Recreational drug use is common in HIV positive gay men and is extensive in a significant minority
Simon Collins, HIV i-Base
An analysis from the ASTRA (Antiretrovirals, Sexual Transmission Risk and Attitudes) study was reported as an oral presentation at EACS 2013.
The results are important because of the size of the study and for highlighting different patterns of recreational drug use that have not been well studied and are therefore likely to have been underestimated. Although the study was carried out two years ago, there is little evidence to suggest that drug use has reduced in 2013.
The ASTRA study included 3,258 HIV positive people attending one of eight HIV out-patient clinics in London, Manchester and Brighton, of whom 69% were men who have sex with men (MSM). Participants were enrolled during 2011-2012 and self-completed a confidential study-specific questionnaire, which recorded information on socio-demographics, lifestyle factors, ART, health and wellbeing, HIV transmission beliefs and sexual lifestyle.
Approximate demographics for the gay men in this survey (n=2,248) included mean age 45 years (+/-SD 9.5), 62% were employed, 44% had a university degree or higher and 89% were white. Median time since HIV diagnosis was 10 years (IQR: 5 to 16 years), 76% had an undetectable viral load (85% were on ART) and 84% had a CD4 count >350 cells/mm3.
Half of gay men in the survey (n=1,140) used one or more recreational drugs in the previous three months, with 32% of this group using only one drug and 21% using only two; 15%, 10% and 21% of this group used 3, 4 and 5 or more different recreational drugs, respectively. Injecting recreational drugs was reported by 3% (n=68 men). Patterns of drugs use varied considerably with the types of drug used. Of men reporting drug use, the most commonly used drugs were poppers (54%), with just over 40% reporting use of each of cannabis, Viagra (or similar) and cocaine. Approximately 15-25% of men who used drugs had taken heavier “party” drugs including ketamine (25%), ecstasy (23%), GHB/GBL (19%), crystal meth (15%) and mephedrone (14%). Fewer men used speed (7%), anabolic steroids (5%), LSD (4%) and codeine (4%). Less than 2% used crack cocaine, khat, heroin, morphine or opium.
Further information on the pattern of drug use was also presented based on the number of drugs used. So, for example, of the people reporting using only one drug (n=369), 37% used poppers and 37% used cannabis, with hardly any use of heavier party drugs. Men reporting using >5 drugs (n=241 men), also reported the highest use of ketamine, ecstasy, GHB/GBL, crystal meth and mephedrone (each accounting for about 10% of all drugs used in this group) and the lowest use of cannabis and poppers.
In adjusted multivariate analysis, risk factors most significantly associated with recreational drug use included younger age (adj Odds Ratio: 2.45 [95% CI: 1.52, 3.96] <30 vs >50 years old), alcohol dependency (adj OR: 1.53 [95% CI: 1.26, 1.86] possible vs not), non-adherence to ART (adj OR: 1.78 [95% CI: 1.35, 2.36] missing >2 days in previous 3 months vs adherent on ART); all p<0.001. Men not on ART had similar levels of drug use to those who were adherent on ART. No independent association was seen for ethnicity, education, employment, housing, financial hardship, CD4 count, depression and anxiety (all p>0.05).
The survey also looked broadly at sexual behaviour in the previous three months using several different measures. These included having more than five partners, not using a condom with a negative partner(s), having group sex, using the internet to find partners, having a previous STI or having more than ten new partners (in the previous year). Recreational drug use was significantly associated with all these measures (all adj OR approximately 2.5-5.0 – compared to not using recreational drugs with narrow 95% CIs, p<0.001 for all).
Broadly, each measure was positively associated with increasing number of drugs used. For example, compared to men who had used only one recreational drug, people who had used five or more drugs were more than twice as likely to use the internet to meet partners, more than four times as likely to have more partners, more than three times as likely to have had group sex, and more than twice as likely to have been recently diagnosed with another STI.
In terms of condom use, men using five or more drugs were almost twice as likely to report having sex without a condom with a partner of “negative or unknown status” (a combined option in the survey) compared to those using only one drug (24% vs 13%), and about 3 times as likely compared to the no drug group (9%).
However, the results on drug use and behaviour need to be interpreted carefully in terms of HIV transmission risk, because behaviour was not reported in relation to viral load (when undetectable viral load is likely to dramatically reduce risk). Some of the outcomes will include sex between positive partners (not relevant for HIV transmission, although potentially important for transmission of other STIs including HCV).
Recreational drug use is commonly associated with dance and club culture. As this has been well established in the gay scene for at least the last twenty years it should not be unexpected that recreational drug use is common among HIV positive gay men, similar to HIV negative gay men and heterosexuals.
However, the results show that 50% of HIV positive gay men at these urban centres are likely to use at least one recreational drug, even though that for most people this is either poppers or cannabis. They also show that at least 10% use heavier party drugs that are associated with health risks including reduced adherence.
The results help describe a minority of HIV positive men for whom recreational drug use involves many drugs and that higher recreational drug use overlaps with using drugs for sex. This overlaps with the risk factors reported for other health problems including sexually transmitted HCV in HIV positive gay men and the increasing demand of drug counselling services from gay men irrespective of HIV status.
These results are from an HIV outpatient sample and so tell us nothing about whether HIV positive gay men are behaving any differently to HIV negative men. However, as the largest study of its kind, future analyses from the ASTRA results will provide important insight into the complex diversity of the HIV population in the UK, including attitudes and patterns relating to sexual behaviour, serosorting, recreational drug use and clinical health.
The design, methods and patient characteristics were published last month as an open access paper in PLoS ONE.  The questionnaire from the study is also available online. 
Simon Collins is a community representative on the Steering Group for the ASTRA study.
- Daskalopoulou M et al. Recreational drug use and high risk sexual behaviour among HIV-diagnosed men who have sex with men (MSM) in the UK: results from the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study. 14th EACS, 16-19 October 2013, Brussels Oral abstract PS 11.3.
- Speakman A et al. Antiretrovirals Sexual Transmission Risk and Attitudes’ (ASTRA) Study. Design methods and participant characteristics. PLoS ONE 8(10): e77230. doi:10.1371/journal.pone.0077230.