Barriers to effective treatment adherence for HIV and Pre-exposure prophylaxis use among men who have sex with men who have experienced problematic Chemsex.

Barriers to effective treatment adherence for HIV and Pre-exposure prophylaxis use among men who have sex with men who have experienced problematic Chemsex.

Monday 10th May 2021
Mike Power

Barriers to effective treatment adherence for HIV and Pre-exposure prophylaxis use among men who have sex with men who have experienced problematic Chemsex

What is Chemsex?

"Chemsex" is used in the United Kingdom to describe intentional sex under the influence of psychoactive drugs, mostly among men who have sex with men. It refers particularly to the use of mephedrone, gamma-hydroxybutyrate (GHB), -butyrolactone (GBL), and crystallised methamphetamine. These drugs are often used in combination to facilitate sexual sessions lasting several hours or days with multiple sexual partners.( BMJ,2015)

Mephedrone and crystal meth are physiological stimulants, increasing heart rate and blood pressure, as well as triggering euphoria and sexual arousal. GHB (and its precursor GBL) is a powerful psychological disinhibitor and also a mild anaesthetic. Anecdotal reports and some small qualitative studies in the UK find that people engaging in chemsex report better sex, with these drugs reducing inhibitions and increasing pleasure. They facilitate sustained arousal and induce a feeling of instant rapport with sexual partners. Some users report using them to manage negative feelings, such as a lack of confidence and self-esteem, internalised homophobia, and stigma about their HIV status. (BMJ, 2015)

Chemsex addiction is a fused dual dependency of sex and drugs. This has become a public health priority in most major city's through out the world. It requires specialized care from drug and alcohol services and sexual health services that work in partnership to reduce the harms associated to a person that is engaging in problematic Chemsex behaviours.

There is an acute risk of chemsex-dependent individuals contracting HIV due to the chaotic nature of the chemsex life style. In this article, I will be exploring how chemsex dependency may affect HIV prevention for those who take Prep along with how it may interfere with the HIV treatment adherence regimes for a person that has an HIV positive diagnosis.

Treatment has prevention

HIV treatment and prevention has come a long way in recent years. With the right medications, a person whose viral load is undetectable cannot pass on the virus to another person. In 2019, the findings of the landmark partner study proved that when a person living with HIV is on effective medication with an undetectable viral load, they cannot pass on HIV to their sexual partner.

The scientific evidence

The final results of the PARTNER 1 and PARTNER 2 studies were announced in 2016 and 2018, respectively. Between the two studies, they recruited 972 gay couples and 516 heterosexual couples in which one partner had HIV and the other did not. Over the course of the studies, the gay couples had 77,000 acts of unprotected penetrative sex and the heterosexual couples, 36,000 acts. The PARTNER studies did not find a single HIV transmission from an HIV-positive partner who had an undetectable viral load.
In 2017, a similar study exclusively of 343 gay male couples, Opposites Attract, also found no transmissions from partners with an undetectable viral load in 17,000 acts of condomless anal sex.

Between the three studies, no transmission of HIV from a sexual partner with an undetectable viral load was seen in nearly 130,000 acts of condomless penetrative sex. This means the risk of transmission by a partner with an undetectable viral load is statistically equivalent to zero. {{,2020}}

Add Prep into the equation and theoretically, no one should be getting diagnosed with HIV. "Before I go on to explain the complications involved, I know that for many they do not understand what Prep is.

" I believe any clinician that is working with men who have sex with men should have this basic knowledge in order to incorporate harm-reduction strategies for Gay or bisexual men that are engaging in condomless chemsex practices"

What is Prep?
Prep stands for pre-exposure-prophylaxis. Prep is a drug taken by HIV-negative people before and after sex which reduces the risk of getting HIV. Taking Prep before being exposed to HIV means there's enough medication inside you to block HIV if it gets into your body.

The medication used for Prep is a tablet which contains tenofovir and emtricitabine (drugs commonly used to treat HIV). It is sometimes called Truvada but most of the Prep we use in the UK is generic Prep. {{}}

"It is wonderful that we have come so far in HIV treatment and prevention in the last decade. However, this can be complicated when it comes to those that engage In or are dependent on Chemsex".

Case Study
Sam had been working with his substance misuse counsellor to abstain from taking methamphetamine. Sam, however, stated that he would still like to enjoy a few glasses of wine on a Friday night. He is HIV negative and on Prep.

He set himself a limit of one bottle of wine coupled with a nice meal when he's out with a friend.

Sam had taken his Prep on that day as per usual, He meets his friend for dinner and drinks with every intention of being home by 10.00 pm. However, he is having such a good time that they order a second bottle of wine, and he extends his restraint to 10.30 pm. On his way home, he decides to go on Grindr when he instantly gets a message from a person who he had partied with on methamphetamine.

Sam is a little bit drunk now and thinks, "What the hell, it's Friday," and goes to meet this person. In his mind, he thinks he will only do it for a few hours. In reality, Sam has never been able to do just a few hours; it always turns into several days. This time was no different. He got high and went to various chemsex parties while having had sex with around15 people over a course of 5 days with all of them being condomless sex.

The main risk with this is that Sam had not taken his Prep for five days, so he was no longer protected. Sam knew this but was on such an awful comedown from his drug binge that he didn't feel that he could make it to the sexual health clinic for another week. So he decided not to go and continued taking Prep. However, given the time lapse, Sam contracted HIV and syphilis.

If we were to reverse this situation to involve a person that was HIV positive who had also not taken their medications for several days, there is also a high chance of their viral load rising, which would then make them infectious to others.

