Abstract
Background
An increasing number of studies are exploring the profiles of men who have sex with men (MSM) in the context of the sexualized use of drugs (chemsex). However, less attention has been paid to MSM who use drugs but do not engage in chemsex. We do not know to what extent the latter are different from the former, or whether they require similar harm reduction services. This study aimed to compare both populations in terms of their sexual risk practices, health, and pre-exposure prophylaxis (PrEP) use.
Methods
We used longitudinal data from the ongoing French cohort study ANRS-PREVENIR, which comprises 3076 MSM receiving PrEP. Analyses were conducted on MSM who engaged in chemsex, MSM who used drugs but did not engage in chemsex, and MSM who did not use drugs. Only persons with available data from at least one follow-up visit between M0 and M36 were included, representing 19,375 visits. We built a three-category outcome: (i) MSM who did not use drugs (non-DU), (ii) MSM who used drugs but did not engage in chemsex (DU), and (iii) MSM who engaged in chemsex (CX). A multinomial logistic functional form was used to estimate odds-ratios and 95% confidence intervals, using the DU category as a reference.
Results
Among the 2493 cohort participants, at baseline, 62.8%, 22.5%, and 14.6% of the participants were classified in the non-DU, DU, and CX categories, respectively. Compared to DU, non-DU were less likely to (i) declare fisting/BDSM practices, (ii) have a moderately risky sex life, ii) report lifetime PrEP use. Compared to DU, CX also had lower alcohol consumption, and were less likely to have (i) a tertiary education qualification, and (ii) a main partner; in contrast, CX were more likely to be depressed. CX were more likely to report fisting/BDSM practices, but less likely not to use PrEP and to report suboptimal PrEP adherence compared to DU participants.
Conclusions
Differences between the DU and CX populations were observed; the latter were more likely to (i) have at-risk sexual practices, (ii) suffer from depression, and (iii) have optimal PrEP adherence. It is essential to provide suitable mental health services to people who engage in chemsex, and to implement tailored sexual health and harm reduction services to MSM who use drugs but who do not engage in chemsex.
Keywords: Chemsex, PrEP, Drug use, MSM, Harm reduction
Introduction
Men who have sex with men (MSM) have more frequent and more diverse drug use than the general population (Barrett et al. 2019; Guerras et al. 2021; Mor et al. 2019; Thurtle et al. 2016). The use of drugs by MSM in a sexual context, called chemsex or “party and play”, has been extensively studied in the last decade (Amundsen et al. 2023; Blomquist et al. 2020; Frankis et al. 2018; von Hammerstein et Billieux 2024; Rosińska et al. 2018). David Stuart defined the term chemsex as the use by MSM before or during sex of any combination of drugs that includes crystal methamphetamine, cathinones and/or gammahydroxybuty-rate (GHB)/gammabutyrolactone (GBL) (and to a lesser extent cocaine and ketamine) (Stuart 2016). In the early 2010s, many researchers, including Stuart, recognized that chemsex is the result of a syndemic of situations/conditions related to gay populations, and highlighted the concerns professionals and field workers had about health risks for MSM arising from its practice (McCall et al. 2015). Results from subsequent studies in 2017 suggested that MSM who engage in chemsex were more likely to experience not only health problems such as sexually transmitted infections (STI) including human immunodeficiency virus (HIV) (Coronado-Muñoz et al. 2024; Sewell et al. 2017; Maxwell, Shahmanesh, et Gafos 2019; Prestage et al. 2018), but also other sexual and mental health issues (Amundsen et al. 2023), due to the combination of drug use and high-risk sexual practices. There are two main reasons for this. First, chemsex is related to the nature of the psychoactive drugs used themselves; these drugs do not have as long a history as ‘standard’ drugs (e.g., cocaine, MDMA, heroin) and accordingly, less in known about them in the context of developing suitable HR strategies (Melendez-Torres et al. 2018a). Second, the culture of chemsex is driven by gay sexual identity and by the desire for intense sexual sensations (Marques Oliveira, Sousa Reis, et Vieira-Coelho 2023). Combined, these two factors may produce unexpected effects in terms of high risk behaviours.
The arrival of HIV Pre-Exposure Prophylaxis (PrEP) in 2010 revolutionized HIV prevention, especially for HIV-negative MSM at high risk of HIV acquisition (Molina et al. 2015). PrEP was immediately promoted by MSM community members and associations and acted as a facilitator for the provision of a range of complementary harm reduction (HR) tools (e.g., HIV/HCV/STI testing and care, etc.) for MSM who engaged in chemsex (Strong et al. 2022). One particular effect of the arrival of PrEP was the recognition by HR stakeholders that HR services were not adapted to the MSM population. This led to some HR services being transferred over to HIV and MSM associations which ensured that these services would be tailored to their MSM members.
Today, PrEP is widely used, and MSM who engage in chemsex have very good access to this and other HR tools (e.g., drug checking, injection equipment and HCV/HIV testing); moreover, PrEP is effective in this population (Roux et al. 2018).
Like other vulnerable populations, the MSM community comprises sub-populations with their own gender, sexual orientation and drug use identities: MSM who engage in chemsex, MSM who use drugs but do not engage in chemsex, those who do not use drugs at all, MSM who do not consider themselves to be gay men with sexual health needs but who frequent HR services, MSM who take drugs but do not self-identify as people who use drugs (PWUD) and do not frequent HR services, etc. All these sub-populations have their own needs and concerns. One example of research reflecting this strong intersectionality between gender, sexual orientation and drug use identity, is an Australian study where self-identified gay MSM who injected methamphetamine but who did not consider themselves to be PWUD, reported not feeling comfortable discussing their drug practices in sexual health services because of the stigma attached to injecting (Schroeder et al. 2023). Various studies have highlighted that HR structures must acknowledge this intersectionality in identity by adapting the services they offer to the specific MSM sub-population (Bourne et al. 2015; Jaspal 2022; Meyers et al. 2021; Strong et al. 2022).
