Chemical bodies: use and abuse of drugs in a specific sub-group of HIV-positive MSM diagnosed with acute hepatitis C PE3.1/7 J-Y. Le Talec1, A. Velter2, C. Larsen2, F. Linard3, E. Delarocque-Astagneau2

Treatments

1/ Certop-Sagesse, Toulouse 2-Le Mirail University, Toulouse, France; 2/ French Institute for Public Health Surveillance (InVS), Saint-Maurice, France; 3/ APHP-Tenon Hospital, Paris, France

• The men undergo their anti-HIV treatment as part of a daily routine. STDs treatments are also largely banalized.

Since 2000, a rise in acute hepatitis C has been reported among HIV-positive men who have sex with men (MSM) in Europe. Most of these cases do not report the usual HCV risk of transmission related to drug injection. However, a frequent use of recreational drugs during sex has been described in this population. In this context, the French HEPAIG study aims to evaluate the incidence of acute hepatitis C in 2006 and 2007. A qualitative study has been added, in order to better describe the circumstances associated with HCV infection in this sample. Among these, the use of so called “recreational drugs” associated with sex appears to be very frequent.

Methods A random and proportional probability sample of 115 medical wards was constructed according to the number of HIV cases in MSM reported to the French national surveillance system, held by the Institut de veille sanitaire (Saint-Maurice, France). Acute hepatitis was defined as a positive anti-HCV antibody test or HCV PCR within one year of a documented negative test. Enrolled MSM were also proposed after separate consent to undergo two successive semistructured interviews, conducted by the sociologist most often at patient’s home: • The first interview focused on their social and sexual history and life, and on the circumstances and impact of HCV infection and its possible treatment. • The second one explored their medical history related to HIV infection, details the six month period prior to hepatitis diagnosis, and questioned the patients on how they percieved the future of their healthiness and sexuality.

Results Among the 86 included MSM, 54 completed the self-administred questionnaire and 31 were interviewed twice between October 2006 and March 2008 at an interval of 6 to 8 weeks. Aged 33 to 58 years, most of these men self-identified as gay, and were living in Paris or in a major regional city. Their social context appears to be very diverse regarding lifestyle, employment and income.

Sexuality • Half of the interviewed men live with a steady partner. All are sexually active and have encounters with multiple casual partners. • Most of them practice unprotected receptive anal intercourse and/or fisting on a more or less regular basis, ranging from occasional relapse to steady barebacking, in which case seroadaptation is usual. • The choice of non-protection is primarily based on a claim for freedom and pleasure. These men also evoke a need to create a space where they may free themselves from the constraints due to HIV-infection and the stress of everyday life, and where sexual risk is managed on an individual responsability basis. • Many respondents relate recent occurrences of STIs besides hepatitis C: syphilis, lymphogranuloma venereum (LGV), gonorrhoea, genital warts, all which have been treated.

HIV and HCV infections According to the clinical data, the median age at HIV diagnosis is 31 years [19, 58], and the median age at HCV diagnosis is 40 [26, 58], with a median interval of 9,5 years [0, 22] between HIV and HCV diagnosis. Most of the time, standard monitoring of HIV infection has lead to acute hepatitis C diagnosis (only a few patients had clinical symptoms such as jaundice or fatigue). The reactions to HCV ranged from shock to surprise or “bad luck”, although many respondents were aware of possible HCV transmission through blood, but thought they were not at risk of infection through unsafe sex. After confirmation of HCV, each patient describe at least two possible routes or factors associated with HCV transmission among the fellowing: unprotected anal intercourse, unprotected fisting, bleeding during sex, having STDs, having a HCV-infected partner, sharing cocaine straws or sex-props (dildoes, lubricant containers, nitrite bottles…). In addition, several respondent don’t use lubricant during unprotected receptive anal intercourse, and most of them have enema before sex.