What the evidence says

Two years ago, researchers in London published a worrying study which found that HIV-positive men who have sex with men (MSM) engaging in Chemsex are less likely to adhere to their antiretroviral (ART) treatment.

Although there is evidence that Chemsex has a negative impact on (ART) adherence, it doesn't seem to have the same association with Prep adherence," said study coauthor Charlotte O'Halloran, senior scientist in HIV/STI surveillance and prevention with Public Health England.

The U.K.-based PROUD study was an open-label, randomized trial that was designed to look at the effectiveness of emtricitabine/tenofovir disoproxil fumarate (Truvada) as Prep among 544 at-risk MSM. The study's primary goal was to evaluate Prep as a risk-reduction tool, and it concluded that Prep was associated with an 86% reduction in HIV risk.

The study also reported that 44% of HIV-negative men who have sex with men had engaged in chemsex at baseline, hinting at a widespread phenomenon that could be exacerbating HIV risk.

The evidence for prep adherence is positive for those men who have sex with men in a Chemsex context, however, I cannot overemphasize the importance of incorporating HIV prevention as well as HIV treatment in to harm reduction and relapse prevention interventions whist working with gay or bisexual male clients regardless of whether this in a community or residential treatment setting.

In the case of Sam, in his naivety, he really did believe he was just going out for dinner. So always suggesting to any client that might be vulnerable to relapse that they should always keep several days' worth of medication with them has an harm reduction strategy, This would also apply to any person that as a diagnosis of being HIV positive.

Harmful effects related to chemsex

Chemsex presents potentially harmful effects that are different from those linked to other recreational drugs and how they are used. Methamphetamine, GHB/GBL, and mephedrone can all lead to unwanted effects including agitation, anxiety, paranoia, aggression, and psychoses. Intense comedowns can cause users to feel suicidal. All drugs can lead to dependency for the user, which can happen quite rapidly after a relatively short, intense period of use. There are reports of overdose with unconsciousness and death. Serious drug interactions with a range of drugs including alcohol and HIV antiretroviral medications can occur (bourne,2015).

The drugs have been associated with increased sexual risk behaviours, such as unprotected sex, which may lead to an increase in sexually transmitted infections (STIs), including HIV. The drugs may also increase disinhibition and hypersexuality, leading to unwanted sexual experiences that users later regret. Some drugs can induce coma and there are reports of use associated with sexual assault. The anaesthetic nature of some drugs facilitates longer sexual encounters, sex with multiple partners, and can lead to increased rectal, penile trauma, all of which may facilitate STI/HIV transmission. Some drugs can be administered intravenously, which increases the risk of transmission of blood-borne viruses including HIV and hepatitis B and C. There are concerns about emerging patterns of injecting drug use, particularly among MSM, and there is evidence to suggest poorer adherence to antiretroviral medications and drug interactions among HIV-positive chemsex users (Bourne,2015).

What can we do to reduce the harm to chemsex clients? In community drugs and alcohol harm reduction services

Do not judge someone for exploring their sexuality through Chemsex but make it very clear that taking these drugs is never completely safe. Support the client in never letting anyone pressure them into taking anything that they don't want to.

If they do plan on participating in Chemsex, give them the following tips to reduce the risks both for your client and the people that they party with.

Suggest that your client pack some protection — "Make sure you have lots of condoms and lubes at hand. You could also consider pre-exposure prophylaxis (Prep) to protect you from HIV."

Support them in knowing their status — "Most HIV transmissions happen among people who have recently caught HIV and don't yet know that they are positive. Regular testing to check your status and to screen for other STIs will help to keep you and others healthy."

*Suggest partying with people they trus*t — "Plan in advance how you will look out for each other and be sure to tell someone where you are going if you leave with someone you don't know."

Support limit setting — "Before you get high, decide what you are prepared to do sexually and talk about which methods of protection you want to use."

Help your client to stay aware — "Keep tabs on what drugs you've consumed and be aware when to stop. Don't share needles or syringes and never let someone else inject you."

Support your client in setting reminders — "If you are taking Prep to prevent HIV or need to take anti-HIV medication because you are living with HIV, use an alarm to make sure you take your pills at the right time."

Abstinence based Residential treatment settings

Risk-assess anyone that enters treatment for their sexual health, being mindful that anyone with untreated HIV is infectious further more their immune system could be compromised.· Discuss Prep with HIV-negative clients, while incorporating anti-retroviral treatment adherence with HIV-positive clients as part of their treatment plan.

Deliver harm reduction strategies for sexual health for all clients regardless of whether it is a harm reduction service or not. Do not assume that because a person is motivated towards abstinence that there will not be a lapse or relapse, unfortunately this is often part of a persons recovery journey.

Create Psycho- educational groups on sexually transmitted infections while exploring what positive sexual health means to each individual now they are on the road to recovery. This needs to be delivered in a confident non judgemental or shaming manner, that is respecting a person autonomy.

Final summary
HIV treatment and prevention has come along way in recent years, however for some who are Chemsex dependent, adherence to prep and anti retro viral therapy can be complicated. This greatly enhances the risk of HIV Transmission.

It is crucial that substance misuse counsellors working in the community or in residential treatment provide harm reduction interventions to reduce the risk of harm to persons sexual health.

As a professional addiction counsellor one of my mains goal is to reduce the harms associated with Chemsex dependence while also supporting a person in maintaining positive sexual health.

Clients that are seeking abstinence from Chemsex, my goal is to equip them with the necessary tools and recourses to achieve a life off sobriety while at same time supporting each individual in cultivating a sober a sex life of their choosing, that is free from judgement ,stigma or shame.

When intensive residential treatment is needed, I refer to my partner rehab Twin Rivers with in South Africa where specialised Chemsex addiction treatment will be provided.