Prevalence of recreational drug use reported by men who have sex with men attending sexual health clinics in Manchester,UK

Abstract

Recreational drug use (RDU) has been reported to be disproportionately higher in men who have sex with men (MSM) when compared to their heterosexual counterparts. To identify RDU, links to risky sexual practices and infections for MSM attending three sexual health clinics across Manchester, United Kingdom, a retrospective case note review was conducted using a random powered sample of service users attending three sites during 2014. Three hundred and fifty-seven case notes were reviewed across three sites. Eighteen per cent of service users reported any type of RDU. Use of at least one of the three drugs associated with chemsex (crystal methamphetamine, mephedrone, gamma hydroxybutyrate/gamma butyrolactone) was reported by 3.6%. A statistically significant difference was identified between non-drug users and any-drug users reporting: group sex (odds ratio [OR] 5.88, p = 0.013), condomless receptive anal intercourse (CRAI) (OR 2.77, p = 0.003) and condomless oral intercourse (OR 2.52, p = 0.016). A statistically significant difference was identified between chemsex-related drug user and non-drug user groups reporting: group sex (OR 13.05, p = 0.023), CRAI (OR 3.69, p = 0.029) and condomless insertive anal intercourse (OR 1.27, p = 0.039). There was also a statistically higher incidence of gonorrhoea infection in chemsex-related drug use compared with those not using drugs (p = 0.002, OR 6.88). This study identifies that substance use is common in MSM attending sexual health clinics in Manchester. High-risk sexual practices and certain sexually transmitted infections are more common in MSM reporting RDU.

Keywords

Epidemiology high-risk behaviour homosexual sexual behaviour sexually transmitted infections drug use

Introduction

Men who have sex with men (MSM) are more likely to engage in recreational drug use (RDU), with statistics sourced from the Crime Survey for England and Wales identifying 12% of MSM having used class A drugs in the past year versus 4% of heterosexual men, between 2011 and 2014.¹

Research indicates that often RDU in MSM appears to be episodic, with weekly or monthly substance use being more commonly reported than daily. This may support that substance use is dependent on circumstance, for example, to facilitate sexual activity.² Recreational substance use in the MSM population and risky sexual practices including condomless sex are well reported in the literature.^3,4 Increasingly sexual health clinics across the UK are responding to the rise of sexualised drug taking, referred to colloquially as ‘chemsex’, and its implications. Chemsex is commonly linked with three recreational drugs – crystal methamphetamine, mephedrone and gamma hydroxybutyrate (GHB)/gamma butyrolactone (GBL).⁵

Polydrug use, referred to as the use of more than one drug at the same time or within the same time period has been established as being prevalent in HIV-diagnosed MSM and is strongly associated with condomless sex.⁶

Patterns of RDU are subject to spatial and temporal variation, evolving according to availability and acceptability. As such, regular assessment of these changes is essential in better understanding service user behaviour. This study aims to establish the prevalence and types of recreational drugs used by MSM service users at three sexual health clinics in Greater Manchester and assess its association with high-risk sexual practices and incidence of sexually transmitted infections (STIs).

Methods

We conducted a retrospective case note review of MSM attending three sexual health clinics in Greater Manchester in 2014 as part of a chemsex health needs assessment. A sample size was calculated for each of the participating clinics using local estimates from a previous PHE survey on hepatitis C risk assessments among MSM clinic attendees in the three sites.⁷ This survey suggested a prevalence of chemsex in MSM between 20 and 40% depending on the clinic. In order to detect similar prevalence rates in each of the clinics, with an 80% power, and basing on a 5% margin of error, we estimated that between 98 and 145 case notes from MSM in each of the clinics would need to be reviewed.

Clinics submit case activity information into a nationally collected database, the Genitourinary Medicine Clinical Activity Dataset (GUMCAD). We extracted a list of all patients identified and coded as MSM in each of the clinics between 2 January 2014 and 31 December 2014, and using R, a statistical programming tool, generated a random sample from the list of patients for each clinics. We reviewed the latest clinic case notes for these patient episodes.

An online data collection survey was created to be completed by clinicians retrospectively from clinic records at their respective sexual health clinic (Appendix 1). The survey was piloted by two clinicians at independent sexual health clinics to ensure ease and adequacy of use. The data collected via this survey included attendance date, self-reported RDU and route of administration to clinicians in the consultation, reported high-risk sexual practices, previous STIs and access to post-exposure prophylaxis following sexual exposure (PEPSE).

To measure the association between drug use or chemsex and risk behaviours and reported STIs we calculated odds ratios (ORs) and 95% confidence intervals, and p-values using Fisher’s exact test (two tailed). All analysis was done in R version 3.3.1 (released 21 June 2016). The review did not require ethics approval as it was a service review, forming part of a health needs assessment; however, approval was gained from the three sites’ research and development departments.

