Beyond-66: A pilot evaluation of a novel,peer-led harm reduction intervention for chemsex dependant men who have sex with men in Kuala Lumpur,Malaysia

Background

Sexualised drug use is the intentional use of recreational drugs to enhance sexual experiences. Chemsex refers to a particular subculture of sexualised drug use among men who have sex with men (MSM) who use crystal methamphetamine (including injecting ‘slamsex’), GHB, ketamine, and/or phosphodiesterase-5 (PDE5) inhibitors before or during sexual activity. ¹ Chemsex is associated with meeting sexual partners using geo-social mobile phone apps, group sex or parties, transmission of HIV and sexually transmitted infections (STI), non-consensual sex and poor mental health.^2,3 Globally, chemsex users experience adverse health outcomes including overdose, dehydration, poor mental health including psychosis, loss of job, STIs including shigella, HIV transmission and non-adherence to HIV antiretroviral therapy.^3–6 Chemsex is not uncommon in MSM in Asia, including Malaysia, where the most popular chemsex drug is crystal methamphetamine including injecting. ⁷ In Malaysia, injecting drug use, knowing someone who is using HIV-PrEP, sharing HIV-PrEP, having a high perceived HIV risk, transactional sex, having a recent sexually transmitted infection (STI) diagnosis, engaging in anal sex and having recent sex with people living with HIV (PLWH) are associated with chemsex. ⁷ A recent online survey suggests that up to 9% of MSM in Malaysia had chemsex in the previous 6 months ⁷ There is a relative paucity of research in Asian settings due to the stigmatization and legal concerns around same sex sexual behaviours and drug use which create barriers for MSM to participate in chemsex related research. ⁸ Malaysia criminalises same-sex sexual activity between men and between women. The gender expression of trans people is also criminalised, and sentences include a maximum penalty of twenty years’ imprisonment with whipping. Lesbian gay and transgender people experience significant stigma and violence as a result of their minoritized and illegitimate status in society which impacts on HIV and STI transmission and other poor health outcomes. ⁹ Providing effective harm reduction interventions to MSM who are chemsex dependant is challenging in high income settings where same sex sexual behaviour and recreational drug use is less criminalised than in Malaysia.^10,11 Malaysia is a transit country for drug trafficking where there are severe punishments for people found in possession of recreational drugs which creates additional challenges for the design and delivery of harm reduction initiatives. HIV and STI prevention strategies face enormous barriers in settings where anti LGBT laws exist further deepening epidemics of STIs, HIV and chemsex use. ⁸ Furthermore, it is important to understand which and how interventions can be used effectively to reduce the potential impact of chemsex behaviour. MSM who are chemsex dependant and seek help often do not have access the specialised support they need. ¹² Traditional drug counselling services usually have insufficient knowledge of the culture and sexual health problems, whereas sexual health clinics can lack expertise on substance use. ¹³

Beyond-66 is a novel, 132-day, peer led intervention programme using a 2-phase approach; habit and mindset reforming model to reach abstinence. ¹⁴ Beyond-66 was wholly designed and produced by peers who have lived experience of chemsex, chemsex dependency and recovery including abstinence and have received formal training in substance misuse harm reduction. Beyond-66 have developed local advertising tools using social media (e.g., Instagram) chat applications (e.g., Telegram), Mandarin online host talks, engaging key opinion leaders or influences in the MSM community via social media channels and word of mouth in the local MSM community to recruit participants. We have also conducted a series of lectures, webinars and training called CHILL, BRO for Malaysian non-government organisations, community health workers, and healthcare providers. Furthermore, we have promoted Beyond-66 in local MSM community events. MSM who have completed Beyond-66 and have remained abstinent are invited to promote the programme via their social networks. The peers (sobriety coaches) were recruited competitively and have undergone intensive training in the Beyond-66 programme including governance and safety for participants. Initial assessment involves assessing the stage of chemsex use including readiness to act on their addiction, a self-assessment of their current mental health using an infographic and a measurement of the severity of substance use. Following the initial assessment, the MSM are assigned and meet with their peer sobriety coaches weekly (physically or virtually) in two phases of the programme: the first 66 days being the foundation phase and the second 66 days to set new habit and mindset where the principles include mindfulness and choice-making leading to awareness. The meetings also facilitate MSM to consider root causes of their chemsex behaviours and self-reflection. During the first 66-day phase, each weekly meeting is themes to address: disconnect, gratitude habit forming, mental conditioning motivation and mindfulness and corresponding structured ‘homework’ is set. Phase-2 meetings focus on the use of mindfulness and reinforce the work and objectives set in the foundation phase. The MSM are prompted to observe their triggers, be wary of their responsive actions, and continue in their practice from the initial 66-day phase. As part of a service evaluation, the aim of this study was to review the outcomes of the first 2 and a half years of MSM entering the Beyond-66 programme. Beyond-66 is advertised via LGBT websites in Malaysia and MSM are invited to self-refer where they are offered an appointment for assessment for the Beyond-66 programme. Initially, Beyond-66 was a payment free service. Subsequently, MSM are means-tested for affordability and those who are able, are asked to pay 1500 Malaysia Ringgit (equivalent to approximately 320USD).