While the number of studies exploring the profiles of MSM who engage in chemsex is increasing with a view to understanding how to best adapt HR to them (Herrijgers et al. 2020), few studies to date have focused on the needs of MSM who use drugs but who do not engage in chemsex.
Our hypotheses are based on the different historical and psychosocial contexts of these two sub-populations. Using a socio-ecological framework (Ma, Chan, et Loke 2017), these hypotheses take into account multiple factors that could influence behaviors. As explained above, the nature of drugs, the socio-cultural and community aspects of chemsex, and the structural responses to chemsex practices (with the rapid deployment of PrEP and associated services) may play different roles in access to prevention and care for MSM who use drugs. In this context, we hypothesized that MSM who use drugs but who do not engage in chemsex are more likely to report non-drug related risky sexual practices but are less aware of HIV prevention, while MSM who engage in chemsex are more likely to report drug-related risky practices and need more tailored prevention responses.
In this context, we used data from the French ANRS-PREVENIR cohort to compare MSM who engage in chemsex with MSM who used drugs but did not engage in chemsex in order to better understand the different characteristics of each group, with a view to proposing suitable public health responses.
Methods
Study design and participants
ANRS-PREVENIR is an ongoing observational cohort study conducted in 26 sites in the greater Paris area in France. Started in 2017, it aims to reduce the number of new HIV infections by providing participants with a range of HR tools: (i) the option to choose event-driven or daily PrEP, (ii) early antiretroviral therapy in case of seropositivity at inclusion or during follow-up, (iii) community-based support or therapeutic education, and (iv) quarterly HIV and STI tests (https://clinicaltrials.gov/ct2/show/NCT03113123). Enrolment in ANRS-PREVENIR, which ended in 2019, used the following inclusion criteria: HIV-negative, over 18 years old, at high risk of HIV infection (defined as condomless anal sex with at least two partners during the six months prior to cohort enrolment).
Quarterly online self-administered questionnaires collect socio-behavioural data on participants, while physicians collect data on PrEP use and other health characteristics using an electronic Case Report Form (eCRF) during the study’s scheduled PrEP visits. The present analysis was carried out on quarterly data collected up to December 2022 between enrolment (M0, i.e., baseline) and three-years of follow-up (M36), corresponding to 13 time points.
Eligibility criteria for the present analysis were: (i) having a fully completed baseline questionnaire, (ii) being an MSM, and (iii) having responded to the two outcome questions (see below) in at least one of the 13 scheduled visits over follow-up (i.e., M0 to M36).
Outcome
For the present analysis we built a three-category outcome based on a time-varying variable which indicated whether or not each participant: (i) engaged in chemsex, (ii) used drugs but did not engage in chemsex, or (iii) did not use drugs at all. This ‘repeated’ measure was constructed at each follow-up visit using the following two questions:
1/ Drug use: “In the past three months, have you used drugs or medication without a prescription from the following list: heroin, cocaine, ecstasy, GHB, LSD, ketamine, morphine, amphetamines, other drug?”. Participants responded ‘yes’ or ‘no’ for each listed drug.
2/ Chemsex: “During your most recent sexual encounter, were you under the effect of any of the following products? ”. Participants chose from a list of substances, responding ‘yes’ or ‘no’ for each listed substance (ecstasy, cocaine, crack/free base, GHB/GBL, amphetamines, ketamine, cathinones, other drug).
Participants who responded ‘yes’ to both questions, or ‘no’ to the first question but ‘yes’ to the second question for one or more of the following drugs were categorized as people who engaged in chemsex (CX hereafter): ecstasy, cocaine, crack/free base, GHB/GBL, amphetamines, ketamine, cathinones. Participants who responded ‘yes’ to the first question but ‘no’ to all of the substances listed in the second question were categorized as people who used drugs but who did not engage in chemsex (DU hereafter). Finally, those who replied ‘no’ to both questions for all the drugs listed were categorised as people who did not use drugs at all (non-DU hereafter).
Independent variables
Time-constant variables
Socio-demographic characteristics measured at enrolment were all considered as time-constant. They included age (continuous), education level (secondary school certificate or lower/ tertiary education below Master’s degree / Master’s degree or higher), living alone (yes/no), perceived financial situation (you are comfortable/ you get by /it is difficult to make ends meet), already taking PrEP before study enrolment (yes/no).
Time-varying variables
-
(i)
Psychosocial aspects: Depression (using the self-reported Center for Epidemiological Studies Depression (CES-D) scale) (continuous), self-esteem (using the Rosenberg scale) (continuous), feeling supported (very supported/ moderately supported /quite alone or very alone), lifetime drug prescription or hospitalization for mental health problems (yes/no), lifetime consultation with a professional for mental health problems (yes/no). All psychosocial variables were measured every 12 months. Missing quarterly values were imputed using the last available annual measurement: e.g., information collected at M12 was used to impute missing values at M15, M18 and M21.
-
(ii)
Drug use: alcohol use (the Alcohol Use Disorders Identification Test-Consumption questionnaire (AUDIT-C)) (continuous), cannabis use in the previous three months (never/occasionally/regularly), poppers use in the previous three months (never/occasionally/regularly).