Results

In total, 357 case notes were reviewed across three sexual health clinics in Greater Manchester. One is a city centre clinic, one is based in suburban setting and one is based in a district general hospital setting. Three case notes were found to have been miscoded as MSM, leading to replacement case notes being included in the review in order to ensure adequate power.

RDU

Sixty-six (18%) service users were recorded reporting any RDU.

The most commonly reported substances recorded were cannabis (25/357, 7%) and cocaine (22/357, 6%), mephedrone (11/357, 3%) and ketamine (9/357, 2.5%). Ecstasy was reported in 7/357 (2%), GHB/GBL by 5/357 (1.4%), crystal methamphetamine by 2/357 (0.6%) ‘speed’ or sildenafil, respectively, by 1/357 (0.3%). ‘Other’ (14/357, 3.9%) drug use included anabolic steroids, ‘pills’ (not defined), methoxetamine, ‘ching’ (methylphenidate) and ‘legal highs’ (not defined).

Timing of drugs

A total of 10.6% (7/66) of those reporting drug use stated they had used substances within the past one month, 4.5% (3/66) within the last 12 months, 6% (4/66) reported ‘other’ drug use timings (including ‘over 12 months ago’, ‘once in a while’ and ‘in the past.’). Seventy-nine per cent (52/66) did not have the timing of drug recorded.

Route of RDU

Route of drug administration was recorded in 45% of the (30/66) reporting RDU. Commonest routes of administration were smoking, which was recorded in 40% of those with a route of administration reported (12/30); injecting, reported in 30% (9/30); and snorting, reported in 20% (6/30). Swallowing of the drug was reported in 13% (4/30). There was no documentation relating to sharing of drug-taking paraphernalia.

The use of more than one recreational drug type was recorded in 30/66 case notes.

Use of at least one of the three associated chemsex drugs was reported by 13 individuals (3.6%), with four using mephedrone and GHB/GBL and one using mephedrone, GHB/GBL and crystal methamphetamine.

High-risk sexual practices

The mean number of sexual partners in the past six months was 3.4 (range 0–60). One individual reported 60 partners. Any drug users were more likely to have a higher mean number of sexual partners in the last six months than the non-drug using group (6.64 versus 2.66, respectively [p<0.001]). Table 1 compares the high-risk sexual practices of patients reporting any drug use with non-drug users. A statistically significant difference was identified in those reporting group sex, condomless receptive anal intercourse (CRAI) and condomless oral intercourse (COI). No statistically significant difference was observed between the two groups and condomless insertive anal intercourse (CIAI). Only one individual (a drug user) reported brachio-proctic insertion (fisting), therefore meaningful comparison is not possible. When comparing the difference between risky sexual practices reported by chemsex-related drug users versus non-drug users (Table 2), a statistically significant difference was identified for group sex, CRAI and CIAI. No significant difference was identified in the two groups for condomless oral sex.

Table 1.

Risky sexual practices reported in any drug users versus non-drug users.

Sexual practice	Non-drug user (n = 291)	Any drug user (n = 66)	OR (95% CI)	p-value
Sexual contacts (mean/SD)	2.66	6.64	1.08 (1.03,1.13)	<0.001*
Group sex	4 (1.37%)	5 (7.58%)	5.88 (1.53, 22.54)	0.013
Condomless anal (receptive)	88 (30.24%)	36 (54.55%)	2.77 (1.6, 4.78)	0.003
Condomless anal (insertive)	96 (32.98%)	21 (31.81%)	0.95 (0.53, 1.68)	0.886
Condomless oral	216 (74.3%)	58 (87.88%)	2.52 (1.15, 5.52)	0.016
Fisting	0	1 (1.5%)	–	0.034

CI: confidence interval; OR: odds ratio; SD: standard deviation.

P-values calculated Fisher’s exact test.

OR and p-value has been estimated using univariate logistic regression.

Table 2.

Risky sexual practices reported in chemsex-related drug users versus non-drug users.

Sexual practice	Non-drug user(n = 291)	Chemsex-related druguser (n = 13)	OR (95% CI)	p-value
Sexual contacts (mean/SD)	2.66	7.27	1.08 (1.01,1.16)*	0.058*
Group sex	4 (1.37%)	2 (15.38%)	13.05 (2.15, 79)	0.023
Condomless anal (receptive)	88 (30.24%)	8 (61.54%)	3.69 (1.17, 11.6)	0.029
Condomless anal (insertive)	95 (32.65%)	8 (61.54%)	1.27 (0.4, 3.98)	0.039
Condomless oral	216 (74.3%)	12 (82.3%)	4.17 (0.53, 32.59)	0.197
Fisting	0	1 (7.7%)	–	0.043

CI: confidence interval; OR: odds ratio; SD: standard deviation.

