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Starting Out | General Recommendations

Recommendation 1: Test for and Treat Sexually Transmitted Infections

Given the association between Chemsex and condomless sex it is important to frequently test for, and treat, Sexually Transmitted Infections (STIs). People who participate in Chemsex should be tested at least every 3 months, and positive results should be promptly treated according to CDC guidelines.

It is recommended that sexually active Men who have Sex with Men (MSM) be tested for Hepatitis C Virus annually.1 In people who participate in Chemsex, especially those who inject drugs (slam) or participate in fisting, more frequent screening for Hepatitis C may be warranted. Trans-feminine people who participate in Chemsex should also be tested for Hepatitis C Virus at least annually. Treatment of Hepatitis C is recommended for all people who are chronically infected, even those who continue to have risk factors such as injection drug use and/or fisting.2 Treatment of Hepatitis C Virus infection benefits both the person and community, as treatment is prevention.

Recommendation 2: Consider Potential of Doxycycline Prophylaxis for Bacterial STIs

For people who participate in circuit parties, large sex/cruising events, or sex parties, doxycycline prophylaxis for bacterial STIs (eg. chlamydia, syphilis, gonorrhea) may be a useful intervention. Doxycycline’s use as prophylaxis has shown promise in several studies and is still being investigated.3,4 While some studies have measured lower incidence of all STIs, it is likely that doxycycline is most effective at preventing Chlamydia and Syphilis.

Recommendation 3: Prescribing Pre-Exposure Prophylaxis for HIV is Essential

All people who participate in Chemsex who are HIV negative should be on Pre-Exposure Prophylaxis (PrEP). Research demonstrates that people who participate in Chemsex are good at taking it, likely because they are aware of their increased risk for HIV.5

In addition to preventing acquisition of HIV, PrEP increases the frequency of preventive sexual health visits as 3 months is the standard follow-up interval. This facilitates earlier diagnosis and treatment of STIs, decreasing community spread as treatment is prevention. It also increases the number of opportunities for providers to identify safety needs, offer information, and distribute materials such as substance safety kits, overdose prevention kits, safer sex kits, and safer injection kits.

Multiple studies have demonstrated that “Risk Compensation,” or an increase in condomless sex and thereby STIs in relation to PrEP use, does not occur.6,7 Research has consistently demonstrated that PrEP is a highly effective public health intervention.6,8 Earlier detection and more frequent testing are responsible for apparent differences in STI prevalence. Furthermore, it is vital to recognize the inherent heterosexism in the concept of “Risk Compensation,” as well as the structural heterosexism that has diverted vital research funds for HIV prevention and treatment towards this topic. Research suggests that health care providers value procreative sex over other kinds of intimacy and intercouse.9,10 There is also a dearth of research addressing “Risk Compensation” in relation to contraceptives, demonstrating a bias favoring procreative sex. Stigma further fuels an association between queer sex or anal sex practices with “promscuity” “carelessness” “perversion” and “deviancy.” This stigma has a quantifiable impact on health as research demonstrates that providers are less likely to prescribe PrEP due to a false beliefs in “Risk Compensation.”11

Recommendation 4: Consider Potential of PrEP 2-1-1 (PrEP On Demand)

Research has demonstrated that “On Demand” or 2-1-1 dosing of TDF/FTC (Truvada) is effective at preventing HIV.12 In this dosing method 2 pills are taken 2 hours before sex (-2 hours), then 1 pill the next day (+24 hours), then 1 pill the next day (+48 hours). At the end of the course TDF/FTC can either be discontinued or, if desired, continued on a once daily dosing schedule.

PrEP 2-1-1 can be an ideal option for people who do not want to take a pill everyday, have infrequent sex, have planned sex, practice occasional non-monogamy, or occasional group sex. PrEP 2-1-1 can also be offered at circuit parties and other sex events alongside rapid HIV testing and safer sex kits that include condoms and lubricants.

Recommendation 5: Minimize Gaps in Care

For people who participate in Chemsex minimizing gaps in care is essential for the health of the individual and the community. This means minimizing gaps for both people living with HIV and those who are not.

