David Fawcett Ph.D., L.C.S.W.
I arrived at the address on a rain-slicked, dark street near Les Halles in Paris. I had been invited to a chemsex harm reduction center for gay men. "Chemsex" is the term commonly used in Europe to describe the use of methamphetamine and other drugs to enhance sexual activity, mostly by gay men. The storefronts were covered, and I thought I had the wrong address, but after a telephone call to my host, a door opened a few meters away and Vincent LaBrouve, the center's coordinator, invited me into a bright, inviting space.
Just inside, there was a table with a man handing out syringe kits, including new, sterile syringes, filter caps to remove adulterants and sterile cookers in which to heat drugs. The syringe packs came in various rainbow colors designed to allow users to identify their own syringes at chemsex parties.
The walls of the center were filled posters about HIV, chemsex harm reduction and other resources for the Paris LGBT community. A comfortable assortment of couches and chairs formed a group area where snacks were being set out for a well-attended meeting on new drug trends in France presented by a government official.
Another man in a white lab coat set up a station where he provided free drug testing with no questions asked for anyone who brought their drugs that evening. Vincent took me down a hall to a room where an artificial arm was set up on a table with an IV of red, blood-like liquid flowing into it. Here, people could practice injecting themselves and others, learning to avoid the pitfalls of missed hits and blown veins.
As in the U.S., methamphetamine, cocaine and GHB/GBL are popular with European gay men. But other drugs are more common in Europe, including ketamine, mephedrone (and its derivatives such as 3MMC and 4MECV), Chloraethyl Dr. Hennig (a topic anesthetic) and a variety of synthetic compounds with chemical names obtained over the internet. France has drug laws as conservative as those in the U.S., but it has been more liberal about providing harm reduction centers like this one.
Simply put, harm reduction incorporates a variety of strategies to make drug use safer and to meet drug users non-judgmentally "where they're at." French attitudes about harm reduction remain conservative, as seen when Paris opened its first "shooting gallery" (a clean space where addicts can safely inject their own drugs) last year near the Gare du Nord. There was widespread public protest until people saw that the area began to have fewer drug users on the street and the area became safer. Hopefully, fewer cases of HIV and hepatitis C (HCV) were transmitted, as well.
In my own work, I have found that harm reduction principles are especially important in the treatment of meth addiction, which is characterized by chronic relapse. While I encourage my clients to move toward total abstinence, I want to keep them as safe as possible in the meantime. This includes education, avoiding shaming and stigmatizing, and (hopefully) access to sterile equipment, which is not yet legal in many parts of the U.S. The general sentiment of the U.S. public is that this is too permissive, but I believe that the criminalization of drug use has done nothing to solve our drug epidemics and has only increased stigma and new HIV and HCV infections.
These French government-funded harm reduction centers (known as CAARUD) are all over the country and, while they generally target chronic drug users (mostly opiates), the center I visited was created by AIDES, the country's largest HIV service organization, and is designed for gay men injecting drugs as part of chemsex.
Despite moral concerns about encouraging drug use, there is solid evidence that harm reduction, including syringe exchange, reduces new HIV and HCV infections. In the U.S., it is estimated that up to 10% of new HIV infections are due to injection drug use, and among certain minorities such as trans women, rates of injection drug use can be over 20%. The Centers for Disease Control and Prevention (CDC) estimates that one-third of active injection drug users aged 18-30 are HCV-infected, with much higher rates of HCV among older users. Systematic reviews by the World Health Organization and UNAIDS have documented the beneficial health impact of syringe exchange programs, and a 2014 study found that one dollar invested in such a program can save $7 in avoided HIV care-related costs.
I met another man named Rob Isaac at CAARUD Des Halles that night. Rob is the pre-exposure prophylaxis (PrEP) coach at The Checkpoint in the Marais district, a sexual health center for the LGBT community. PrEP has only been available in France for one year, and Rob is one of the few PrEP coaches in the country. Rob has no official affiliation with Vincent's center, but he works closely with other programs serving gay men to ensure that those who engage in chemsex have complete information about all harm reduction options, including PrEP (60% of PrEPers in Paris are chemsexers, according to Rob).
In France, PrEP can only be distributed through medical facilities, so Rob works hand-in-hand with medical staff to determine what kind of PrEP program would be most beneficial for each client. Unlike the U.S., in France PrEPers are offered either the "classic" dose of Truvada (tenofovir/FTC -- one pill per day with coaching) or dosing following the IPERGAY study protocol (two pills minimum two hours /maximum 24 hours before risky sex, followed by one pill 24 hours after the first and another pill 24 hours after that). PrEP uptake is growing. As word spreads, the number of persons on PrEP in France doubles every few months.
Back here in the U.S., we finally had progress when the ban on syringe exchange programs was lifted in the Consolidated Appropriations Act of 2016, which gives states and local communities, under limited circumstances, the opportunity to use federal funds to support certain components of syringe exchange programs (excluding the syringes themselves). The Department of Health and Human Services has issued a guidance, and a list a syringe exchange programs is available through the North American Syringe Exchange Network.
Despite these advances, we have a long way to go. Here in my home state of Florida, it took a five-year legislative fight to create a trial syringe exchange program in Miami-Dade County, which, along with its neighbor Broward County, consistently ranks among the top areas in the U.S. for new HIV infections.
I'll admit I was a bit shocked seeing the rainbow-colored syringe packs and the "blood-filled" dummy arm for practicing injection. But, I also longed to have more governmental support for educating drug users about epidemiological trends and free, onsite drug compound testing with no questions asked. I ask myself whether I am enabling. But, I must also consider at what point my moral dilemma begins costing lives. These elements of harm reduction are effective and, like PrEP, they are all components of our toolkit. Education, psychotherapy, peer support and a host of other interventions must work in tandem. Can we really afford not to utilize every tool we have to prevent HIV and HCV? For me, keeping clients safe while I work with them to become abstinent is essential. It's not necessary to wait for an HIV and HCV "hotspot" like the one in Indiana to emerge before we take action. Let's check our moral outrage, become fully informed and use every tool possible. Countless lives are at stake.
David Fawcett, Ph.D., LCSW, is a substance abuse expert, certified sex therapist and clinical hypnotherapist in private practice in Ft. Lauderdale, Florida. He is the author of Lust, Men, and Meth: A Gay Man's Guide to Sex and Recovery.