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Up to 4.7% of adult men have experienced attempted non-consensual sexual contact in Britain.1 Male sexual assault is frequently under-reported and the consequences include physical harm, anxiety, depression, substance misuse, suicidal ideation and suicide. Drug-facilitated sexual assault involves many types of pharmacological agents including alcohol and amphetamines. Consensual use of recreational drugs during sex (chemsex) with multiple partners has been described with a particular focus on STI acquisition. Men who have sex with men (MSM) …

ObjectiveWe investigated syphilis prevalence among men who have sex with men (MSM) in China, as well as potential risk factors. Our principal hypothesis was that syphilis would be associated with the use of recreational drugs such as methamphetamines.MethodsFrom April to October 2013, we used several methods to recruit MSM in Qingdao, collecting demographic/behavioural information via self-administrated questionnaires. Trained health workers collected blood for the Treponema pallidum particle assay (TPPA) with positives confirmed by a toluidine red unheated serum test. We used an unmatched case–control study to identify factors that might predict syphilis infection using multivariable logistic regression.ResultsWe recruited 447 MSM who agreed to participate and who completed syphilis testing. Of 71 (15.9%) syphilis-positive MSM, 44 (62.0%) used drugs. Of 376 (84.1%) syphilis-negative MSM, 186 (49.5%) used drugs. We found a positive association with syphilis for any recreational drug use (crude OR (cOR) 1.7, 95 % CI 1.0 to 2.8), frequent methamphetamine use (cOR 2.4, 95% CI 1.1 to 5.3) and multiple drug use (adjusted OR (aOR) 3.4, 95% CI 1.3 to 9.2). Syphilis-positive men were more likely to have a higher physical depression score (aOR 5.2, 95% CI 1.1 to 24.4), be > 30 years old (aOR 2.7, 95% CI 1.5 to 4.8), report a prior STI (aOR 4.1, 95% CI 2.3 to 7.3) and report a sex party experience (aOR 2.2, 95% CI 1.1 to 4.4).ConclusionsRecreational drug use, depression and high-risk sexual behaviours were associated with syphilis infection among MSM in China. Only a multifaceted approach is likely be effective in control of both syphilis and HIV .

Recent evidence highlights an increase in ‘chemsex’, the use of recreational drugs during sex, in men who have sex with men (MSM) and an association with risky sexual behaviours and outbreaks of STIs.1 However, the extent of sexualised drug use in people attending sexual health clinics (SHCs) is unknown. STI surveillance in England is performed by Public Health England (PHE) using a disaggregated patient-level dataset of all diagnoses and services at SHCs.2 This is a minimum dataset with key demographic and clinical variables, but lacks behavioural data. To address this gap, PHE …

In this issue, Weatherburn et al and Pakianathan et al provide a combination of practical and empirical insights into ‘chemsex’. This is particularly relevant to clinicians working with gay and bisexual men who have sex with men (GBMSM). Here we outline further issues for practitioners working with GBMSM who engage in chemsex. Chemsex describes GBMSM's use of new recreational drugs (primarily mephedrone, crystal methamphetamine and γ-hydroxybutyric/γ-butyrolactone) to enable, enhance and prolong sexual interactions. Unlike alcohol and most other recreational substances, chemsex drugs provide men with the ability to improve their sexual performance and experiences, by increasing arousal, stamina and pleasure.1 Arising in tandem, the proliferation of geospatial sociosexual networking apps provide access to local sexual activities and drug procurement on demand.2 Together, these developments allow multiple and group sexual hook-ups to be arranged, outside the spatiotemporal constraints of the commercial (gay) scene, which usually last many hours or even several days. As well allowing increased partner numbers and turnover, chemsex users operate within a distinct cultural ‘bubble’, where risky sex and recreational drug use are normalised and advance negotiation of drug supply/use, intravenous drug taking, specific sexual behaviours, sexual safety, HIV serostatus, pre-exposure prophylaxis (PrEP) and condom use/non-use may all take place online. These online sociosexual networks and chemsex sexual cultures are disconnected from the commercial gay scene and, therefore, associated health promotion. In addition, difficulties in engaging men via sociosexual media—and in particular men within the chemsex culture—mean that presentations at sexual health and HIV care clinical interactions may provide the …

