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HIV and drugs

So how much do we actually know about the risks posed by ‘chemsex’?

4 Dec, 15 | by Leslie Goode, Blogmaster

A recent BMJ editorial (3rd November) calls for ‘chemsex’ (the term used by the gay community to designate sex under the influence of drugs taken to heighten pleasure) to be made a ‘public health priority’.  The editorial has evidently been triggered by the publication of findings from a research project conducted by Sigma Research and commissioned by the London Boroughs of Lambeth, Southward and Lewisham (LSL).  These have recently appeared both in the official report (Executive Summary), and in papers in various journals, including STIs (see Bourne & Weatherburn (STIs)).

So far as the nature of chemsex itself is concerned, there is an informative short guide produced by 56 Dean Street that offers a down-to-earth insight into the nature of ‘chemsex’ events (ChemSex and heptatis C/STIs/blog).   On importance of the phenomenon for STI transmission within the MSM community, however, there would seem to remain considerable uncertainty – at least according to the editorial.  Evidence for condom use and sero-sorting in this setting would be a helpful indicator of degree of risk, but is apparently a contested issue in the current literature.

So what does the Chemsex Study itself have to contribute on these issues?  Concerning the extent of the chemsex phenomenon, it gives a ‘quantitative context’ on the basis of data from EMIS (European Men-who-have-sex-with men Survey).  The analysis of this data indicates a proportion of MSM living in LSL who have used drugs known to be employed for chemsex that is respectively seven-fold (GHB/GBL), and eight-fold (crystal meth), what we find amongst MSM elsewhere in the UK – as against a proportion for other drugs that is two or three-fold.

Regarding risks posed by behaviours associated with chemsex events – the question discussed by Bourne & Weatherburn (STIs) – the Chemsex Study employs qualitative data from a thematic analysis of 30 interviews conducted with MSM having participated in such events from LSL.

The researchers isolate four key ‘narratives’.  (1) More than a quarter, all sero-positive, had made a conscious decision to engage in unprotected anal intercourse (UAI) with those they believed were sero-concordant. (2) A third found it hard to control their behaviour under the influence of drugs, and took risks they subsequently regretted.  (3) A ‘small sample’ sought out risky sex.  (4) A ‘sizeable minority’ felt perfectly in control of their actions, and relatively safe, while engaging in chemsex.  The authors do not indicate whether, and how far, these four groups overlap, and how the membership of any but the first correlates with HIV sero-status.

They conclude there is little evidence that use of drugs had influenced engagement in UAI, though their use had facilitated sex with more men and for longer.  Much, it would seem, remains to be clarified by future studies.


Indiana State ban on Needle Share programmes faces challenge of an IDU-fuelled HIV spike

20 Apr, 15 | by Leslie Goode, Blogmaster

In 2011 18.5% of HIV infections in the US were attributable to intravenous drug-use (IDU) – a significant proportion (Lansky & Wejnert (STIs)).  The issue of IDU fuelled HIV transmission has been brought forcibly to the attention of Americans in the last few weeks by the recent HIV outbreak in Scott County, Indiana, US.  This local epidemic appears to have been the result of the recreational use of the opiate, Opala. The number of infections has continued to rise, reaching a new peak of 130 this last week (Indystar/needle exchange; npr/Indiana’s HIV spike).

The effectiveness of public health interventions amongst IDU, including needle exchange programmes is well-established. Recent studies in Russia and East-European contexts (Vagaitseva & Demyanenko (STIs); Boci & Bani (STIs)), where IDU accounts for greatest proportion of infections,  have also come to very positive conclusions about their cost-effectiveness (Demyanenko & Vagaitseva (STIs).  They have also considered ways of improving uptake among drug-users (Boci & Hallkaj (STIs).  Sadly, in 23 states of the US – as in Russia and some East-European countries – traditional legal restrictions on needle exchange programmes remain in force (LawAtlas/US).  Indiana just happens to be one of these US states.  Its governor, who has had to authorize a short-term moratorium on the legal restriction of needle exchange in response to the outbreak, just happens to be Mike Pence, a republican who is known for his especially hawkish views on social issues (see “US Republicans prepared to put the poor at risk” (STI/blogs)) and favours continuation of the ban.

