Do men who have sex with men who report alcohol and illicit drug use before/during sex (chemsex) present moderate/high risk for substance use disorders?

Highlights

• The prevalence of sexualized drug use among MSM from Rio de Janeiro was 64 %.

• Moderate/high risk for substance use disorders were associated with sexualized drug use.

• MSM in PrEP programs should be screened for substance use treatment.

Abstract

Background

We evaluated the prevalence of sexualized drug use (Chemsex) and its association with moderate/high risk for substance use disorders and HIV sexual risk behavior among men who have sex with men (MSM).

Methods

We conducted a cross-sectional web-based survey among MSM from Rio de Janeiro (Brazil). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was used to screen people at moderate/high-risk for substance use disorders. Individuals found to be using substances in the prior three months were asked if they used before/during sex. Sexualized drug use was classified into: no sexualized drug use, sex using only alcohol (alcohol-sex), sex using only illicit drugs (drug-sex) and sex using alcohol and illicit drugs (alcohol-drug-sex). The questionnaire included questions about sociodemographic, HIV status/prevention and risk behavior. A multinomial regression model was performed to assess the factors associated with sexualized drug use.

Results

Overall, 1048 MSM completed the questionnaire; median age was 29 years. Prevalence of alcohol and illicit drug use in previous 3 months was 89 % and 49 %, respectively. Most MSM (64 %) reported sexualized drug use: 28 % alcohol-sex, 9 % drug-sex and 27 % alcohol-drug-sex. Median ASSIST scores were higher among those reporting sexualized drug use compared to no use. All HIV sexual risk behavior variables presented increasing prevalence across the outcome categories. In the adjusted multivariate model, having moderate/high-risk for substance use disorders were associated with sexualized drug use.

Conclusions

MSM reporting sexualized drug use should receive brief intervention for substance use disorders and be evaluated for combination HIV prevention strategies including PrEP.

Introduction

HIV continues to disproportionately affect gay, bisexual, and other men who have sex with men (MSM) worldwide (Baral et al., 2007; Beyrer et al., 2012; De Cock et al., 2012, 2012). This burden has been explained both by biological factors, related to the increased chance of HIV infection through condomless anal sex (Patel et al., 2014), and by sociostructural factors, such as stigma, discrimination and lack of appropriate health services (Davis et al., 2017). In Latin America, the HIV epidemic is still concentrated among key populations (De Boni et al., 2014; Luz et al., 2019), and approximately 40 % of new infections occur among MSM (UNAIDS, 2019) and their sexual partners. Despite Brazil having in place polices of free access to universal treatment and prevention, the burden of HIV infection continues to increase among MSM. The second National HIV Biological and Behavioral Surveillance Survey (BBSS), conducted in 2016, showed an increased HIV prevalence (18.4 %; 95 % CI: 15.4–21.7) among MSM compared to the first survey (Kerr et al., 2018), conducted in 2009 (12.1 %; 95 % CI: 10.0–14.5) (Kerr et al., 2013). In 2016, HIV-infected MSM were notably younger than in the previous study (Guimarães et al., 2018) and data from the Ministry of Health shows that MSM aging 15–24 years-old are at increased risk for HIV infection (Brasil, Ministério da Saúde, 2018). Among Brazilian MSM, data point to an unequal distribution of poor HIV treatment and prevention outcomes among Black/Afro-Brazilians, including late HIV diagnosis, not on ART, not virologically suppressed, and poor pre-exposure prophylaxis (PrEP) adherence (Grinsztejn et al., 2018; Pascom et al., 2018).

MSM present higher prevalence of substance use and substance use disorders than heterosexual cisgender men and women (Allen and Mowbray, 2016; Boyd et al., 2019; Evans-Polce et al., 2019, p.; Kerridge et al., 2017; McCabe et al., 2019). More recently, there has been an increased interest in the evaluation of sexualized drug use. Sexualized drug use is the intentional use of illicit drugs before or during sex to enable, enhance or prolong sexual interactions (Edmundson et al., 2018), which sometimes is also called as chemsex. Chemsex is defined as a subset of sexualized drug use and usually refers to the use of certain substances, particularly methamphetamine, gamma-hydroxybutyric acid/gamma-butyrolactone (GHB/GBL), or mephedrone (Edmundson et al., 2018). However, there is no consensus on the definition of chemsex as its concept is socially constructed and is subject to the popularity and availability of illicit drugs across countries and among sub-cultures within countries (Maxwell et al., 2019).

Studies on sexualized drug use among MSM are scarce in Latin America. Prevalence of alcohol use before sex ranged from 20 % to 56 % in studies conducted in Brazil and Peru, while the prevalence of illicit drug use before sex ranged from 4 % to 20 % (Cunha et al., 2015, 2014; Deiss et al., 2013; Delgado et al., 2017; Galea et al., 2017; Young et al., 2016). A web-based survey recently conducted among MSM from Brazil, Mexico and Peru found a prevalence of alcohol and illicit drug use before/during sex of 36 % and 16 %, respectively (Torres et al., 2019a). Major limitations from the aforementioned studies include small sample sizes (which make it difficult to disaggregate the types of substances used) and a lack of standardized questionnaires, which preclude the evaluation of substance use disorders.

The understanding of the patterns of sexualized drug use among MSM, including the presence of alcohol and illicit drug use disorders, sociodemographic characteristics and HIV sexual risk behavior is an important step to build better strategies for HIV and sexual transmitted infections (STI) prevention. Individuals reporting sexualized drug use could benefit from combination HIV prevention technologies including PrEP, and those who are presenting moderate/high risk for substance use disorders may benefit from substance use disorder treatment. This information presents a gap in both the international literature and in Latin American countries. In this context, this study aims to evaluate in a sample of MSM from Rio de Janeiro, Brazil: (1) prevalence of sexualized drug use, including alcohol; (2) the association of moderate/high risk for substance use disorders with sexualized drug use; (3) the association of HIV sexual risk behavior with sexualized drug use.