Public Health England's (PHE) recent report described transmission of sexually transmitted infections (STIs) among men who have sex with men (MSM) despite evidence of access and engagement with services.1 In 2014, a London Health Protection Team (HPT) was notified of 40 men linked to a single residence, all newly infected with HIV and other STIs. Investigation revealed high levels of drug use such as crystal methamphetamine—a known ‘chemsex drug’. Chemsex is sex that occurs while using recreational drugs, frequently unprotected and high risk in nature.1 As part of a service improvement, …

Do we know what’s really going on? The National Alliance of State and Territorial AIDS Directors (NASTAD) in the United States has described the increased use of crystal methamphetamine among men who have sex with men (MSM) as a “public health crisis.”1 However, outside the United States, evidence concerning recreational drug use and it implication in the rising rates of sexually transmitted infections (STI) and HIV among MSM is much more patchy.2–4 In the United Kingdom, data on changing patterns and practice of recreational drug use in the post-HAART era are incomplete, often disjointed, and generally inconsistent.5–7 If, as seems apparent from reports from other industrialised countries, there are important emerging issues concerning recreational drug use and MSM, then there is an urgent need in the United Kingdom to address the deficit in our knowledge. We set out a case for redressing the gap in our evidence base and propose simple strategies for developing better surveillance of this key behavioural aspect of STI/HIV transmission risk. In North America and Australia the contribution of crystal methamphetamine and other recreational substance use to high risk behaviour is becoming an increasing focus of public health research.8,9,10,11 Crystal methamphetamine (CMA) is a potent stimulant drug, chemically related to amphetamine. It is similar to cocaine in its euphoric effects; but CMA is more potent, much cheaper, and longer lasting (the half life of cocaine is 50 minutes while that of CMA is up to 12 hours).12 Recent community studies have revealed important associations between the growing popularity of CMA and other recreational drugs and an apparent sexual culture shift towards more high risk behaviour.4,13,14 Although prevalence of use in individual studies varies, there is substantial evidence of widespread recent (3–6 months) non-injecting …

Background/introduction Reports of sexualised drug taking (chemsex) have increased significantly in recent years. To establish the risks associated with chemsex and the services required by participants in Greater Manchester, a health needs assessment was undertaken. Aim(s)/objectives To identify links between chemsex and adverse health outcomes, and to determine the perceived barriers seeking support. Methods An online survey was devised, and then promoted with the support of local voluntary organisations and sexual health clinics. Data were analysed on acute Hepatitis C diagnoses for the previous 5 years using data collected by PHE. Interviews were conducted with key stakeholders. Results In total, 54 participants completed the anonymous online survey, of which 52 were men who have sex with men (MSM). 76% were HIV positive and 20% were Hepatitis C positive. The most commonly used recreational drugs were Mephedrone (81%) and GHB/GBL (79%). Of respondents, 78% felt they would prefer to access support in a specialist clinic within a sexual health service. Qualitative data on barriers to accessing support were determined. Using PHE Acute Hepatitis C data, 46% of the 57 patients diagnosed via Greater Manchester sexual health clinics between 2009 – 2015 had used at least one chemsex drugs in the past 12 months. Stakeholder interviews gave insight into perceived barriers to accessing care. Discussion/conclusion We identify demographic factors of chemsex users and the perceived barriers to accessing support. These findings will be useful in guiding commissioning and tailoring specialist services.

Background/Introduction Patients attending sexual health services report higher rates of drug and alcohol use. This may lead them to ignore safer sex messages putting them at greater risk of STIs. ‘Chemsex’ has been recognised as an additional risk factor in MSMs, but it is unclear how widespread this is in heterosexual individuals or outside large conurbations. Aims/Objectives This service evaluation aimed to assess the extent of the alcohol and drug use in all patients attending a GU clinic and its impact on sexual behaviour. Methods Self-completed detailed questionnaires were incorporated into the clinic dataset for 600 consecutive patients during February 2016. Data was anonymised and analysed using SPSS v23. Results Results show 70% of women and 75% of men reported alcohol use in the last month, however fewer than 1/3 reported drug use. Men were more likely to have taken recreational drugs (37% v 25%). Fewer women than men reported engaging in chemsex (2% v 5% respectively). 25% of women and 30% of men regretted sex they had had in the last year with men more likely to attribute this to alcohol. Women reported alcohol use contributing to worse partner choice but better sex, with the converse for men. There was no association between drug and alcohol use and STI rates. Discussion/conclusion Alcohol does not appear to impact as much upon sexual behaviour as previously suggested. Chemsex is prevalent amongst heterosexuals as well as MSMs and questions on this should be incorporated into standard data collection in clinic.

