Men who have sex with men diagnosed with a sexually transmitted infection are significantly more likely to engage in sexualised drug use

Abstract

The sexualised use of recreational drugs (Mephedrone, GBL/GHB, Crystal Meth) generally known as ‘chemsex’ in men who have sex with men (MSM) is thought to be associated with sexually transmitted infection (STI) acquisition; however there is little data showing a direct relationship. We reviewed 130 randomly selected cases of MSM with an STI attending our STI service and 130 controls (MSM attending the STI service who did not have an STI) between 5 May 2015 and 2 November 2015. Reported condomless anal sex was significantly higher in cases 90/121 (74%) compared with controls 65/122 (53%); (χ²= 11.71, p < 0.005, OR 2.54). Recreational drug use in the cases 38/122 (31%) was significantly greater than in controls 20/125 (16%); (χ²= 7.88, p < 0.005, OR 2.37). This demonstrates a link between STI acquisition and recreational drug use in MSM. Harm reduction initiatives identifying and addressing party drug use can help to improve the sexual health of MSM, including reducing risk-taking behaviours.

Keywords

MSM sexually transmitted infections gonorrhoea drug use high-risk behaviour

Introduction

The sexualised use of drugs such as Mephedrone, gamma-hydroxybutyric acid (GHB)/gamma-butyrolactone (GBL) and crystal methamphetamine, generally known as ‘chemsex’, is an increasing public health issue in Westernised nations, amongst men who have sex with men (MSM).^1,2

Globally MSM (both HIV-positive and HIV-negative) have been shown to report higher rates of substance misuse and more recently the sexualised use of recreational drugs has been observed and has been shown to be associated with harm.^3–7

MSM in Brighton, UK use high amounts of recreational drugs; over a third disclosed having ever used Mephedrone, a quarter to ever using GHB/GBL and one in 10 to using crystal methamphetamine.⁸ Twenty-two percent of Brighton’s HIV-positive MSM have reported injecting drug use (known as ‘slamming’) in the context of sexual encounters.⁸

Global rates of sexually transmitted infections (STIs) continue to increase amongst MSM.^9–10 In the UK, MSM experience high rates of STIs and rates are increasing, with gonorrhoea being the most commonly diagnosed STI in this group.¹¹ Locally in Brighton & Hove, there is a very high prevalence of STIs (1534/100,000 new diagnoses in over 25 s).¹² Rates of HIV in Brighton are the highest anywhere in the UK, outside of London, at 8 per 1000 of the city’s population.¹³ Around one in 20 MSM in the UK have HIV, with more than a half of those newly diagnosed in 2014 being MSM.¹⁴

MSM are already at high risk of acquiring STIs and sexualised drug use is believed to be contributing to a further increased sexual risk taking and subsequent infections (STIs).¹ Establishing sexualised drug use during history taking is an opportunity to identify potential risk behaviours and detect reservoirs of asymptomatic infection through appropriate STI testing.

We aimed to evaluate and determine the relationship between current sexualised drug use and STI acquisition locally. The purpose of this project was to improve awareness, help guide future public health interventions and help target services for MSM having sex whilst under the influence of psychoactive substances. We hypothesise that sexualised drug usage is contributing to current STI and HIV transmission.

Methods

A cross-sectional case-control method was used: all MSM attending the Brighton (UK) Genito-Urinary Medicine clinic during a six-month period in 2015 were identified using unique clinic numbers. From this randomly selected 130 MSM, cases with a diagnosed STI infection (all site gonorrhoea, all site chlamydia, new HIV diagnosis, primary and secondary infectious syphilis) and age-matched controls without an STI diagnosis were selected.

Cases were selected via STI coding and data were anonymised and collected using the electronic records system. The total sample size selected was 260 MSM (130 cases and 130 controls).

Excluded from analysis were those with no documentation of condomless anal sex and those with sole use of cannabis. Also excluded from analysis were MSM with missing data; for example, those who reported drug use, but in whom type was not specified.

The use of the following drugs either alone or in combination were included in the analysis: mephedrone, GHB/GBL, crystal methamphetamine, cocaine, 3,4-methylenedioxymethamphetamine, alkyl nitrites, ketamine, amphetamine sulphate and ‘legal highs’. Data on drug use is a routine question on the electronic notes proforma.

Results

There were 5013 MSM attendances to the sexual health and HIV units in Brighton during a six-month period (May to November 2015). Of these, we randomly selected 130 cases (median age 44 years) and 130 controls (median age 48 years).

Gonorrhoea accounted for half of all STIs (70/139) and nine cases had multiple infections (more than one STI diagnosed). New HIV acquisition accounted for one of the detected STIs (1/139). HIV prevalence was significantly higher in the cases: 71/130 (55%) compared to controls 33/130(25%); (χ²= 23.14, p < 0.001), see Table 1.

Table 1.

Frequency of detected STIs, pre-existing HIV prevalence, sexual behaviour and sexualised drug use in cases and controls.

	Controls n (%)	Cases n (%)	P-value
Chlamydia	0	37/139 (27)^c	NS
Gonorrhoea	0	70/139 (50)^c	NS
Syphilis	0	31/139 (22)	NS
New HIV (incidence)	0	1/139 (1)	NS
Pre-existing HIV (prevalence)	33/130 (25)	71/130 (55)	<0.001
Condom-less anal sex	65/122 (53)^a	90/121 (74)^d	<0.005
Sexualised drug use	20/125 (16%)^b	38/122 (31)^e	<0.005

Eight controls had no documentation of condom-less anal sex and were therefore excluded.