Method

We reviewed the demographics of the MSM who had been referred to Beyond-66 and collected data on entry into the programme, completion and remaining abstinent at their final review between January 2021 through to August 2023. Using a bespoke peer designed 10-point Likert scale, participants are routinely asked to provide a score of how motivated they felt to enter the programme and then at the end were asked to repeat the score focussing on their motivation to remain abstinent. Participants are also asked to score their mental wellbeing using a bespoke, peer designed 10-point Likert scale at the beginning and the end of the programme. We used Kruskal Wallis test to compare pre- and post- programme Likert scores.

Results

To date 37 MSM were self-referred into the Beyond-66 programme for an initial assessment. 12 are either waiting for initial assessment or are mid programme, and 25 have either completed or dropped out/been referred out of Beyond-66. Twelve out of the 25 (48%) were PLWH and the median duration of chemsex use was 5 years (interquartile range (IQR) = 4–6). In total, nineteen (76%) have completed the 132-day Beyond-66 programme; 3 were referred out for a psychiatry assessment and 3 dropped out of the programme. (Figure 1) Fourteen out of 19 (74%) remain abstinent and 5 have subsequently relapsed. The median motivation score from the 19 completers (Likert score out of 10 where 10 is most motivated to become or remain abstinent) increased significantly between the pre-programme and post-programme period (7/10 (IQR = 4–8) to 9/10 (IQR = 5–10), p = .04) and the median mental health score (Likert score out of 10 where 10 is poor mental health) reduced significantly between the pre-programme and post-programme periods (5/10 (IQR = 4–7) to 2/10 (IQR 1–6), p = .008). Of the 5 who relapsed, 3 have entered back into programme and 3 have remained in contact and are pre-contemplative to restart the programme. Only one participant has been requested to pay for treatment to date following means testing.OPEN IN VIEWER

Discussion

Our pilot evaluation of the Beyond-66 programme for MSM who are chemsex dependant in Kuala Lumpur, Malaysia suggests that the success rate for completing the programme is 76% and the abstinence rate of MSM who have completed the programme is 74%. MSM in this programme experience improved motivation to remain abstinent and improved mental wellbeing throughout the programme.

There are little data evaluating the success of chemsex intervention programmes globally and we believe this is the first evaluation of an intervention in Southeast Asia. Our data suggests that peer led, peer designed interventions can have a relatively high success rate. It is interesting that the Beyond-66 programme promotes abstinence; many chemsex services in high income settings do not aspire for abstinence and aim to provide users with increased control of their chemsex use. ¹⁰ Like other studies of participants in successful drug harm reduction initiatives, mental wellbeing of those participants who remained in the programme increased significantly. ¹⁵ It is important that we attempt to understand the characteristics of people who are likely to successfully complete a chemsex harm reduction programme and those who are likely to relapse.^16,17 More work is needed globally to assess the optimum strategy to support people who are chemsex dependant to provide effective harm reduction programmes. Peer led co-designed and co-produced programmes where (some of) the facilitators and coaches have lived experience of living with chemsex dependence is most likely to be effective.^18,19

There are several limitations to this study including being from a single centre with a small number of participants and no control group to formally assess the effect of the programme. Furthermore, as this is not a controlled trial and there are likely to be confounding factors which could have affected abstinence and mental wellbeing outside of the Beyond-66 programme which were not identified in this pilot study. The participants are self-selecting and responded to internet advertising and were likely to be already seeking abstinence and recovery. The tools used to measure motivation to become or remain abstinent, and wellbeing are not currently validated. The participants in this evaluation were likely to be highly heterogenous in their chemsex experiences and behaviours making direct comparisons overall challenging. Malaysia remains a deeply stigmatised society for minority groups and many individuals will experience significant barriers to accessing services such as Beyond-66 meaning that the participants in this study will not be a true representation of all MSM who are chemsex dependant. This is a pilot evaluation and we do not currently have long term data on abstinence post the 132-day programme including whether MSM relapsed after the end of the programme.

Beyond-66 is a novel peer led chemsex intervention programme which our pilot evaluation suggests is currently experiencing high completion rates, high reported abstinence success rates and increases mental wellbeing. Further research is needed to design, develop, and deliver peer led interventions for MSM who are chemsex dependant particularly in Asian settings including Malaysia. Going forward, the scale up of the Beyond-8 programme with a more robust investigation of outcomes including efficacy, acceptability and cost effectiveness is now needed.