Background/introduction Recreational drug (RD) use is increasing in men who have sex with men (MSM) and increases sexual risk taking behaviour and possibly increasing attendances for PEPSE. Aim(s)/objectives To identify Club drug use during PEPSE attendances in MSM in 2013/4 compared to 2015. Methods Review PEPSE (MSM) attendance during two 4-month periods: November 2013 to February 2014 and March 2015 to June 2015. Results 152 MSM attended for PEPSE: 51 in 2013/4 and 101 in 2015. The median age was 31 (18–79) years. Documentation of Club drug use during PEPSE episode increased significantly from 27/51 (53%) in 2013/14 to 100/101 (99%) during 2015 (p gamma -Butyrolactone(GBL), Mephedrone and Crystal Meth being the most frequent reported. Discussion/conclusion Episodes of unsafe sex leading to access of PEPSE appear to be more associated with club drug use in 2015 than in 2013/4 and our documentation of this has improved. Identification of club drug use in MSM is an important harm intervention.

Background/introduction The sexualised use of recreational drugs (Mephedrone, GBL/GHB, Crystal Meth) is thought to be associated with STI acquisition however there is little data showing a direct relationship. Methods We reviewed 130 cases of MSM with an STI attending our STI service and 130 controls (MSM attending the STI service who did not have an STI) between 5th May 2015 and 2nd Nov 2015 (6 months). We collected demographic data, sexual behaviour, drug use and STI diagnoses. Results In the 6-month period there were 5,013 appointments with MSM. Reported condom-less anal sex was significantly higher in cases 90/121 (74%) compared with controls 65/122 (53%); (X2 = 11.71, p Discussion/conclusion This data demonstrates a clear correlation between STI acquisition and recreational drug use in Men who have sex with men. Interventions to reduce party drug use should be implemented on an individual, local and national level to improve the sexual health of MSM, including reducing risk-taking behaviours.

Club drugs such as mephedrone, GBL/GBH and crystal meth are increasingly popular among men who have sex with men (MSM) and are associated with high-risk sexual behaviour (chemsex).1 ,2 As part of a service improvement project locally to evaluate how to best improve services for MSM using recreational drugs, we asked MSM about their current drug use. Research ethical approval was not …

Background/introduction PEPSE is a significant tool for preventing HIV transmission among MSM. Further understanding is required on the extent and risk factors for repeat PEPSE (rPEPSE) presentations. Aims/objectives This study aimed to determine the rate of repeat PEPSE and identify factors involved in rPEPSE presentations. Methods MSM attending for PEPSE in Brighton, May 2009–May 2014 were included. Information was collected retrospectively on demographics, number of rPEPSE prescriptions, recreational drug and alcohol use, type of sexual exposure, condom use, mental health (MH), continued risk taking while on PEPSE, partner factors, PEPSE regime and risk reduction interventions. Data were analysed using Excel functions (Spearmann’s rank correlation coefficient). Results 929 MSM accessed PEPSE – 110 (11.5%) had repeat PEPSE prescriptions (48.2% twice, 25.5% 3×, 9.1% 4×, 7.3% 5×, 6.4% 6×, 1.8% 7×, 1.8% 8× and 0.9% 9×). rPEPSE prescriptions were associated with low condom use (25.2% used condoms), MH problems (43.9% had at least one recorded) and alcohol/recreational drug use (49.1% patients had used alcohol prior to their attendance for rPEPSE, 40% had used drugs). Those with > 4 episodes rPEPSE reported more recreational drug use (significant association: (p = 0.04). Lower numbers of rPEPSE prescriptions (2/3) were associated with alcohol use (p = 0.07). 6.4% of those accessing rPEPSE became HIV positive. Discussion/conclusion This study identified an 11.5% rate of rPEPSE among MSM in this area and highlights contributory factors to rPEPSE and could help inform behavioural and risk reduction interventions at a local level.