-
(iii)
Sex practices: having a main partner (yes/no), number of casual sex partners in the previous three months (< 5/between 5 and 8/between 10 and 19/≥20, based on quartiles), fisting/BDSM sexual practices in the previous three months (yes/no), satisfaction with current sexual life (not at all or not very satisfied /quite satisfied/very satisfied), self-perceived risky sex life (not at all risky or not really risky/ yes, quite risky/yes, definitely risky);
-
(iv)
Condom- and PrEP-related indicators: We constructed the following variable: ‘systematic condom use during sexual intercourse in the previous three months’. This variable contained two questions: “Have you only used condoms (i.e., no PrEP) with casual sex partners in the previous three months?” and “Have you used both PrEP and condoms with casual sex partners in the previous three months?”. Both questions had the following answer options: always, most of the time, sometimes, never. Participants who responded ‘always’ to one or both questions, were categorized under ‘yes’ (i.e., systematic use of condoms); otherwise, they were categorized under ‘no’. If a respondent declared no casual partners during the previous three months, data regarding his main partner were used.
We built a variable to measure PrEP adherence in terms of the number of PrEP pills taken before and after sexual intercourse from the quarterly self-administered questionnaires and participants’ electronic case report forms. To do this, we build a three-category adherence variable: optimal adherence (PrEP taken according to the prescribed regimen (whether daily or on-demand)); suboptimal adherence (taking PrEP but not following the prescribed regimen or not taking enough PrEP pills to obtain effective adherence); no PrEP use.
Statistical analysis
Descriptive statistics were performed using variables measured at baseline. First, Fisher’s exact test was used to compare DU with CX in terms of the drugs they reported using. Second, a pairwise Chi2 test and Student’s t-test were used for proportions and means, respectively, to verify significant differences between DU and non-DU and DU and CX in terms of the independent variables. We used Bonferroni’s technique for this multiple comparison, in order to correct for the significance thresholds. A Generalized Estimating Equation (GEE) multinomial logistic model was then used to estimate the factors associated with being a non-DU and CX, with DU as the reference group. Univariate analyses were conducted; variables with a p-value < 0.20 were considered eligible for the multivariable analysis. A backward stepwise selection was performed on the basis of p-values (i.e., accounting for the variable-specific effect) and the Akaike Information Criterion (AIC) (i.e., the lower the AIC value, the better the global goodness-of-fit of the model). Finally, we performed sensitivity analyses to assess (i) whether psychosocial aspects (which were measured annually and imputed quarterly) modified the final estimation, and (ii) the contribution of these aspects to the model. All statistical analyses were performed using R software (Anon s. d.).
Results
Selection of the population study
A total of 3076 persons were included in the ANRS-PREVENIR study (M0). Of these, 2493 participants met the three criteria for the present study, for a combined 19 375 analysable observations. Of note, 217 only had data available for one follow-up visit (i.e., M0). Figure 1 describes the process of selection of the eligible participants.
Fig. 1.
Flowchart of the PREVENIR study and sample selection for the analysis
Descriptive results of comparisons between groups
Compared to DU in terms of drug use at baseline, CX declared greater use of GHB/GBL (71% vs. 44%, p < 0.001), cathinones (66% vs. 32%, p < 0.001), amphetamines/methamphetamines (20% vs. 11%, p < 0.001) and cocaine/crack (59% vs. 56%, p = 0.004). However, there was no significant difference between CX and DU in terms of ecstasy (p = 0.2) or ketamine (p = 0.15) (Table 1). The proportion of CX remained relatively stable over the follow-up, from 14.6% at M0 to 16.9% at M36. In contrast, the proportion of DU decreased from 22.5% at baseline to 12.4% at M36; this is most likely explained by the increase in the proportion of non-DU: from 62.8 to 70.7% (Fig. 2).
Table 1.
Drug use during the previous three months among MSM who used drugs but did not engage in chemsex (DU) and MSM who engaged in chemsex (CX) at M0 (N = 2 493 participants)
| Drug | DU* (n = 562, 22.5%) | CX** (n = 365, 14.6%) | p-value | Total (n = 927) |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| Tobacco | > 0.9 | |||
| No | 301 (54) | 195 (53) | 496 (53.5) | |
| Yes | 261 (46) | 170 (47) | 431 (46.5) | |
| GHB/GBL | < 0.001 | |||
| No | 317 (56) | 126 (35) | 443 (47.8) | |
| Yes | 245 (44) | 239 (65) | 484 (52.2) | |
| Cathinones | < 0.001 | |||
| No | 383 (68) | 145 (40) | 528 (57) | |
| Yes | 179 (32) | 220 (60) | 399 (43) | |
| Amphetamines / Methamphetamines | < 0.001 | |||
| No | 502 (89) | 298 (82) | 800 (86.3) | |
| Yes | 60 (11) | 67 (18) | 127 (13.7) | |
| Ecstasy | 0.012 | |||
| No | 237 (42) | 185 (51) | 422 (45.5) | |
| Yes | 325 (58) | 180 (49) | 505 (54.5) | |
| Cocaine/Crack | 0.6 | |||
| No | 249 (44) | 168 (46) | 417 (45) | |
| Yes | 313 (56) | 197 (54) | 510 (55) | |
| Ketamine | 0.2 | |||
| No | 454 (81) | 283 (76) | 737 (79.5) | |
| Yes | 108 (19) | 82 (24) | 190 (20.5) | |
| Drug injection | 0.010 | |||
| No | 538 (96) | 334 (91.5) | 872 (94) | |
| Yes | 24 (4) | 31 (8.5) | 55 (6) |
* DU = MSM who used drugs but did not engage in chemsex
** CX = MSM who engaged in chemsex
Fig. 2.
MSM who engaged in chemsex (CX), MSM who used drugs but did not engage in chemsex (DU) and MSM who did not use drugs (non-DU) at each follow-up visit, (N = 2 493 participants, 19 375 follow-up visits)
The following two paragraphs describe, respectively, the comparisons made for non-DU and CX with respect to the reference group DU (see Table 2):
Table 2.
