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NATAP: NYC PrEP/STIs-Club Drugs/Higher Odds of STI

Jules Levin
 


www.natap.org

Short report

in NYC - Club drug users had higher odds of reporting a bacterial STI compared with non-club drug users: results from a cross-sectional analysis of gay and bisexual men on HIV pre-exposure prophylaxis

"Overall, a quarter (26%, n=17) reported a BSTI [bacterial STI ]diagnosis in the prior 6 months; nearly half (42%) of club drug users had a BSTI compared with 9% of non-club drug users…..On average, men reported 5.1 sexual partners (SD=4.4) and 5.1 CAS acts (SD=5.4) in the past 30 days, and half (51%) of the sample reported recent engagement in club drug use (per study design)…..Nearly half (48%) were whitemost (72%) had a bachelor’s degree or higher education, and most (79%) had annual income of $20 000 or more. Sixty-three per cent received their PrEP-related care from a primary care provider, and 62% reported not missing a PrEP dose in the past 90 days….Men with higher education and club drug users were more likely to report a recent BSTI in bivariate analyses. GBM who reported a higher number of CAS acts were also significantly more likely to report a BSTI diagnosis; however, the number of sexual partners and other variables analysed were not significantly associated with BSTI

In this study, GBM who engaged in club drug use and those who reported a greater number of recent CAS acts were more likely to self-report a BSTI diagnosis while on HIV PrEP. Of particular note, 42% of club drug users reported a BSTI in the past 6 months. Based on this study and previous research among PrEP users that identified comparable rates of BSTIs,2 regular BSTI testing and risk-reduction counselling for PrEP users are warranted. PrEP users who report club drug use and CAS are particularly important for ongoing BSTI testing and counselling. Club drug use is one mechanism to increase sexual arousal and motivations for sex,6 which could be uniquely enhanced with diminished concern about HIV with PrEP use.4 However, because club drug use is not an activity that causes transmission of BSTIs in and of itself, we posit club drug users on PrEP could be members of higher risk sexual networks.9 10 This hypothesis is supported by findings indicating higher engagement in group sex activities among GBM and other MSM who combine drug and PrEP use compared with those who only use PrEP.7 As such, healthcare providers providing PrEP and follow-up maintenance care should initiate ongoing BSTI risk-reduction counselling with their patients, particularly if they report club drug use and/or CAS engagement.
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The objective of this study was to compare the prevalence of polydrug use, use of drugs associated with chemsex, specific drug use, and HIV-related behaviours, between two time periods , using two groups of HIV-negative men who have sex with men (MSM) attending the same sexual health clinics in London and Brighton, in two consecutive periods of time from 2013 to 2016.

Results In total, 991 MSM were included from AURAH and 1031 MSM from AURAH2. After adjustment for sociodemographic factors, use of drugs associated with chemsex had increased (adjusted PR (aPR) 1.30, 95% CI 1.11 to 1.53) and there were prominent increases in specific drug use; in particular, mephedrone (aPR 1.32, 95% CI 1.10 to 1.57), γ-hydroxybutyric/γ-butryolactone (aPR 1.47, 95% CI 1.15 to 1.87) and methamphetamine (aPR 1.42, 95% CI 1.01 to 2.01). Use of ketamine had decreased (aPR 0.54, 95% CI 0.38 to 0.78). Certain measures of HIV-related behaviours had also increased, most notably PEP use (aPR 1.50, 95% CI 1.21 to 1.88) and number of self-reported bacterial STI diagnoses (aPR 1.24, 95% CI 1.08 to 1.43).

Conclusions There have been significant increases in drug use associated with chemsex and some measures of HIV-related behaviours among HIV-negative MSM in the last few years. Changing patterns of drug use and associated behaviours should be monitored to enable sexual health services to plan for the increasingly complex needs of some clients.

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Club drug users had higher odds of reporting a bacterial STI compared with non-club drug users: results from a cross-sectional analysis of gay and bisexual men on HIV pre-exposure prophylaxis

 

Aug 2018

In a meta-analysis of literature published during August 2017, BSTIs were significantly higher among PrEP users pooled across eight studies reporting BSTI prevalence, with most studies in the overarching meta-analysis of 17 open-label and observational studies reporting evidence of an increase in condomless sex after PrEP uptake.3 These findings are supported by newer evidence indicating young MSM who used PrEP engaged in more receptive condomless anal sex (CAS) compared with those not taking PrEP,4 and although PrEP can protect against HIV it cannot protect against BSTIs. It is plausible that subgroups of PrEP users could be at a higher BSTI risk, especially MSM who combine club drug use (ie, ketamine, MDMA (3,4-methyl​enedioxy​methamphetamine)/ecstasy, GHB (γ-hydroxybutyricacid), cocaine or methamphetamine) and PrEP.