Background Drug and alcohol use by patients attending sexual health clinics is not widely assessed as routine. BASHH history taking guidelines and position statement on recreational drug use recommend obtaining such histories, enabling identification of patients at risk and refer appropriately. Aim To identify drug and alcohol use among GU patients attending a routine clinic appointment. Methods Anonymous questionnaires were offered to all patients over a five day period. Drug and alcohol use over past 6 months, whether it was patient-identified as problematic and where help would be sought were obtained Results Of the 116 respondents, with an average age of 30 years, there were 61 (52%) women, 30 (26%) MSM and 25 (22%) heterosexual men. Of these 60 (52%) disclosed drug use and 105 (81%) disclosed drinking alcohol; 4 respondents were concerned about their drug use and 48 (49%) reported high alcohol intake. Conclusion There is a high level of drug and high alcohol use by a significant number of patients of all genders and ages. However it is self-deemed as problematic by only a small proportion. More routinely collected data is required to fully understand this and the potential impact it may have on sexual health.

There is a rising trend in high risk sexual behaviour among men who have sex with men (MSM), with concomitant use of recreational drugs. Activities include fisting and unprotected anal intercourse with a partner who is HIV serodiscordant or of unknown status. We describe three cases of HIV positive MSM who have recently attended our unit as a result of complications secondary to fisting.

Background There is an increased prevalence of many sexually transmitted infections (STIs) among HIV+ gay men. In addition, the increase of the use of recreational drugs within this population is associated with increased sexual risk taking. There is a need for specific services to address sexual risk taking within this population. A clinic was set up to deliver an MI based intervention to gay men who engage in “high risk” sexual activity, including unprotected anal intercourse. This is a case study of one of the patients referred to this clinic. Aims The patient is a 47-year-old gay man with a long standing diagnosis of HIV; he has had a number of other STI9s in the past. He was engaging in a high frequency of unprotected anal intercourse (both single partner and group sex) with partners he met on the internet. He reported always using recreational drugs during sex sessions. The aim of the intervention was to reduce the frequency of the patient9s unprotected sex, thereby reducing patient9s risk of acquiring and/or transmitting STIs. Methods Intervention consisted of five individual sessions of MI with a Clinical Psychologist over a period of 3 months. Results After five sessions, the patient reported discontinuation of all recreational drugs, a reduction in the volume of sexual encounters, an improvement in mood and increased satisfaction with his sex life. Discussion This clinical case study provides preliminary data to support the value and the appropriateness of MI for sexual risk reduction coupled with recreational drug use. Despite the level of complexity of the patient9s presenting problems, MI proved to be an effective intervention. Further research is needed to investigate the efficacy of MI for sexual risk reduction with this population.

Background Data on the frequency of recreational drug use (RDU) are collected at a population level through representative national surveys (eg, British Crime Survey). Anecdotally it appears that RDU is more common in men who have sex with men (MSM), but there are few systematic data to prove this. The aim of this study was to investigate the pattern of RDU in patients attending a sexual health clinic and to determine whether drug use was greater among MSM. Methods We administered a questionnaire to all patients attending the sexual health clinics at two inner-city London teaching hospitals over a 3-month period (July 2011–September 2011). The questionnaire was self-completed by patients while waiting to see a clinician. Data were collected on age, gender, gender of sexual partner(s) and previous/current RDU (type and frequency of drugs used). Results 1328 questionnaires were completed (mean±SD age 30.5±8.5 years, 54.9% female); 254 (19.1%) were MSM. Life-time use of all drugs, except cannabis, was more common in MSM; last-month use of all drugs, except cannabis, cocaine powder and amphetamine, was more common in MSM (abstract P179 table 1). Conclusion Sexual health clinics provide an ideal forum to identify individuals using recreational drugs and to implement behavioural interventions and education programmes to promote safer RDU, reduce drug-related harm and, in view of the association between RDU and high risk sexual behaviours, to decrease the risk of subsequent STIs. Our data show that both life-time and last-month use of most recreational drugs are more common in MSM and therefore interventions should be targeted to this population.

