The complex association between chemsex — a form of sexualized drug use that includes elements of planning and a clear intent to use specific drugs to enhance the sexual experience — and HIV among gay, bisexual, and other men who have sex with men (GBMSM) requires deeper understanding and integrated interventions that treat chemsex practitioners as the heterogenous group that they are, according to a review published online on August 1 in Lancet HIV.

People engaging in chemsex may not present at conventional drug services. Instead, they go to infectious disease or HIV specialists for testing and treatment of sexually transmitted infections (STIs),” said co-author Stephane Wen-Wei Ku, MD, director, Division of Infectious Diseases, Taipei City Hospital Renai Branch, Taiwan, in an interview with Medscape Medical News. “It’s a great opportunity for these healthcare providers to incorporate screening and even brief interventions, if possible, for substance use at their clinics as an integrated sexual health promotion.”

“We know that sexualized drug use has been a cultural phenomenon that exists across different societies,” said study co-author Poyao Huang, MPH, assistant professor at the Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, Taiwan, in an interview with Medscape.

However, says Huang, the close association of chemsex with GBMSM and methamphetamine, gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), and mephedrone highlights the fact that “the rise of this specific sexual practice and/or culture is in part related to social apps where mobile communication technology plays a significant role. This technological change further reflects that GBMSM’s social spaces — bars, parks, saunas, and the like — are shifting to a more mobile, fluid, private direction.”

Jeffrey Wickersham, PhD, added, “Among MSM in general, there’s a sense of social connection that comes with drug use, particularly methamphetamine. The methamphetamine acts as a social lubricant. It allows for the abandoning of inhibitions in a community that often is highly stigmatized or experiences a lot of discrimination.” An assistant professor of medicine specializing in infectious diseases at Yale University School of Medicine in New Haven, Connecticut, Wickersham was not involved with the study.

Over the past decade, authors write, entities such as London’s 56 Dean Street, Australia’s Thorne Harbour Health, and Amsterdam’s Mainline Foundation have proven that sexual health clinics can provide integrated mental health, substance use, and HIV and STI prevention in an environment where GBMSM can discuss drug use comfortably, without fear of being judged.

“The authors are correct that clinicians need to engage GBMSM patients in more and better communication about their sexual health and drug use practices,” said Wickersham in an interview with Medscape. “However, such dialogues are often not prioritized by clinicians, especially in environments where clinical encounters are limited.”

In many countries, said senior author Carol Strong, PhD, associate professor, Department of Public Health, National Cheng Kung University in Taiwan, chemsex is a legally sensitive topic. “Without decriminalization of substances,” she told Medscape, “harm-reduction efforts are very often short of sustainable financial resources. Stigma also affects attitudes and willingness from healthcare providers and creates barriers for individuals engaging in chemsex to access the services even if they are available.”

Wickersham added, “GBMSM who live in less progressive places, particularly where being gay or bisexual is highly stigmatized or even criminalized, may find that their physicians are reluctant to discuss sexual health or drug-related harm reduction.” Such situations underscore the need for innovative strategies to engage GBMSM who participate in chemsex. “These approaches can include key population-led outreach programs, online models of healthcare and harm reduction service delivery, and decentralized nurse-led models of care.”

Only when patients trust their healthcare professionals regarding their sexuality and substance use can important conversations about harm reduction and HIV prevention occur, said Wickersham. “Physicians and other healthcare professionals need training in how to talk with their sexual and gender minority patients about their sexual health and substance use — especially clinicians who are not working in facilities that specialize in lesbian, gay, bisexual, trans, and queer (LGBTQ) patient care, which is most clinics around the world.”

Similar strategies apply to the burgeoning monkeypox outbreak. As with any infectious disease, said Wickersham, education about how to reduce the risk of acquiring or transmitting monkeypox is essential. “GBMSM who engage in chemsex may be less likely to have conversations with their sexual partners about harm reduction, including when it comes to monkeypox. Encouraging GBMSM to talk with their sex partners about monkeypox is crucial to preventing onward transmission,” he says.

GBMSM who acquire monkeypox need avenues that allow for safe, stigma-free notification of recent sex partners, Wickersham adds. “We also need to include the communities most affected by monkeypox — including GBMSM who engage in chemsex — in the public-health response. One of the best ways to ensure we engage those most affected is to ensure they have a voice in the design and deployment of the public health response.”

Ku has been a speaker and advisory board member for ViiV Healthcare, Gilead, MSD, and Janssen. Strong, Huang, and Wickersham report no relevant financial interests. The study was funded by the Taiwan Ministry of Science and Technology.

Lancet HIV. Published online August 1, 2022. Summary

John Jesitus is a Denver-based freelance medical writer and editor.

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