Study population characteristics at baseline according to drug use groups (N = 2 493 participants, 19 375 follow-up visits)
| M0 | |||||||
|---|---|---|---|---|---|---|---|
| DU* | Non-DU** | p-value§ | CX*** | p-value§ | Total | ||
| (N = 562) | (N = 1 566) | No-DU vs. DU | (N = 365) | CX vs. DU | (N = 2 493) | ||
| n(%) | |||||||
|
Agea (years) Mean (± SD) Median [IQR] |
35.0 (± 9) 34 [28–41] |
37.0 (± 10.0) 36 [29–44] |
< 0.001 |
38.0 (± 9.0) 37 [31–44] |
< 0.001 |
37.0 (± 10.0) 36 [29–43] |
|
| Education level a | |||||||
| Upper secondary school certificate or lower | 69 (12.3) | 221 (14.1) | 0.929 | 50 (13.7) | 1.000 | 340 (13.6) | |
| Tertiary education below Master’s degree | 213 (37.9) | 541 (34.5) | 0.508 | 141 (38.6) | 1.000 | 895 (35.9) | |
| Master’s degree or higher | 280 (49.8) | 804 (51.3) | 1.000 | 174 (47.7) | 1.000 | 1258 (50.5) | |
| Living alone a | 329 (58.5) | 911 (58.2) | 1.000 | 216 (59.2) | 1.000 | 1456 (58.4) | |
| Perceived financial situation | |||||||
| Comfortable | 176 (31.3) | 440 (28.1) | 0.494 | 92 (25.2) | 0.160 | 708 (28.4) | |
| You get by | 207 (36.8) | 695 (44.4) | 0.007 | 154 (42.2) | 0.352 | 1056 (42.4) | |
| It’s hard to make ends meet | 179 (31.9) | 431 (27.5) | 0.175 | 119 (32.6) | 1.000 | 729 (29.2) | |
| PrEP-experienced before enrolment a | 322 (57.3) | 840 (53.7) | 0.446 | 254 (69.8) | 0.001 | 1416 (56.8) | |
|
Center for Epidemiologic Studies-Depression scale score Mean (± SD) Median [IQR] |
15.0 (± 10.0) 13 [8–20] |
15.0 (± 10.0) 13 [8–20] |
1.000 |
16.0 (± 11.0) 15 [8–22] |
0.032 |
15.0 (± 10.0) 13 [8–20] |
|
|
Rosenberg self-esteem scale score Mean (± SD) Median [IQR] |
31.6 (± 5.3) 32 [28–36] |
32.0 (± 5.3) 32 [29–36] |
0.230 |
31.1 (± 5.5) 31 [28–36] |
0.552 |
31.8 (± 5.3) 32 [28–36] |
|
| Feeling… | |||||||
| Very supported | 128 (22.9) | 233 (14.9) | < 0.001 | 58 (16.0) | 0.040 | 419 (16.9) | |
| Quite supported | 242 (43.3) | 774 (49.6) | 0.033 | 162 (44.6) | 1.000 | 1178 (47.4) | |
| Quite or very alone | 189 (33.8) | 555 (35.5) | 1.000 | 143 (39.4) | 0.296 | 887 (35.7) | |
| Lifetime care received from a professional for mental health problems | 299 (53.6) | 671 (43.0) | < 0.001 | 172 (47.5) | 0.245 | 1142 (46.0) | |
| Lifetime medical treatment or hospitalization for mental health problems | 173 (31.0) | 413 (26.5) | 0.595 | 109 (30.1) | 1.000 | 695 (28.0) | |
|
Alcohol Use Disorders Identification Test- Consumption score Mean (± SD) Median [IQR] |
5.2 (± 2.3) 5 [4–7] |
4 (± 2.4) 4 [2–6] |
< 0.001 |
4.4 (± 2.6) 4 [2–6] |
< 0.001 |
4.3(± 2.5) 4 [2–6] |
|
| Cannabis use b | |||||||
| Never | 313 (55.7) | 1218 (77.8) | < 0.001 | 213 (58.5) | 1.000 | 1744 (70.0) | |
| Occasionally | 159 (28.3) | 263 (16.8) | < 0.001 | 115 (31.6) | 0.989 | 537 (21.5) | |
| Regularly | 90 (16.0) | 85 (5.4) | < 0.001 | 36 (9.9) | 0.030 | 211 (8.5) | |
| Poppers use b | |||||||
| Never | 106 (18.9) | 627 (40.0) | < 0.001 | 39 (10.7) | 0.003 | 772 (31.0) | |
| Occasionally | 271 (48.2) | 586 (37.4) | < 0.001 | 189 (51.9) | 1.000 | 1046 (42.0) | |
| Regularly | 185 (32.9) | 353 (22.5) | < 0.001 | 136 (37.4) | 1.000 | 674 (27.0) | |
| Having a main partner | 267 (47.5) | 773 (49.4) | 1.000 | 157 (43.0) | 0.607 | 1197 (48.0) | |
| Number of casual sex partners b | |||||||
| < 5 | 121 (21.6) | 425 (27.2) | 0.032 | 75 (20.7) | 1.000 | 621 (25.0) | |
| Between 5 and 8 | 122 (21.8) | 328 (21.0) | 1.000 | 56 (15.4) | 0.061 | 506 (20.3) | |
| Between 10 and 19 | 157 (28.0) | 417 (26.6) | 1.000 | 96 (26.4) | 1.000 | 670 (26.9) | |
| ≥ 20 | 160 (28.6) | 395 (25.2) | 0.443 | 136 (37.5) | 0.019 | 691 (27.8) | |
| Systematically used condoms b | 92 (16.4) | 324 (20.8) | 0.035 | 34 (9.3) | 0.009 | 450 (18.1) | |