Five controls had no documentation of drug type used or had cannabis sole use and were therefore excluded.

Nine cases had multiple pathogen infection (i.e. more than one STI type isolated).

Nine cases had no documentation of condom-less anal sex and were therefore excluded.

Eight cases had no documentation of drug type used and were therefore excluded

Sexual behaviour

Cases reported higher numbers of sexual partners within the preceding three months (median number 3 vs. 2 respectively), and significantly more condomless anal sex 90/121 (74%) compared with controls 65/122 (53%); (χ²= 11.71, p < 0.005), see Table 1.

Reported sexualised drug usage

Reported sexualised drug use in the cases 38/122(31%) was significantly greater than in controls 20/125(16%); (χ²= 7.88, p < 0.005). Mephedrone was the most frequently reported drug, followed by GBL/GHB, see Table 1.

Associations were found between STI acquisition and: HIV prevalence, the number of sexual partners, more condomless anal sex and reported sexualised drug usage.

Discussion

These data further demonstrate and support the relationship between STI diagnosis and sexualised drug use in MSM locally. Not only were those with STIs more likely to report sexualised drug use, they were also more likely to be HIV-positive and engage in condomless sex. However, the relationship between sexualised drug use and sexual risk is complex and there are few published UK studies examining the link between sexualised drug use and STIs; indeed, this is the first case control study showing a relationship. As such, more research is needed to support this assumption.^1,2,7,8,15

Thorough history taking regarding drug use in MSM may help to identify those at high risk of STI acquisition due to their higher partner numbers (potentially related to increased libido and sexual stamina secondary to sexualised drug use and leading to increased potential for exposure to STIs), HIV status (HIV-positive concordant partners maybe less concerned regarding transmission of other STIs) and engagement in particular high-risk behaviours which are common amongst those engaging in sexualised drug use.

These identified high-risk individuals would benefit from enhanced sexual health services including regular STI screening, Pre-Exposure Prophylaxis (PREP) and drug use support and behavioural change interventions. Furthermore, by identifying those MSM with recurrent STIs, we may identify those with higher sexualised drug use and therefore increased need for specialist and targeted interventions.

Clinic- and community-based public health interventions to reduce STI rates should include assessment and harm reduction initiatives (dealing with both sexual health and drug use) to support MSM who engage in sexualised drug use.

The purpose of this project was to improve awareness, help guide future public health interventions and help target services for MSM having sex whilst under the influence of psychoactive substances.

Limitations of the study include the relatively small sample size within a single UK centre and failure to disclose drug use to the consulting health profession may also have confounded results.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Bourne

Reid

Hickson

. Illicit drug use in sexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in South London: findings from a qualitative study. Sex Transm Infect 2015; 91: 564–568.

Wall

Chiasson

. Complex drug use patterns and associated HIV transmission risk behaviors in an Internet sample of U.S. men who have sex with men. Arch Sex Behav 2015; 44: 421–428.

Warner

McKeown

Griffin

. Rates and predictors of mental illness in gay men, lesbians and bisexual men and women: results from a survey based in England and Wales. Brit J Psychiat 2004; 185: 479–485.

Clatts

Goldsamt

. Homelessness and drug abuse among young men who have sex with men in New York city: a preliminary epidemiological trajectory. J Adolesc 2005; 28: 201–214.

Measham

Wood

Dargan

. The rise in legal highs: prevalence and patterns in the use of illegal drugs and first and second generation ‘legal highs’ in south London gay dance clubs. J Subst Use 2011; 16: 263–272.

Kirby

Thornber-Dunwell

. High-risk drug practices tighten grip on London gay scene [World news report]. Lancet 2013; 381: 101–102.

Daskalopoulou

Rodger

Phillips

. Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV 2014; 1: e22–e31.

Kurka

Soni

Richardson

. High rates of recreational drug use in men who have sex with men. Sex Transm Infect 2015; 91: 394–394.

Fenton

Imrie

. Increasing rates of sexually transmitted diseases in homosexual men in Western Europe and the United States: why? Infect Dis Clin North Am 2005; 19: 311–331.

10.

Ciesielski

. Sexually transmitted diseases in men who have sex with men: an epidemiologic review. Curr Infect Dis Rep 2003; 5: 145–152.

11.

Public Health England. Health Protection Report 2015, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/437433/hpr2215_STI_NCSP_v6.pdf (accessed July 2016).

12.

Public Health England. Sexual and reproductive health profiles, http://fingertips.phe.org.uk/profile/sexualhealth (accessed July 2016).

13.

Public Heath England. HIV in the United Kingdom 2014, https://www.gov.uk/government/uploads/system/uploads /attachment_data/file/401662/2014_PHE_HIV_annual_report_draft_Final_07-01-2015.pdf (accessed July 2016).

14.

Public Health England. HIV: Surveillance, data and management 2014, http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HIV (accessed July 2016).

15.

Melendez-Torres

Borne

. Illicit drug use and its association with sexual risk behaviour among MSM: more questions than answers?. Curr Opin Infect Dis 2016; 29: 58–63.