicit drugs are linked to CVD in HIV patients. This leads to the need to create special programs to address the addiction to smoking and illicit drugs, in order to mitigate their consequences and reduce cardiovascular risk.

Incidence of new hepatitis C virus infection is still increasing in French MSM living with HIV

OBJECTIVE

High hepatitis C virus (HCV) treatment uptake combined with effective direct-acting antiviral-based regimens resulted in a dramatic decline of HCV infection in French people living with HIV (PLWH). We assessed the yearly incidence of new HCV infection in PLWH enrolled in the large French Dat'AIDS cohort from 2012 to 2016 with a specific focus on MSM.

METHODS

The incidence of new HCV infection was determined yearly in HCV-negative PLWH with serological follow-up during 2012-2016. The incidence of HCV reinfection was determined in patients who were cured of a previous infection.

RESULTS

Among 40 714 PLWH, HCV status was available in 38 217 (94%). A total of 5557 PLWH (15%) were HCV infected at first time-point, 82% of whom were cured of HCV by the end of 2016. Among 21 519 HCV-negative PLWH with serological follow-up (63 449 patient-years), 219 first HCV infections occurred (MSM: 188, others: 31). Similarly, among 3406 patients who were cured of a previous infection (10 602 patient-years), 73 reinfections occurred (MSM: 51, others: 22). From 2012 to 2016, the incidence of a first infection in MSM rose from 0.5 to 0.92% patient-years, whereas the incidence or reinfection remained stable (2.52-2.90% patient-years).

CONCLUSION

Despite a high HCV treatment uptake and cure rate, the incidence of first HCV infection regularly increased in French HIV-positive MSM between 2012 and 2016. The incidence of reinfection fluctuated but remained constantly higher than the incidence of first infection, suggesting that a subgroup of MSM pursued high-risk practices following cure of a first infection.

New types of drug use and risks of drug use among men who have sex with men: a cross-sectional study in Hangzhou, China

Background

The use of new types of drugs has become more common among men who have sex with men (MSM). The aim of this study was to describe the patterns of the use of new types of drugs, such as methamphetamine, ketamine, ecstasy, and rush poppers, and to examine the factors associated with drug use and HIV infection among MSM in Hangzhou, China.

Methods

This cross-sectional study was conducted between August 2015 and April 2016. We used snowball sampling to recruit MSM; participants were recruited from voluntary counseling and testing centers, baths, bars, Blued (an app for the gay community), QQ groups, clubs, and other types of venues. MSM were included if their previous HIV test results were negative or unknown, or they had not been tested for HIV. MSM were excluded if they were known to be HIV positive before the survey. Face-to-face questionnaires were conducted and a venous blood specimen was drawn from each participant following the interview.

Results

In total, 555 MSM were included; 18.2% (101/555) of the participants had used new types of drugs in the past 3 months. Among the users, 65.3% used single-use rush poppers, while the remainder used ketamine, methamphetamine, ecstasy, or other mixed combinations of drugs. The HIV positivity rate was 14.8% (82/555). Factors associated with increased odds of using new types of drugs in the past 3 months were higher education levels (adjusted odds ratio [AOR] 4.45, 95% confidence interval [CI] 2.12–9.37), having multiple sexual partners (AOR 1.76, 95 CI 1.02–3.05), alcohol use before sexual intercourse (AOR 33.44, 95% CI 10.80–103.50), and seeing friends using new types of drugs.

Conclusion

We revealed the widespread use of new types of drugs, as well as a high diagnosis rate of new HIV infection, among MSM in Hangzhou. The use of new types of drugs was associated with an increased number of sexual partners among MSM; the high-risk sexual behaviors increased the risk of HIV infection. Attention should be given to the use of new types of drugs in MSM, and supervision programs should be strengthened to combat drug use.