P-values calculated Fisher’s exact test.

OR and p-value has been estimated using univariate logistic regression.

STIs

Tables 3 and 4 show the diagnosis of selected STIs ever reported. There was a notable increase in the proportion of patients with diagnosis of these STIs in those that used chemsex-related drugs compared with the non-drug user group; however, this is only statistically significant for a gonorrhoea diagnosis (Table 4).

Table 3.

STI diagnosis ever reported in any drug users versus non-drug users.

	Non-druguser(n = 291)	Any druguser (n = 66)	OR (95% CI)	p-value
Syphilis	58 (19.93%)	15 (15.15%)	1.18 (0.62, 2.25)	0.614
HIV	83 (28.52%)	23 (34.85%)	1.34 (0.76, 2.36)	0.371
HCV	7 (2.41%)	3 (4.55%)	1.93 (0.49, 7.68)	0.401
GC	95 (32.65%)	28 (42.42%)	1.52 (0.88, 2.62)	0.152

CI: confidence interval; GC: gonorrhoea; HCV: hepatitis C; HIV: human immunodeficiency virus; OR: odds ratio; STI: sexually transmitted infection.

P-values calculated Fisher’s exact test.

Table 4.

STI diagnosis ever reported in chemsex-related drug users versus non-drug users.

	Non-druguser(n = 291)	Chemsex-relateddrug user (n = 13)	OR (95% CI)	p-value
Syphilis	58 (19.93%)	5 (38.46%)	2.51 (0.79, 7.96)	0.153
HIV	83 (28.52%)	6 (46.15%)	2.15 (0.7, 6.58)	0.212
HCV	7 (2.41%)	1 (7.69%)	3.38 (0.38, 29.71)	0.298
GC	95 (32.65%)	10 (76.92%)	6.88 (1.85, 25.57)	0.002

CI: confidence interval; GC: gonorrhoea; HCV: hepatitis C; HIV: human immunodeficiency virus; OR: odds ratio; STI: sexually transmitted infection.

P-values calculated Fisher’s exact test.

Post-exposure prophylaxis

Of the individuals reporting no RDU, 19/291 (6.53%) reported ever accessing PEPSE versus 7/66 patients reporting drug use (10.61%; p = 0.2912) and 2/13 of the chemsex-related drug users (15.38%; p = 0.2238).

HIV-positive cohort

One hundred and six individuals were HIV-positive (29.7%). Of those, 21.7% used recreational drugs. A total of 6/106 (5.67%) specifically reported engaging in chemsex. A total of 7/106 (6.6%) reported cannabis use, 7/106 (6.6%) cocaine use, 7/106 (7.7%) ecstasy use, 6/106 (5.67%) mephedrone use, 4/106 (3.77%) ketamine use, 3/106 (2.8%) GHB/GBL use and 2/106 (1.89%) methamphetamine use.

Discussion

Our review demonstrates a high rate of self-reported drug use in MSM sexual health clinic attenders. Clinic attenders reporting RDU report a higher number of sexual partners and certain risky sexual practices, including group sex, CRAI and COI. A statistically significant difference was identified between chemsex-related drug users and those who did not report drug use, and ever having a diagnosis of gonorrhoea. There was a statistically significant difference between those reporting chemsex drug use and non-drug users and the following sexual practices: group sex, condomless receptive and CIAI.

The Crime Survey of England and Wales identified that use of certain specific substances (GHB/GBL and methamphetamine) is more common in gay and bisexual men than their heterosexual counterparts.¹ Recent polydrug use has been identified in studies as being a risk factor for high-risk behaviour for acquiring HIV than in those who reported a single drug use.^8,9 The National Drug Treatment Monitoring System report on MSM accessing treatment for problematic substance use and in 2013–14, a greater proportion of MSM presented to treatment with problematic amphetamine use (32% versus 7% of their heterosexual counterparts) and GBL use (16% versus 0.1%).¹ The rates for injecting opiates were the same for gay and bisexual men as for heterosexual men. However, MSM in treatment for the misuse of non-opiate drugs were more likely to inject (16%) than their heterosexual counterparts (3%). Our findings demonstrate a worryingly high rate of injecting drug use recorded (30% of those who had a route of drug administration recorded), highlighting the need for education surrounding needle exchange and safer injecting practices.

Chemsex can be described as sex whilst under the influence of drugs, which have been taken immediately before or during a sexual session.⁵ Links to high-risk sexual practices, including sex with a large number of casual partners whilst under the influence of these drugs, are increasingly reported, and our study contributes to this evidence.¹⁰ The chemsex drug use subgroup in our review were more likely to have accessed PEPSE, engage in high-risk sexual practices and have been diagnosed with a STI in the past when compared to non-drug users. Manchester sexual health physicians are increasingly identifying drug-related complications in those engaging in chemsex, including inpatient-related admissions for overdose, psychosis, abscesses, cardiac arrhythmias, deep vein thrombosis and withdrawal.¹¹ A dedicated chemsex support clinic has been commissioned to provide substance misuse support, psychological support and sexual health advice and testing.