| PrEP adherence | |||||||
| Optimal | 137 (24.4) | 372 (23.8) | 1.000 | 138 (37.8) | < 0.001 | 647 (26.0) | |
| Sub-optimal | 104 (18.5) | 297 (19.0) | 1.000 | 73 (20.0) | 1.000 | 474 (19.0) | |
| No PrEP use | 321 (57.1) | 897 (57.3) | 1.000 | 154 (42.2) | < 0.001 | 1372 (55.0) | |
| Fisting or BDSM sexual practices c | 29 (5.2) | 78 (5.0) | 1.000 | 121 (33.2) | < 0.001 | 228 (9.1) | |
| Status of current sex life | |||||||
| Not at all satisfied or not really satisfied | 136 (24.2) | 432 (27.6) | 0.400 | 93 (25.5) | 1.000 | 661 (26.5) | |
| Quite satisfied | 324 (57.7) | 882 (56.4) | 1.000 | 200 (54.9) | 1.000 | 1406 (56.5) | |
| Very satisfied | 102 (18.1) | 250 (16.0) | 0.776 | 71 (19.5) | 1.000 | 423 (17.0) | |
| Having a risky sex life | |||||||
| Not at all or not really | 203 (36.1) | 703 (44.9) | 0.001 | 100 (27.4) | 0.021 | 1006 (40.4) | |
| Yes, quite risky | 262 (46.6) | 647 (41.3) | 0.099 | 164 (44.9) | 1.000 | 1073 (43.0) | |
| Yes, definitely risky | 97 (17.3) | 216 (13.8) | 0.164 | 101 (27.7) | 0.001 | 414 (16.6) | |
§Pairwise comparison with Bonferroni’s correction; a Baseline data; b Previous 3 months; c During the most recent sexual intercourse
* MSM who used drugs but did not engage in chemsex
** MSM who did not use drugs
*** MSM who engaged in chemsex
Non-DU were older (median [IQR] age of 36 [29–44] years vs. 34 [28–41] years, p < 0.001) and were more likely to report feeling moderately supported (49.6% vs. 43.3%, p = 0.033), (although the proportion who said they felt very supported was lower (14.9% vs. 22.9%, p < 0.001)). In terms of mental health, a lower proportion of non-DU declared receiving lifetime care from a professional (43.0% versus 53.6%, p < 0.001). Non-DU also consumed less alcohol (median[IQR] AUDIT score of 4 [2–6] vs. 5 [4–7]), cannabis and poppers (p < 0.001). Non-DU were more likely to report fewer than five sexual partners (27.2% vs. 21.6%, p = 0.032) and systematic condom use (20.8% vs. 16.4%, 0.035). Finally, a higher proportion of non-DU answered ‘not at all/not really’ to the question regarding a risky sex life (44.9% vs. 36.1%, p = 0.001). No difference was found between both groups in terms of PrEP adherence (23.8% vs. 24.4%, p = 1).
CX were older than DU (37 (31–44] years vs. 34[28–41] years, p < 0.001). They also had a higher depression score (15[8–22] vs. with 13[8–20], p = 0.032), and were less likely to report they felt very supported (16.0% vs. 22.9%, p = 0.040). CX had a lower alcohol consumption score (4[2–6] vs. 5[4–7], p < 0.001), and were less likely to consume cannabis (9.9% vs. 16.0%, p = 0.030). In contrast, they were more likely to report using poppers (10.7% vs. 18.9%). CX were also more likely to report 20 or more partners (37.5% vs. 28.6%, p = 0.019). Only 9.3% (vs. 16.4%, p = 0.009) of CX declared systematic use of condoms. The proportion of participants who had already taken PrEP at enrolment was higher among CX (69.8% vs. 57.3%, p = 0.001). In addition, CX were more likely to report optimal PrEP adherence (37.8% vs. 24.4%, p < 0.001). The proportion of CX not taking PrEP was lower (42.2% vs. 57.1%, p < 0.001). CX were much more likely to report fisting/BDSM sexual practices (33.2% vs. 5.2%, p < 0.001). Finally, a higher proportion of CX declared definitely having a risky sex life (27.7% vs. 17.3% of DU, p < 0.001).
Multivariable analysis
The results of the multivariate analysis in Table 3 show the factors associated with being a CX or non-DU compared with being a DU, repeated responses over time being taken into account. We investigate each in the following two paragraphs.
Table 3.