Background The exchange of sex for money, drugs, goods/services (transactional sex) is a recognised risk factor for HIV infection, particularly among men who have sex with men (MSM). We investigated the prevalence and correlates of transactional sex among MSM recruited into the Vancouver component of the Public Health Agency of Canada9s M-Track second generation national surveillance system of MSM (ManCount). Methods In 2008−2009, ManCount recruited MSM aged ≥19 years through community venues and events catering to MSM to complete a self-administered questionnaire and provide a blood sample for testing for HIV. We examined responses to questions on having given or received money, drugs or goods/services in exchange for sex in the past 6 months (P6M) and used multivariate logistic regression to explore association of seeking and providing transactional sex with a number of recognised HIV risk factors. The complete dataset included MSM recruited from a drop-in centre for male sex workers (MSW)—we first compared these men to the rest of the sample and then, to reduce confounding, these data were excluded from our detailed analysis of correlates. Results Of the 1169 participants, 1130 answered the transactional sex questions and 38 were MSW. Of the MSW, 81% reported transactional sex P6M. The MSW differed significantly from the other MSM and were predominantly not gay-identified; reported lower income and education; higher injection drug use, drug use with sex and public sex (all p Conclusion The exchange of money, drugs or goods/services for sex is common among MSM in ManCount and may be more prevalent in MSM culture than previously thought. Lower income, non-gay identity and more sex partners were associated with receiving consideration for sex, whereas older age, IDU P6M, seeking sex in public places and risky sex were associated with giving consideration. Transactional sex was strongly associated with use of recreational drugs along with sex and emphasises an intimate connection between drug use and sex in the production of HIV risk.

Background Previous studies have shown that recreational drug use is associated with high-risk sexual behaviour and STI. Little is known about the relationship between the use of specific recreational drugs during sex, sexual behaviour and the risk for any STI (chlamydia (CT), gonorrhoea (NG) and/or syphilis) or the three STI separately in heterosexual men, men having sex with men (MSM) and women. We assessed the prevalence of recreational drug use during sex, and assocations of drug use during sex with high-risk sexual behaviour and STI. Methods Attendees of the STI clinic of the Public Health Service of Amsterdam were interviewed during three waves of a bi-annual anonymous survey (2008–2009) about sexual behaviour in the preceding 6 months (number of steady and casual sex partners, condom use during vaginal or anal sex) and specific recreational drug use just before or during sex in the preceding 6 months (cannabis, XTC, poppers, heroine, cocaine, GHB, apomorfine, amphetamine, methylamphetamine, mushrooms, ketamine and explosion). Participants were tested for CT, NG and syphilis. Associations between drug use during sex and high-risk sexual behaviour and STI were analysed using multivariable logistic regression analyses. Analyses were done separately for heterosexual men, men who have sex with men (MSM) and women. Results In total, 1012 heterosexual men, 749 MSM and 1254 women participated in this study. Of these, 11.7% had CT, 3.5% NG and 1.4% syphilis. Recreational drug use during sex in the previous 6 months was reported by 22.5% of heterosexual men, 52.7% of MSM and 15.6% of women. In all three groups, drug use during sex was associated with unprotected vaginal and anal sex and more casual sex partners. In multivariable analyses among MSM, adjusting for age, ethnicity, educational level and sexual behaviour, poppers use was associated with any STI (adjOR 1.8, 95% CI 1.2 to 2.6) and with NG (adjOR 2.6, 95% CI 1.6 to 4.2), and GHB use with syphilis (adjOR 2.3, 95% CI 1.0 to 5.0). In multivariable analyses among women, GHB use was associated with any STI (adjOR 4.7, 95% CI 1.8 to 12.2) and CT (adjOR 3.5, 95% CI 1.1 to 11.4). In heterosexual men, drug use during sex was not associated with STI. Conclusions STI clinic clients frequently report recreational drug use during sex and this is associated with high-risk sexual behaviour in heterosexual men, MSM and women. The use of drugs during sex is associated with STI in MSM and women, but not in heterosexual men.