Our review demonstrates the drug users are more likely to engage in COI and CRAI. Links between RDU and risky sexual practices are increasingly reported in the literature. A large, cross-sectional questionnaire study involving British HIV-negative or -undiagnosed MSM attending 20 UK sexual health clinics identified chemsex drug use to be strongly associated with previous STI, PEP use, group sex and high number of new sexual partners.¹² Several studies have identified a strong correlation between substance use and sexual risk after controlling for potential confounders, showing the use of club drugs including ecstasy, GHB/GBL, crystal methamphetamine, cocaine and ketamine, before or during sex to be independently associated with condomless anal intercourse with casual partners of unknown HIV serostatus.^13–16

Strengths and limitations

Our findings have identified types of recreational drugs reported, routes of administration and links to STIs and risky sexual practices in MSM attending sexual health clinics in Manchester. Our findings will help us to improve upon specialist advice and support which can be offered to this group of service users.

In order to preserve anonymity and to keep the survey brief, our review did not collect information on individual demographic data. Collection of more detailed information, including age and ethnicity of clinic attendees may have enabled us to better tailor interventions.

Our study did not capture event-level data, so use of chemsex-related drugs may not necessarily translate to chemsex participation. Similarly, use of other substances not typically associated with chemsex may have been used in the chemsex setting.

There is the potential of duplication of case note reviews if the same patient attended different clinics with the same issue. Patient unique identifications in GUMCAD are only unique to the clinic. As a pseudo-anonymised data set, there is no way to de-duplicate episodes beyond the clinic level. Since completion of our study, the numbers of individuals reporting chemsex-related substance use are likely to have increased, evidenced locally with increasing attendances, drug-related inpatient admissions and attendances to specialist support services.

It is possible that there was some clinic-to-clinic variation in discussion with service users about recreational drugs. A comprehensive recreational drug history is embedded in each clinic’s proforma; however, there is a possibility that certain clinics may dedicate different times to this area. In the coming months, all three sexual health clinics will adopt standard clinic proformas which will help improve the quality and uniformity of data collection.

Previous research by Ireland et al.⁷ identified that 37% of the 2094 Manchester sexual health clinic attendees had used recreational drugs in the previous 12 months, and 25% reported having sex whilst under the influence of recreational drugs in the past 12 months, when asked to complete an anonymous questionnaire that was distributed in the respective clinics. The lower prevalence in our study may in part be explained by individuals feeling uncomfortable about disclosing substance use to a health care professional as opposed to completing an anonymous questionnaire. It is also possible that clinicians either did not ask or accurately record the use of recreational drugs in the consultation. This highlights the need for sexual health clinicians to receive appropriate training in eliciting histories of substance use and chemsex, in order to ensure education and support service availability is highlighted.

Due to the lower prevalence of drug use than expected, a multivariate analysis was not able to be completed. It is possible that several variables will influence and impact on each other possibly confounding the results. Although our analysis suggests that those who engage in chemsex also engage in high-risk sexual behaviours, the low numbers in our study result in wide confidence intervals, thus requiring cautious interpretation.

Our review highlights the need for holistic assessments to be implemented in MSM patients, to ensure an accurate assessment of substance use is made and chemsex support offered, if required. It is also important that this assessment is included as part of routine HIV patient care, particularly as we identified a higher proportion of HIV-positive individuals reporting chemsex drug use than the overall cohort (5.67% versus 3.6%). Our sample population included a high proportion of HIV-positive individuals (29.7%). Further reviews into recreational substance use and, in particular, the reporting of chemsex-related engagement will be useful on a frequent basis in order to help ensure sexual health physicians are identifying and supporting those with problematic substance use.

Conclusion

Use of recreational drugs to enhance sexual activity is associated with increased high-risk sexual practices, number of sexual contacts and inevitably the incidence of certain STIs in MSM. Our findings support the increasing literature on the risks associated with recreational substance use in relation to sexual activity.

Footnotes

Acknowledgements

We would like to thank clinical staff at Central Manchester University NHS Foundation Trust, Pennine Acute Hospitals Trust and University Hospital South Manchester for their assistance in collecting the data for this report.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article RV is supporting the implementation of seroprevalence surveys for blood-borne viruses (HCV, HBV and HIV) in attendees at Emergency Departments in the North West of England partly funded by Gilead Sciences, Inc. The other author(s) 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.

Appendix 1: Chemsex questionnaire

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