For people living with HIV (PLWH) it is important to recognize the provider’s role in each step of the care cascade: prompt diagnosis, notification and linkage to care, receipt of antiretrovirals, and achieving and maintaining viral suppression. It is estimated that 14% or 1 in 7 PLWH do not know it and require testing.13 Additionally, many opportunities for PLWH to be tested, and linked to care are missed in primary care and sexual health care settings.14 Addressing gaps in HIV care occurs at the individual, institutional, and systems levels. As health care providers, knowledge of institutional and systems level barriers and how to navigate them will help best serve PLWH who participate in Chemsex.

Barriers to accessing care exist for people who participate in Chemsex who are HIV negative as well. Common barriers in the US are related to accessing affordable insurance, accessing affordable care, and accessing affirming providers who are competent in the care of sexual and gender diverse people. It is important to be aware of where people can access affordable and affirming sexual health, PrEP, substance-use, and HIV care in your area regardless of ability to pay, insurance coverage, and immigration status. Each state and region is different, meaning it is up to providers to gather this information.

Recommendation 6: Promote Undetectable = Untrasmitable

All people living with HIV (PLWH) who participate in Chemsex should be informed of Undetectable = Untransmitable or U=U. The PARTNER study demonstrated that there is effectively no risk of transmitting HIV through any kind of sexual intercourse if the sexual partner living with HIV is virally suppressed with a HIV Viral Load < 200 copies/mL.15 Informing PLWH of U=U helps to encourage them to remain undetectable. Providers have a duty to tell PLWH about U=U according to the principles of beneficence and justice, as it can relieve PLWH from the shame and stigma that accompanies the fear of transmitting HIV to others. PLWH deserve to have the same experiences of sexual intimacy as people who are HIV negative.

Recommendation 7: Advise to Avoid Combining Substances When Possible

People who participate in Chemsex should be advised to avoid combining substances, especially those with synergistic effects. Polysubstance use is increasingly implicated in accidental overdose deaths.16 Many people will titrate their highs by using stimulants or “uppers” simultaneously with depressants or “downers.” It is best to advise people combining stimulants and depressants to pick one substance from each class rather than combining multiple stimulants with multiple depressants. This reduces the risk of unwanted side effects or accidental overdose. In the event of an overdose, using fewer substances also simplifies treatment.

It is important for providers to be mindful also of combining antiretrovirals with Chemsex substances. For providers caring for people living with HIV who participate in Chemsex, it is best to choose regimens that avoid these interactions, specifically regimens without protease inhibitors, cobicistat, or certain non nucleoside reverse transcriptase inhibitors (NNRTIs).17,18 Some HIV drug interaction checkers, such as the Liverpool HIV interactions, allow providers to check for interactions between HIV antiretrovirals and Chemsex substances.

Recommendation 8: Stress the Importance of Hydration, Nutrition, and Sleep Hygiene

Regardless of what substances are being used and in what context, hydration, good nutrition, and sleep hygiene go a long way to prevent unwanted consequences. All people who participate in Chemsex should be encouraged to drink plenty of water to help prevent dehydration, substance toxicities, and kidney damage. Additionally, it is important to encourage proper caloric intake as hypoglycemia and unsafe weight loss can occur, especially with stimulant use. For people unable to tolerate solid food while high, or with concerns about preparedness to bottom (ie. receptive anal intercourse), liquid supplements like Ensure Plus or Boost Plus can be helpful. Other elements of a clear liquid diet such as meat or vegetable broths are also advisable.

Sleep hygiene is important as poor sleep and lack of sleep in of itself have been proven to cause psychosis in healthy people.19 Some have suggested that the psychosis associated with prolonged use of stimulants like amphetamines may in part or entirely be due to sleep deprivation.20 7-9 hours of sleep is recommended for adults in every 24-hour period.21 All people who participate in Chemsex should be advised on the importance of sleep, with the goal of achieving 7-9 hours of sleep per 24-hour period. Additionally, they should be advised to avoid staying up longer than 48 hours, and that the risk for unwanted side effects increases with time awake.