GEE multinomial logistic regression: multivariate analysis of factors associated with being a MSM who engaged in chemsex (CX) and being an MSM who did not use drugs at all (non-DU) compared with MSM who used drugs but did not engage in chemsex (DU) (N = 2 493 participants, 19 375 follow-up visits)
| Univariate models | Multivariate model | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Non-DU* (vs. DU**) | CX*** (vs. DU) | No-DU (vs. DU) | CX (vs. DU) | ||||||
| OR [IC 95%] | p | OR [IC 95%] | p | aOR [IC 95%] | p | aOR [IC 95%] | p | ||
| Agea (years) | 1.04 [1.03;1.05] | < 0.001 | 1.04 [1.03;1.05] | < 0.001 | 1.03 [1.02;1.04] | < 0.001 | 1.02 [1.01;1.03] | < 0.001 | |
| Education level a | |||||||||
| Upper secondary school certificate or lower | ref | ref | ref | ref | |||||
| Tertiary education below Master’s degree | 0.78 [0.61;1.00] | 0.053 | 0.89 [0.68;1.15] | 0.365 | 0.81 [0.64;1.02] | 0.073 | 0.86 [0.67;1.11] | 0.240 | |
| Master’s degree or higher | 0.78 [0.61;1.00] | 0.046 | 0.72 [0.56;0.93] | 0.011 | 0.79 [0.62;0.99] | 0.042 | 0.70 [0.55;0.90] | 0.005 | |
| Perceived financial situation a | |||||||||
| Comfortable | |||||||||
| You get by | 1.09 [0.91;1.32] | 0.342 | 1.11 [0.90;1.36] | 0.351 | |||||
| It’s difficult to make ends meet | 0.86 [0.71;1.05] | 0.144 | 1.19 [0.96;1.47] | 0.109 | |||||
| Had already taken PrEP at enrolment a | 0.80 [0.68;0.93] | 0.003 | 1.27 [1.07;1.51] | 0.006 | 0.74 [0.64;0.86] | < 0.001 | 1.04 [0.87;1.23] | 0.664 | |
| Center for Epidemiologic Studies-Depression scale score b | 1.00 [0.99;1.01] | 0.934 | 1.01 [1.00;1.02] | 0.026 | 1.00 [1.00;1.01] | 0.854 | 1.01 [1.00;1.02] | 0.006 | |
| Rosenberg self-esteem scale b | 1.01 [1.00;1.02] | 0.218 | 0.99 [0.98;1.01] | 0.453 | |||||
| Feeling… b | |||||||||
| Very supported | 0.84 [0.73;0.96] | 0.011 | 0.75 [0.62;0.91] | 0.004 | |||||
| Quite supported | |||||||||
| Quite or very alone | 1.02 [0.94;1.15] | 0.660 | 1.14 [0.98;1.32] | 0.089 | |||||
| Lifetime care received from a professional for mental health problems b | 0.88 [0.76;1.02] | 0.095 | 0.91 [0.77;1.07] | 0.237 | |||||
| Alcohol Use Disorders Identification Test-Consumption score | 0.86 [0.84;0.88] | < 0.001 | 0.86 [0.84;0.89] | < 0.001 | 0.90 [0.88;0.92] | < 0.001 | 0.91 [0.88;0.93] | < 0.001 | |
| Cannabis use c | |||||||||
| Never | |||||||||
| Occasionally | 0.51 [0.46;0.57] | < 0.001 | 0.59 [0.50;0.70] | < 0.001 | 0.62 [0.55;0.69] | < 0.001 | 0.67 [0.57;0.78] | < 0.001 | |
| Regularly | 0.31 [0.26;0.37] | < 0.001 | 0.49 [0.39;0.60] | < 0.001 | 0.40 [0.34;0.48] | < 0.001 | 0.62 [0.50;0.76] | < 0.001 | |
| Poppers use c | |||||||||
| Never | |||||||||
| Occasionally | 0.60 [0.54;0.67] | < 0.001 | 1.14 [0.99;1.32] | 0.077 | 0.70 [0.63;0.78] | < 0.001 | 1.19 [1.03;1.37] | 0.021 | |
| Regularly | 0.48 [0.42;0.55] | < 0.001 | 1.16 [0.97;1.38] | 0.102 | 0.61 [0.53;0.70] | < 0.001 | 1.14 [0.96;1.37] | 0.141 | |
| Having a main partner | 1.04 [0.95;1.14] | 0.406 | 0.75 [0.66;0.86] | < 0.001 | 0.93 [0.85;1.02] | 0.104 | 0.74 [0.65;0.84] | < 0.001 | |
| Number of casual sex partners c | |||||||||
| < 5 | |||||||||
| Between 5 and 9 | 0.70 [0.63;0.77] | < 0.001 | 0.93 [0.81;1.08] | < 0.329 | 0.73 [0.66;0.81] | < 0.001 | 0.91 [0.78;1.06] | 0.241 | |
| Between 10 and 19 | 0.61 [0.55;0.68] | < 0.001 | 0.96 [0.83;1.11] | 0.577 | 0.64 [0.57;0.71] | < 0.001 | 0.90 [0.77;1.06] | 0.206 | |
| ≥ 20 | 0.55 [0.49;0.63] | < 0.001 | 1.14 [0.96;1.34] | 0.131 | 0.61 [0.54;0.69] | < 0.001 | 1.08 [0.91;1.27] | 0.390 | |
| Systematic use of condoms c | 0.97 [0.97;1.07] | 0.529 | 0.73 [0.63;0.85] | < 0.001 | 0.97 [0.87;1.09] | 0.642 | 0.76 [0.64;0.81] | 0.002 | |
| PrEP adherence | |||||||||
| Optimal | |||||||||
| Sub-optimal | 0.81 [0.73;0.89] | < 0.001 | 0.65 [0.57;0.74] | < 0.001 | 0.91 [0.83;1.00] | 0.058 | 0.70 [0.61;0.80] | < 0.001 | |
| No PrEP use (at or after baseline) | 0.89 [0.82;0.98] | 0.013 | 0.53 [0.47;0.60] | < 0.001 | 0.94 [0.86;1.03] | 0.192 | 0.65 [0.57;0.75] | < 0.001 | |
| Fisting or BDSM sexual practices d | 1.87 [1.49;2.34] | < 0.001 | 5.60 [4.26;7.36] | < 0.001 | 1.64 [1.34;2.01] | < 0.001 | 4.73 [3.69;6.05] | < 0.001 | |
| Satisfaction with current sex life b | |||||||||
| Not at all satisfied or not really satisfied | |||||||||
| Quite satisfied | 0.80 [0.71;0.89] | < 0.001 | 0.87 [0.76;1.01] | 0.063 | 0.87 [0.78;0.98] | 0.024 | 0.92 [0.79;1.07] | 0.291 | |
| Very satisfied | 0.76 [0.64;0.89] | < 0.001 | 0.85 [0.68;1.05] | 0.138 | 0.88 [0.75;1.03] | 0.112 | 0.95 [0.77;1.16] | 0.602 | |
| Having a risky sex life b | |||||||||
| Not at all or not really | |||||||||
| Yes, quite risky | 0.86 [0.78;0.95] | 0.003 | 1.07 [0.94;1.22] | 0.304 | 0.89 [0.81;0.98] | 0.017 | 1.07 [0.94;1.22] | 0.329 | |
| Yes, definitely risky | 0.86 [0.73;1.00] | 0.055 | 1.29 [1.06;1.57] | 0.011 | 0.92 [0.79;1.07] | 0.277 | 1.23 [1.01;1.49] | 0.038 | |