• In addition, one patient out of two takes psychoactive drugs (antidepressant, anxiolytic and/or sleeping pills), prescribed either before the hepatitis C or during its treatment. Some patients use them in order to ease party drugs after-effects. • Finally, a majority of these men (21/31) take or at least have tried Viagra® or Cialis®, which they use more to improve and prolong sexual activity rather than to correct an actual erectile dysfunction or lack of libido, linked for example to their anti-HCV or anti-HIV treatment.

Drug use • During the six month period prior to HCV diagnosis, only two patients report no drug use, and four report having only used poppers. The other 25 have taken at least two different substances associated with sexual activity, more or less regularly: 12 patients have used between two and four drugs, and 13 patients have used between five and eight different drugs. Only one respondent mentions a past experience of injection. • A majority of this men (22/31) don’t drink alcohol when they have sex. Nitrites (poppers) appears to be the most popular drug (23/31), fellowed by cannabis (19/31). • Cocaine, gamma-Hydroxybutyric acid or gamma-butyrolactone (GHB/GBL), MDMA (ecstacy), and ketamine (Special K) are mentionned by half of the sample. At least two out of this four substances are used in ten cases, and up to three or four all together in ten other cases. These substances may be taken separately at different occasions, but most often they are sequentially used during sex. • Some other substances are much less refered to: amphetamine (speed) by one patient, metamphetamine (crystal meth) by four, LSD (acid) by one, and an unusual inhalation of ethyle chloride during sex (known as “Dr Henning’s spray” ) by three patients. • As a main motivation, these men take drugs in order to improve sexual activity and to increase and prolong sexual pleasure. Although some of them say they cannot have sex without such or such substance (e.g. poppers, or GHB), none of them refer to “party drugs” as an addiction or describe themselves as being addicts. • Several men display some practicle knowledge about side effects: they for instance avoide to take GHB/GBL with alcohol, or poppers with Viagra®, but they seem to be much less aware of possible interactions with their anti-HIV or anti-HCV treatments. • Despite the occurrence of sexually transmitted hepatitis C, most respondants don’t foresee to change radically their sexual behaviour or give up doing drugs, but may more seriously consider risk reduction strategies.

Synthesis and discussion 1. This sociological sample has been set up after an epidemiological inclusion process and a specific consent. It may give a more accurate qualitative description than a standard selection or “snowball” inclusion method. 2. The men included in this sample have a specific profile: they are HIV-positive, have unprotected sex, are treated for multiple infections, and do drugs. They are well aware of taking chemicals everyday, which soak up and change their bodies in the long run, as they tell. 3. They express a profound trust in medical and pharmaceutical technology, and take advantage of any available prescription in order to better their health or reduce possible harm. For instance, those who have been prescribed with anti-HCV treatment are very confident toward their chances of being cured. 4. Besides actual treatments (e.g. HAART) and actual party drugs (e.g. cocaine), several chemicals have an intermediate status: they stand as prescribed medecines but are used as party drugs (e.g. Viagra® or anxiolytics). 5. The sexuality of these men is highly medicalized, though in a paradoxical way: they aim to increase their pleasure and reduce possible harm by any chemical means, but relativize the risks and side-effects related to party drugs and deny constraints related to safer sex. This could be explained by their ideology of individual enjoyment, and guiltfree beliefs based on optimism.

Conclusion This study demonstrates how far recreational drugs and treatments have become commonplace in this sub-group of HIV-positive MSM. Public Health’s efforts should focus on risk reduction with regard to either unprotected sex or drug use and abuse. These men may be sensible to such information more through personal doctor-to-patient conversation, than through public campaigns, in order to raise awerness of potential STDs or drug addiction risk. Either way, peer education within sexual gay networks (including Internet) sould also be explored to spread information and recommandations.

Contact : Jean-Yves Le Talec ([email protected]) - Université de Toulouse 2-Le Mirail - Certop-Sagesse - 5, allées Antonio Machado F-31058 Toulouse Cedex 9 - Tél. : 33 (0)5 61 50 43 94

April 2009

Background

• Nonetheless, anti-HCV treatment causes concern, because it is known to be long, exhausting and depressing. Depending on subjects, these side-effects are variously experienced during treatment.