Abstract

Objectives Pre-exposure prophylaxis (PrEP) can reduce HIV transmission risk for many gay, bisexual and other men who have sex with men. However, bacterial STI (BSTI) associated with decreasing condom use among HIV PrEP users is a growing concern. Determining the characteristics of current PrEP users at highest BSTI risk fills a critical gap in the literature.

Methods Gay and bisexual men (GBM) in New York City on HIV PrEP for 6 or more months (n=65) were asked about chlamydia, gonorrhoea and syphilis diagnoses in the past 6 months. By design, half (51%) of the sample were club drug users. We examined the associations of length of time on PrEP, type of PrEP care provider, PrEP adherence, number of sexual partners, number of condomless anal sex acts and club drug use on self-reported BSTI using multivariable, binary logistic regressions, adjusting for age, race/ethnicity, education and income.

Results Twenty-six per cent of GBM on HIV PrEP reported a diagnosis of BSTI in the past 6 months. Men who reported club drug use (adjusted OR (AOR)=6.60, p<0.05) and more frequent condomless anal sex in the past 30 days (AOR=1.13, p<0.05) had higher odds of reporting a BSTI. No other variables were significantly associated with self-reported BSTI in the multivariable models.

Conclusions Club drug users could be at a unique BSTI risk, perhaps because of higher risk sexual networks. Findings should be considered preliminary, but suggest the importance of ongoing BSTI screening and risk-reduction counselling for GBM on HIV PrEP.


Introduction

HIV pre-exposure prophylaxis (PrEP)—a once-daily oral pill of tenofovir disoproxil fumarate/emtricitabine—greatly reduces HIV risk for many gay, bisexual and other men who have sex with men (MSM).1 2 However, bacterial STIs (BSTIs) associated with decreasing condom use among HIV PrEP users is a growing concern. In a meta-analysis of literature published during August 2017, BSTIs were significantly higher among PrEP users pooled across eight studies reporting BSTI prevalence, with most studies in the overarching meta-analysis of 17 open-label and observational studies reporting evidence of an increase in condomless sex after PrEP uptake.3 These findings are supported by newer evidence indicating young MSM who used PrEP engaged in more receptive condomless anal sex (CAS) compared with those not taking PrEP,4 and although PrEP can protect against HIV it cannot protect against BSTIs.

It is plausible that subgroups of PrEP users could be at a higher BSTI risk, especially MSM who combine club drug use (ie, ketamine, MDMA (3,4-methyl​enedioxy​methamphetamine)/ecstasy, GHB (γ-hydroxybutyricacid), cocaine or methamphetamine) and PrEP. Club drugs can be used by MSM to stimulate sex, particularly when used in combinations (ie, ‘chemsex’), and are especially relevant to ‘party-n-play’ scenes often including group sex and condomless sex.5 6 Therefore, PrEP users engaging in club drug use could be at a higher BSTI risk because of network prevalence resulting from partner concurrency and condomless sex compared with their non-drug using counterparts.7 With limited prior research on BSTI acquisition among PrEP users, we sought to determine the characteristics of self-identified gay and bisexual men (GBM) who had higher odds of self-reporting a BSTI diagnosis while on daily oral PrEP for HIV prevention.

Methods

Data used for this analysis were taken from PrEP & Me, a study of 104 GBM who were active HIV PrEP users at the time of enrolment (see online supplementary appendix A for more details). GBM were recruited via targeted sampling8 in New York City from November 2015 to November 2016. Passive recruitment strategies included posting advertisements on social media and geosocial sexual networking apps, and active recruitment was conducted by the research staff within gay-concentrated neighbourhoods and settings. To join the study, participants had to call our office, whereby they were screened for eligibility and scheduled for an appointment (if eligible). To be eligible for the study, participants had to (1) be 18 years or older, (2) be cisgender male, (3) identify as gay/bisexual, (4) have been taking HIV PrEP for at least 30 days, but not via a research study that provided the PrEP medication, (5) reside in the New York City area, and (6) have access to the internet. By design of the parent study, half of the enrolled participants self-reported club drug use (ketamine, MDMA/ecstasy, GHB, cocaine or methamphetamine) in the past 30 days. The study was marketed as an opportunity for participants to describe their experiences on PrEP, and we did not mention club drug use in our advertising for the study. For the purposes of this analysis, we excluded 39 GBM who were on PrEP for less than 6 months.

