Recreational Drug Use Associated With Increased High-Risk Sexual Behaviors Among Young Gay Men Living With HIV

Intense recreational drug use and high-risk sex are strongly linked in young HIV-infected MSM (men who have sex with men). This may have negative impacts on treatment adherence and virus transmission, requiring targeted harm-reduction advice and support, as well as a renewed prevention focus on recreational drug use, according to study results presented at EACS 2013 in Brussels, Belgium.

Recreational drug use is a significant public health problem, especially in the United Kingdom (UK), where the study was conducted. The UK is the single largest market of new psychoactive substances, such as mephedrone, ketamines and GHB/GBL (also known as liquid Ecstasy). Among MSM from Europe and the United States, recreational drug use is much more prevalent with a higher frequency of specific drugs, like methamphetamines ("crystal meth"), nitrites ("poppers") and erectile dysfunction drugs, such as Viagra (sildenafil) and Cialis (tadalafil).

Despite this, the UK has very little data about the association between recreational drug use and sexual lifestyles among HIV-infected MSM. This is important information, considering these drugs can lead to high-risk sex. In order to help fill this gap, Marina Daskalopoulou and principal investigators Fiona Lampe, M.D., and Andrew Phillips, Ph.D., conducted a study to assess the prevalence of drug use among HIV-infected MSM, and its associations with socio-demographic factors and markers of high-risk sexual behavior.

The study included 2,248 MSM -- about 90% white, with a mean age of 45.4 -- who answered a self-completed confidential questionnaire on demographics, lifestyle, HIV and health, antiretroviral therapy (ART), sexual behavior and drug use in the previous three months.

Of the total study population, a little over 50% (1,140) had used one or more drugs in the past three months, with 32.4% having used only one and 21.2% using five or more. The most prevalent drugs were nitrites (27.1%), cannabis (21.2%), erectile dysfunction drugs (20.5%), cocaine (20.2%) and methamphetamines (7.8%).

Club drugs (mephedrone, ketamines, GHB/GBL and Ecstasy) were used by about 22% in total. However, the proportion of participants who use club drugs increases as the number of drugs used in the past three months increases: from less than 5% for one drug to more than 40% for five or more. This is also the case for erectile dysfunction drugs.

Daskalopoulou found that recreational drug use is strongly associated with a younger age (< 30 years), being non-religious, having a possible alcohol dependency and being on ART, but not adhering to it (odds ration [OR] of 2.45, 1.37, 1.53 and 1.78, all with P < .001).

The association of recreational drug use was also significant (P < .001) for markers of high-risk sexual behavior in the previous three months, when compared between drug users and non-drug users:

  • Five or more sexual partners (23.3% vs. 7.4%)
  • Condomless sex with an HIV-uninfected partner or partner of unknown status (19.5% vs. 8.8%)
  • Group sex (32.3% vs. 9.7%)
  • Using the Internet to find sexual partners (48.9% vs. 24.8%)
  • Being diagnosed with a sexually transmitted disease (14.6% vs. 6.6%)
  • Having 10 or more new sexual partners in the previous year (34.1% vs. 11.7%)

The data also showed that as the number of drugs taken increases, so does the prevalence of high-risk sex markers (P < .003). For example, only 17.6% of those who used one drug in the past three months had had group sex, while among those who had taken five or more drugs this percentage increased to 57.9%.

The adjusted OR analysis confirmed the association between recreational drug use and high-risk sexual behavior, as well as the increased prevalence of these markers as the number of drugs taken increases. Finally, Daskalopoulou analyzed the association between one marker, group sex, and specific classes of drugs, finding a strong link with, in decreasing order, methamphetamines, club drugs, erectile dysfunction drugs and nitrites.

According to Daskalopoulou, the results show that recreational drug use among young HIV-infected MSM who are on ART, but not adherent to it, is extremely high and strongly associated with risky sexual practices, such as having group sex and multiple sexual partners. The results "could be seen as representative of clinic-based HIV-diagnosed MSM in the U.K., but may not necessarily represent the situation in other countries," Daskalopoulou told

Furthermore, the researchers were quick to address any possible homophobic misinterpretations of the study. "We are studying sexual behaviour in MSM exactly because of our concern about increasing HIV incidence and to ultimately inform prevention and harm-reduction policy developed with the gay community," Daskalopoulou said.

In the end, the researchers conclude that young HIV-infected MSM on ART could benefit from targeted harm-reduction advice and support, especially concerning adherence to treatment and safer sex while under the influence of drugs. Moreover, they suggest that prevention policies focus on recreational drug use and its implications for HIV transmission.

Fred Furtado is a science writer based in Rio de Janeiro, Brazil.

Follow Fred on Twitter: @Patchlord.