aBaseline data; bAnnual imputed data; c Previous 3 months. dDuring the most recent sexual intercourse
* MSM who used drugs but did not engage in chemsex
** MSM who did not use drugs
*** MSM who engaged in chemsex
Compared with DU, non-DU were more likely to be older (per year, OR: 1.03, 95%CI[1.02;1.04], p < 0.001), to practice fisting/BDSM (1.64 [1.34;2.01], p < 0.001), but less likely to have already used PrEP at enrolment (0.74 [0.64;0.86], p < 0.001). However, they were less likely to have a Master’s or Doctorate degree (0.79 [0.62;0.99], p = 0.042), and to have a high AUDIT-C score (0.90 [0.88;0.92], p < 0.001). They were also less likely to use cannabis (occasionally: 0.62 [0.55;0.69], p < 0.001; regularly: 0.40 [0.34;0.48], p < 0.001) and poppers (occasionally: 0.70 [0.63;0.78], p < 0.001; regularly: 0.61 [0.53;0.70], p < 0.001). In addition, non-DU were less likely to report having had 5 to 9 partners in the previous 3 months: (0.73 [0.66;0.81], p < 0.001), 10 to19 partners (0.64 [0.57;0.71], p < 0.001), and 20 or more partners (0.61 [0.54;0.69], p < 0.001)). Finally, non-DU were less likely to report being quite satisfied with their current sex life (0.87 [0.78;0.98], p = 0.024), and to answer “yes, quite risky” when talking about their sexual life (0.89 [0.81;0.98], p = 0.017).
Compared with DU, CX were also more likely to be older (per year, 1.02 [1.01;1.03], p < 0.001), to have a higher depression score (per point, 1.01 [1.00;1.02], p = 0.006), to report fisting/BDSM (4.73 [3.69;6.05], p < 0.001), to occasionally consume poppers (1.19 [1.03;01.37], p = 0.021), and to reply “definitely risky” to the question on their sex life (1.23 [1.01;1.49], p = 0.038). In contrast, CX had a lower AUDIT-C score (0.91 [0.88;0.93], p < 0.001), and were less likely to report consuming cannabis either occasionally or regularly (0.67 [0.57;0.78], p < 0.001; 0.62 [0.50;0.76], p < 0.001, respectively), to have a main partner (0.74 [0.65;0.84], p < 0.001), to use condoms systematically (0.76 [0.64;0.81], p = 0.002), and to report sub-optimal or no use of PrEP (0.70 [0.61;0.80], p < 0.001; 0.65 [0.57;0.75], p < 0.001, respectively).
The sensitivity analyses did not highlight any major change in other co-variable effects when all annual variables were removed. Accordingly, we decided to retain these variables in the final analyses.
Discussion
Our findings show that while a non-negligible proportion (15%) of MSM included in the ANRS-PREVENIR cohort reported engaging in chemsex (CX), the proportion of MSM who used drugs but did not engage in chemsex (DU) was even higher (23%). These results are in line with previous findings showing that in MSM using PrEP, 10% (Hovaguimian et al. 2024) to 24% (Flores Anato et al. 2022) reported they engaged in chemsex. There were similarities between the DU and CX groups in our study, including PrEP initiation before enrolment in ANRS-PREVENIR, the number of casual partners in the previous three months, and a moderately risky sex life. There were also differences between both these groups (i.e., CX and DU) in terms of mental health and prevention practices, which are detailed above.
The main findings of our study were that the DU group, which represented 23% of the study sample at baseline, were more likely than persons who did not use drugs at all (no-DU) to report sexual risk behaviours. Specifically, they had more casual partners and were more likely to declare having a moderately risky sex life. In terms of PrEP adherence, the DU group was more likely to report sub-optimal adherence compared to the CX group, and had a tendency of suboptimal adherence compared to the no-DU group. The latter result corroborates previous findings showing good PrEP adherence among MSM who engage in chemsex. Specifically, a Canadian cohort of MSM showed that chemsex was not a barrier to PrEP use (Flores Anato et al. 2021) and results from the French IPERGAY trial showed that MSM engaging in chemsex were more likely to use PrEP correctly than other MSM (Roux, 2018).
Our results also corroborate previous findings which suggested that certain psychosocial vulnerabilities are specific to MSM who engage in chemsex (Blanchette et al. 2023). In our study, CX were less likely to have a high education level (compared with non-DU and DU) and to have a main partner. In contrast, they were more likely to have a higher depression score. These vulnerabilities may be linked to specific past experiences linked to their homosexual status or to childhood trauma (Shelly, Bost, et Moreau 2023). Recent articles highlight that MSM who engage in chemsex need tailored psychosocial support which takes into account their relationship with sexuality and mental health, and which ensures respect, empathy and non-judgment (Blanchette et al. 2023).