Results

Sixty-five GBM who had been taking HIV PrEP for more than 6 months were included in this cross-sectional analysis (see online supplementary appendix A for more details); 59% had been on PrEP for 1 year or longer (see table 1). Men ranged in age between 21 and 61 years old (Mage=32 years). Nearly half (48%) were white, most (72%) had a bachelor’s degree or higher education, and most (79%) had annual income of $20 000 or more. Sixty-three per cent received their PrEP-related care from a primary care provider, and 62% reported not missing a PrEP dose in the past 90 days

On average, men reported 5.1 sexual partners (SD=4.4) and 5.1 CAS acts (SD=5.4) in the past 30 days, and half (51%) of the sample reported recent engagement in club drug use (per study design). The average club drug use was reported on 4.9 days (SD=4.5) among those reporting using at least once in the past 30 days, and 82% of club drug users reported using on more than 1 day. Overall, a quarter (26%, n=17) reported a BSTI diagnosis in the prior 6 months; nearly half (42%) of club drug users had a BSTI compared with 9% of non-club drug users. Although we aggregated the three BSTIs for data analysis, the most commonly reported BSTI was gonorrhoea (n=13), followed by chlamydia (n=10) and syphilis (n=3).

Men with higher education and club drug users were more likely to report a recent BSTI in bivariate analyses. GBM who reported a higher number of CAS acts were also significantly more likely to report a BSTI diagnosis; however, the number of sexual partners and other variables analysed were not significantly associated with BSTI (see table 1). After adjusting for age, race/ethnicity, education and income, club drug users had higher odds of reporting a BSTI compared with non-users. Men who had more CAS also had higher odds of reporting a recent BSTI diagnosis. No significant differences in self-reported BSTI diagnosis were observed by length of time on PrEP, type of PrEP-related care provider, PrEP adherence or number of sexual partners (see table 1) (see online supplementary appendix A for supplemental analyses).

Discussion

In this study, GBM who engaged in club drug use and those who reported a greater number of recent CAS acts were more likely to self-report a BSTI diagnosis while on HIV PrEP. Of particular note, 42% of club drug users reported a BSTI in the past 6 months. Based on this study and previous research among PrEP users that identified comparable rates of BSTIs,2 regular BSTI testing and risk-reduction counselling for PrEP users are warranted. PrEP users who report club drug use and CAS are particularly important for ongoing BSTI testing and counselling. Club drug use is one mechanism to increase sexual arousal and motivations for sex,6 which could be uniquely enhanced with diminished concern about HIV with PrEP use.4 However, because club drug use is not an activity that causes transmission of BSTIs in and of itself, we posit club drug users on PrEP could be members of higher risk sexual networks.9 10 This hypothesis is supported by findings indicating higher engagement in group sex activities among GBM and other MSM who combine drug and PrEP use compared with those who only use PrEP.7 As such, healthcare providers providing PrEP and follow-up maintenance care should initiate ongoing BSTI risk-reduction counselling with their patients, particularly if they report club drug use and/or CAS engagement.

Limitations

Our findings should be understood in light of their limitations. First, this study is based on retrospective recall data with differing recall periods, and we are unable to determine temporality of events or causality. Second, we rely on self-reported BSTI diagnosis data, which could under-report the number of BSTIs because of asymptomatic or unrecognised infections that went undiagnosed. Third, this was a small sample size of PrEP users in New York City. It is likely that a larger sample size might have identified additional significant differences. Additional research is needed with larger samples of GBM on PrEP—including club drug users on PrEP—with comparative samples of men not on PrEP to determine heightened or comparable BSTI risk associated with PrEP and/or club drug use.

Conclusion

Our findings highlight the importance of ongoing BSTI screening and risk-reduction counselling for GBM on HIV PrEP. Club drug users could be at unique BSTI risk, perhaps because of higher risk sexual networks. However, our data provide no means of establishing a causal link between club drug use and BSTI acquisition, rather only a correlation. GBM engaging in CAS more often are also important for frequent testing and ongoing BSTI risk-reduction counselling.

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