Needless to say, an order authorizing the temporary suspension of the restrictions on needle exchange was issued last month.  A needle-exchange programme has distributed 5,300 clean needles to drug-users since 8th April when it began its activities.

Unfortunately, however, the temporary suspension is due to expire on 25th April.  It also applies only to Scott County. Health experts are pushing legislators to allow needle exchange in neighbouring counties of Indiana, where high levels of HCV indicate a high risk of similar outbreaks.  On Monday, a joint Senate and House Legislative Committee will consider a measure, authored by Ed Clere, a representative from a neighbouring county, to authorize local public health and law enforcement authorities to work together to start their own need exchange programmes. But Governor Pence has threatened to veto the measure.  He declines to explain his position in public, but is said by Senate President, David Long, to believe that needle exchange programmes lead to greater drug use (News & Tribune/Indiana’s needle exchange bill).

Living dangerously in the Dominican Republic and Mexico City: can cash transfer payments be used to counteract the “risk premium”?

17 Dec, 14 | by Leslie Goode, Blogmaster

The Caribbean has the highest levels of HIV outside sub-Saharan Africa – and the Dominican Republic (DR), which together with Haiti accounts for 70% of all people living with HIV in the Caribbean region, is a hotspot.  While there has been a 73% reduction in the rate of new infections in the DR between 2001 and 2011, prevalence of HIV remains high among key populations of MSM (6%) and female sex-workers (3%).  A recent qualitative study has sought to investigate the relations between the drug trade, sex tourism, and risk taking which may hold the secret of the obstinately high-levels of HIV in these key populations (Guillamo-Ramos & Robles).  In-depth interviews, along with drug screening, were conducted with 30 local drug users in Sosua, known for its tourist sex industry.

Three major themes emerge.  First, drugs are freely available as a result of diversion from the major drug routes running from N to S America through the DR.  Second, they have become integral to the local tourist industry – specifically as a vital component of sex work.  Third, the engagement of locals, along with tourists, in commercial sex fuelled by drug use gives rise to the kind high-risk behaviours that sustain the spread of HIV in the local population.

What, from the public health angle, seems particularly challenging in this situation is that the element of risk-taking isn’t merely an incidental effect of the sexual activity; it is precisely the element that makes that activity attractive, and – from the locals’ point of view – lucrative.  Participants associate sex work and drug use with improved livelihood, and describe how risk behaviours are part of the economic negotiating process.

This is the same general kind of problem described in the reported base-line study of a pilot trial of an intervention among male sex workers in Mexico City (STI/Galarraga & Sosa-Rubi).  These male sex-workers are at particular risk of infection because they receive market-based inducements from clients to engage in condomless sex.  It is not simply that MSW are neglecting to take precautions; the average price for a sex transaction is 35% higher for condomless sex – and, given MSW may be unemployed (16%), or dependent for their income on sex work (37%), the economic pressures to engage in unsafe practices are considerable.

The Punto Seguro pilot trial, based at the Clinica Condesa, an HIV centre in Mexico City, is considering as a potential solution the idea of a conditional cash transfer (CCT) whereby MSW are rewarded for keeping themselves free of curable STIs over a six-month period.  Within Mexico CCT has been employed, since the 1990s to provide incentives for poor people to keep their children in school, and to attend preventative check-ups, though not apparently in the sphere of HIV.  In the US, however, it has been used to prevent persistent STIs and pregnancy amongst the Latino population (STI/Minnis & Padian), in Pakistan to encourage infected men to disclose to their wives, and have them tested (STI/Khan & Khan).

The paper sets out the procedures and the baseline data for investigating the effectiveness of a form of this kind of intervention.  The 267 participants have been randomized to four groups: control; medium conditional incentive ($50); high conditional incentive ($75); unconditional incentive ($50). Previous formative work established the incentive levels necessary for behaviour change ($156 per year).  It is also hoped that CCT interventions may benefit participants by helping to link them into care – since of the participants in the trial who knew they were infected with HIV, only 40% were on treated, and of these, only 61% had achieved viral suppression.

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