Combining our results with those from other studies, what emerges is that MSM who engage in chemsex and MSM who use drugs but do not engage in chemsex have different HR needs. It is therefore not enough to simply add generalised HR responses to sexual health prevention services for the MSM population as a whole (von Hammerstein et Billieux 2024). Responses must be adapted to the psychosocial vulnerabilities of each MSM subpopulation. This challenge has been already highlighted by Hibbert et al. (Hibbert et al. 2019) who showed that MSM who engaged in chemsex were less satisfied with their lives and perceived that chemsex had a negative impact on their life.
A much greater number of studies to date have focused on MSM who engage in chemsex than on MSM who use drugs but do not engage in chemsex. In our study, the latter group were more likely to have a risky sex life and a large number of casual sex partners, but were less likely than the CX group to be optimally adherent to PreP. A recent study conducted on MSM using a latent class analysis found an interesting typology of MSM who use drugs: minimal users, low-threshold users, old-skool users, chemsex-plus users and diverse users (Melendez-Torres et al. 2018b). This finding corroborates our results highlighting a number of different characteristics between DU and CX. As the authors of that study explained, “it points the need [sic] to consider that drug-related harm may arise from more than the subset of drugs considered ‘chemsex drugs’” and “the greatest number of cases of a disease may not necessarily occur in the highest-risk (and thus generally small) subgroup or the population, but in the larger medium-risk group, even though average risk is lower. Thus, the greatest number of sexual encounters leading to HIV transmission may well occur in the largest classes, in which prevalence of chemsex drug use was not especially high.” (Melendez-Torres et al. 2018b). Our findings clearly show that MSM who used drugs that did not engage in chemsex had many casual partners but sub-optimal adherence to PrEP. Although the emergence and recognition of chemsex as a public health issue has changed the HR response to MSM communities in terms of tailored prevention services - for example PrEP distribution (as PrEP is “far more than just a prescription” (Razon et al. 2021), and associated STI and HIV testing - it is important to also consider the HR needs of MSM who use drugs but who do not engage in chemsex.
More generally, our findings emphasize the need for a better understanding of MSM relationships with drug use, especially given the high prevalence of drug use in this population, and the negative health consequences associated with chemsex. While some findings have documented the link between minority stress due to stigmatization related to sexual orientation and drug use (Felner et al. 2021), no data exist on the causal relationships between structural factors, the negative consequences of drug use, and MSM drug-use trajectories (i.e., whether they lead to chemsex or not).
Our findings suggest the need to systematically integrate HR in HIV prevention services for MSM who practice chemsex and to include HIV prevention strategies in standard HR services for MSM who do not engage in chemsex. More globally, all recognized and validated HR services (e.g., access to HR tools, drug-checking services, psychosocial follow-up, psychiatric care) should be adapted to these two subpopulations.
Several study limitations have to be acknowledged. The ANRS-PREVENIR cohort study only enrolled PrEP users in the Paris region and found it difficult to reach young MSM and those with a lower socioeconomic status. In addition, the two questions regarding drug use and chemsex practice which we used to build our study outcome did not use the same timeframe. The former concerned the previous three months while the latter concerned the most recent sexual encounter. This may have led to chemsex being underestimated. Further studies are needed to better understand the trajectories of drug use and chemsex practice among MSM, and the patterns of switching from one status to another (i.e., CX to DU and vice-versa) according to socio-ecological factors. This would help to better adapt HR prevention responses.
To conclude, our findings highlight that some MSM use drugs but do not engage in chemsex. For this subpopulation, it is important to promote prevention through PrEP distribution and to provide adequate tailored HR services. Our results also underline the fact that chemsex is associated with psychosocial vulnerabilities, and consequently, adequate mental health care is essential.
Acknowledgements
We want to thank all the people who took part in the ANRS-Prévenir study for their participation in the research, as well as the site investigators, the scientific committee, the community advisory board, staff and the funders: The French National Agency for Research on AIDS and Viral Hepatitis– Emerging Infectious Diseases (ANRS| MIE), Sidaction, Gilead and the Regional Council of Île-de-France administrative region.
Author contributions
CP, LST, BS, PR are responsible for the study design. MH and CD led the data analysis under the supervision of LST and CP. LST and PR drafted the manuscript with input from GJ, DC and JMM. PR supervised and critically reviewed and revised the manuscript. LST critically reviewed and revised the manuscript, especially the methods and results sections. LA and AS provided ongoing support to design and data collection. AS performed the data management. All authors assisted to the project as well as read and approved the final manuscript.
Funding
This work was supported by The French National Agency for Research on AIDS and Viral Hepatitis– Emerging Infectious Diseases (ANRS| MIE); Sidaction; Gilead; and the Regional Council of Île-de-France administrative region. The sponsors had no role in the study design, in the collection, analysis and interpretation of data, or in the writing of the article.
Data availability
Please contact the corresponding author for requests of datasets or material.
Declarations
Ethical approval and consent to participate
The protocol was approved by the French Drug Agency (Agence nationale de sécurité du médicament et des produits de santé) and by the CPP Paris Ile de France IV ethics committee. All participants provided written informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare the following financial interests, personal and/or professional relationships which may be considered as potential competing interests: • DC reports an HIV grant from Janssen (2019-2020), personal fees from Gilead (2020) and Pfizer (2022) for lectures outside the submitted work. • JG reports receiving supports as an advisor for Gilead Sciences, Merck, Janssen, Roche, AstraZeneca, Theratechnologies, and ViiV, and grants from Gilead Sciences an ViiV. • JMM reports receiving support as an advisor for Gilead Sciences, Merck, Janssen, and ViiV, and research grants from Gilead Sciences. • All other authors declare no conflict of interest.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Christel Protiere and Perrine Roux contributed equally to this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Please contact the corresponding author for requests of datasets or material.