Recommendation 9: Encourage Candor and Accountability

The DSM V outlines 11 criteria in order to differentiate substance use from a substance use disorder, which can be further categorized as mild, moderate, or severe depending on the number of symptoms.22 Hallmarks of substance use disorders are loss of control, drug tolerance, withdrawal, cravings, and social consequences. It is not possible to predict who will progress to meet criteria for a substance use disorder. Health care providers can help prevent, slow, or reverse this progression by creating an open and non-judgemental environment where people who participate in Chemsex can speak freely and discuss their care needs. Fear of discrimination and stereotyping in healthcare settings is a key access barrier for people who participate in Chemsex.23 However, safety counseling in an environment free from discrimination was attractive to people who participate in Chemsex in a qualitative study, and harm reduction based community interventions have proven effective.24,25 Additionally, health care providers should encourage people who participate in Chemsex to have open and honest relationships with their friends, as social support networks can be protective.26

Recommendation 10: Educate Yourself on Local Resources

Health care in the US is decentralized and care is often siloed. A myriad of community-based and community-led organizations exist around the country that offer invaluable services. These include social support services, community building, peer connections, care navigation, and various assistance programs. As a health care provider, familiarizing yourself with local resources, especially those that are affirming of sexual and gender diverse people and embrace harm reduction frameworks, can help you to provide the highest quality and most comprehensive care to people who participate in Chemsex. Community resources are especially important for covering gaps in the psychosocial aspects of care which are difficult to address within the confines of an outpatient office visit or hospital stay. Additionally, know the location and quality of local syringe exchange programs, and distributors of harm reduction materials such as overdose prevention, safer sex, and safer substance use kits in order to be able to provide confident referrals.

Recommendation 11: Understand Local and State Good Samaritan Laws, and Advocate for Progressive Drug Policy

Large variations in policies surrounding substance use exist in both the private and public sectors. Health care providers can help to guide businesses, institutions, local governments, and federal law towards a more just future rooted in evidence-based policy. Safety optimization or harm reduction is an evidence-based practice. Good samaritan laws and policies save lives, and are essential for events and businesses like circuit parties, gay party cruises, music festivals, gay saunas, and sex clubs. As a health care provider, your voice matters and actions as simple as writing a letter to a business or contacting local officials can help save countless lives.

Citations:

  1. AASLD-IDSA. Summary: HCV in Key Populations: Men Who Have Sex With Men | HCV Guidance. Accessed March 2, 2021. https://www.hcvguidelines.org/node/2502/summary
  2. AASLD-IDSA. Key Populations: Identification and Management of HCV in People Who Inject Drugs| HCV Guidance. Accessed March 3, 2021. https://www.hcvguidelines.org/unique-populations/pwid
  3. Bolan RK, Beymer MR, Weiss RE, Flynn RP, Leibowitz AA, Klausner JD. Doxycycline prophylaxis to reduce incident syphilis among HIV-infected men who have sex with men who continue to engage in high-risk sex: a randomized, controlled pilot study. Sex Transm Dis. 2015;42(2):98-103. doi:10.1097/olq.0000000000000216
  4. Grant JS, Stafylis C, Celum C, et al. Doxycycline Prophylaxis for Bacterial Sexually Transmitted Infections. Clin Infect Dis. 2020;70(6):1247-1253. doi:10.1093/cid/ciz866
  5. Hammoud MA, Vaccher S, Jin F, et al. The new MTV generation: Using methamphetamine, TruvadaTM and ViagraTM to enhance sex and stay safe. International Journal of Drug Policy. 2018;55:197-204. doi:10.1016/j.drugpo.2018.02.021
  6. Fonner VA, Dalglish SL, Kennedy CE, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016;30(12):1973-1983. doi:10.1097/QAD.0000000000001145
  7. Koechlin FM, Fonner VA, Dalglish SL, et al. Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature. AIDS Behav. 2017;21(5):1325-1335. doi:10.1007/s10461-016-1627-z
  8. Nwokolo N, Hill A, McOwan A, Pozniak A. Rapidly declining HIV infection in MSM in central London. Lancet HIV. 2017;4(11):e482-e483. doi:10.1016/S2352-3018(17)30181-9
  9. Calabrese SK, Earnshaw VA, Underhill K, et al. Prevention paradox: Medical students are less inclined to prescribe HIV pre-exposure prophylaxis for patients in highest need. J Int AIDS Soc. 2018;21(6):e25147. doi:10.1002/jia2.25147
  10. Marcus JL, Katz KA, Krakower DS, Calabrese SK. Risk Compensation and Clinical Decision Making - The Case of HIV Preexposure Prophylaxis. N Engl J Med. 2019;380(6):510-512. doi:10.1056/NEJMp1810743
  11. Blackstock OJ, Moore BA, Berkenblit GV, et al. A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians. Journal of General Internal Medicine. 2017;32(1):62-70. doi:10.1007/s11606-016-3903-z
  12. Molina J-M, Capitant C, Spire B, et al. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection. New England Journal of Medicine. 2015;373(23):2237-2246. doi:10.1056/NEJMoa1506273
  13. June 30 CSH govDate last updated:, 2020. U.S. Statistics. HIV.gov. Published June 30, 2020. Accessed March 16, 2021. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics
  14. Pathela P, Jamison K, Braunstein SL, Schillinger JA, Tymejczyk O, Nash D. Gaps along the HIV care continuum: findings among a population seeking sexual health care services in New York City. J Acquir Immune Defic Syndr. 2018;78(3):314-321. doi:10.1097/QAI.0000000000001674
  15. Rodger AJ, Cambiano V, Bruun T, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. 2019;393(10189):2428-2438. doi:10.1016/S0140-6736(19)30418-0
  16. Other Drugs | Drug Overdose | CDC Injury Center. Published January 26, 2021. Accessed March 16, 2021. https://www.cdc.gov/drugoverdose/data/otherdrugs.html
  17. Bracchi M, Stuart D, Castles R, Khoo S, Back D, Boffito M. Increasing use of ‘party drugs’ in people living with HIV on antiretrovirals: a concern for patient safety. AIDS. 2015;29(13):1585-1592. doi:10.1097/QAD.0000000000000786
  18. Baecke C, Gyssens IC, Decoutere L, van der Hilst JCH, Messiaen P. Prevalence of drug-drug interactions in the era of HIV integrase inhibitors: a retrospective clinical study. Neth J Med. 2017;75(6):235-240.
  19. Waters F, Chiu V, Atkinson A, Blom JD. Severe Sleep Deprivation Causes Hallucinations and a Gradual Progression Toward Psychosis With Increasing Time Awake. Front Psychiatry. 2018;9. doi:10.3389/fpsyt.2018.00303
  20. Bramness JG, Gundersen ØH, Guterstam J, et al. Amphetamine-induced psychosis - a separate diagnostic entity or primary psychosis triggered in the vulnerable? BMC Psychiatry. 2012;12:221. doi:10.1186/1471-244X-12-221
  21. Watson NF, Badr MS, Belenky G, et al. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. Sleep. 2015;38(8):1161-1183. doi:10.5665/sleep.4886
  22. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.; 2013.
  23. Hibbert MP, Germain JS, Brett CE, Van Hout MC, Hope VD, Porcellato LA. Service provision and barriers to care for men who have sex with men engaging in chemsex and sexualised drug use in England. International Journal of Drug Policy. 2021;92. doi:10.1016/j.drugpo.2020.103090
  24. Stardust Z, Kolstee J, Joksic S, Gray J, Hannan S. A community-led, harm-reduction approach to chemsex: Case study from Australia’s largest gay city. Sexual Health. 2018;15(2):179-181. doi:10.1071/SH17145
  25. Bourne A, Reid D, Hickson F, Torres-Rueda S, Steinberg P, Weatherburn P. “Chemsex” and harm reduction need among gay men in South London. International Journal of Drug Policy. 2015;26(12):1171-1176. doi:10.1016/j.drugpo.2015.07.013
  26. Rapier R, McKernan S, Stauffer CS. An inverse relationship between perceived social support and substance use frequency in socially stigmatized populations. Addictive Behaviors Reports. 2019;10:100188. doi:10.1016/j.abrep.2019.100188