The HIV Endgame conference logo stands beside a drawing of several people linking arms

Targeted interventions for men who have sex with men, trans women, and people who inject drugs

Healthy relationships for men who have sex with men

Starting a dialogue on chemsex

As part of a panel on mental health and addictions, David Stuart, of Dean Street Health, spoke about strategies to start conversations about chemsex with men who have sex with men.

Stuart explained that, while the model of drug addiction we’re familiar with is from heroin and crack cocaine, gay men have historically preferred party drugs like ecstasy (MDMA). Although these drugs have historically posed less risk, the invention of social networking apps such as Grindr, and the increased availability of drugs such as GHB, GBL, crystal meth, and mephedrone, have changed the chemsex landscape so that gay men are now arriving in hospitals with symptoms of withdrawal, overdose, and psychosis, as well as higher rates of STIs and HIV.

“There is no amazing chemsex school in the sky where you go to learn to do chemsex support,” Stuart said. “What we might call an addiction problem, these guys are calling a sex problem. Something associated with gay sex, with Grindr, with loneliness, with isolation, with modern gay trends, with hooking-up culture, with peer pressure, with shame around sex, with HIV stigma, complicated communication skills, inabilities to form intimacies and relationships. I don’t know the right place for that support to happen, but we decided that it was in our testing centre.”

The clinic, which has developed a resource page for patients and clinicians, tries to open dialogue about chemsex with its clients by asking three questions:

  • Do you use party drugs for sex?
  • What’s your favourite one?
  • Are you having a good time?

Stuart emphasized that clinic workers don’t have to have all the answers in order to start a meaningful conversation about chemsex, but that asking these questions in a positive way can open more doors than traditional addiction screening questions.

Understanding relationships as central to prevention for young men who have sex with men

Brian Mustanski, of Northwestern University, discussed HIV risk factors for young men who have sex with men, highlighting the “three Rs” of prevention work:

  • Reach, which involves finding realistic ways to reach people with interventions, and balancing reach with impact when creating a portfolio of interventions.
  • Risk factors in the community of interest, meaning that interventions developed for different populations might not be transferrable.
  • Relevance to members of the community, meaning an intervention should be targeted to what the community wants and has identified as being important.

“Gay people do not emerge at age 18 fully formed like the Greek goddess Venus from the sea. We exist before the age of 18.”

Mustanski explained that, in the United States, adolescent and young adult men who have sex with men show an increase in new HIV infections, noting that most of these new infections are among black and Latino men. Although youth are not one of the priority populations identified by Ontario’s HIV/AIDS Strategy, Mustanski argued that understanding the curve in new HIV infections requires studying key populations before they reach the age of 18.

Data from recent studies with LGBT youth have shown that many are coming out online. Mustanski explained that, in the face of discriminatory sex education policies, the internet provides an opportunity to reach young people with messages that can help them manage their health.

Mustanski’s own research has shown that one of the biggest risk factors for young men who have sex with men (a risk even greater than drug use) is being in a serious romantic relationship. In this situation, the partners may stop using condoms. Modelling data suggests that, among young people, nearly 80% of transmissions occur from sex with a serious partner rather than casual sex.

“We need to shift the frame and think about romantic relationships as the lens through which we need to think about HIV prevention.”

Because survey responses have shown that young men who have sex with men prioritize learning how to build long-term, healthy relationships ahead of learning about HIV, Mustanski’s team developed Keep It Up as an intervention that addresses both topics. Data from a pilot study completed in 2010 show that Keep It Up participants were 44% less likely to engage in sex without condoms. The team is now completing trials in Chicago, New York, and Atlanta.

Addressing the priorities of trans women living with and affected by HIV

Zack Marshall, of the University of Waterloo, and Yasmeen Persad, of Women’s College Research Institute, discussed results from the REACH-funded Trans Priorities Project, which interviewed 78 trans women living with or affected by HIV in Vancouver, Edmonton, Winnipeg, Toronto, and Montreal. Women were asked about accessing HIV services, issues facing trans women, and potential interventions.

Marshall explained that, based on the available data from other studies, trans women – particularly black and Latina trans women – appear to have the highest concentrations of HIV in the world, with risk factors including stigma, lack of social and legal recognition, and exclusion from employment and education opportunities. Syndemic models also show a strong, cyclical relationship between sex work, substance use, hormone use or misuse, and incarceration.

Among participants in the Trans Priorities Project, 78% had been involved in sex work, and 72% had used drugs. Preliminary analysis revealed that participants prioritized research on stigma reduction, interactions between hormone therapy and antiretroviral medications, improving service delivery, and trauma and interpersonal violence.

Suggestions to improve service delivery included:

  • a media campaign to raise awareness of trans women’s issues
  • developing wrap-around services (housing, employment, etc.)
  • integrating health services
  • implementing a trans-focused approach to programming and services
  • placing more focus on education, economic empowerment, and employment.

Harm reduction, policing, and risk for people who inject drugs

Thomas Kerr, of the BC Centre for Excellence in HIV/AIDS, discussed challenges and opportunities in harm reduction for people who use drugs, particularly highlighting interventions at the social, structural, and environmental level.

Kerr explained that policing is one of the most cited drivers of harm for people who inject drugs. Studies done in Thailand have shown that people who have experienced police brutality or had their urine tested by police are more likely to share syringes. People are also less likely to get tested for HIV when they perceive an increased police presence.

Studies in Vancouver’s downtown east side have shown that drug enforcement policing has led people to rush injection, and a risk analysis has shown that 21% of new HIV infections in people who inject drugs in Vancouver are among people in prison. A study done with people living with HIV who were on antiretroviral medication before entering prison revealed short-term treatment interruptions during intake and transfers, delays in obtaining medication through institutional health care, high levels of discrimination and stigma, and problems ensuring treatment continuity after release.

Kerr noted that findings from the latter study led to policy changes related to intake procedures, pharmacy-related delays, contingency supplies of medications, and providing medication at discharge.

Kerr explained that hospitals are also risk environments. People who use drugs often discharge themselves from the hospital against the advice of their doctors. Reasons for this include pain management, withdrawal, untreated addiction, abstinence-only policies, security guards, and lack of access to syringes.

Sometimes interventions intended to reduce harm can backfire. Citing a paper by David Moore, Kerr emphasized that many people who use drugs are not able to adhere to interventions that require rational, self-regulating behaviour. Qualitative interviews with people who inject heroin also revealed that posters put out by the Coroner’s Office warning people to avoid an unusually strong batch of heroin actually produced the opposite behaviour.

More successful strategies include supervised injection sites where people who use drugs can take their time, break one hit into two, and use sterile needles. In a survey of people who use injection drugs, 68% said they would use supervised injection services if those services were offered in hospitals, because this would allow them to stay in the hospital for other medical treatments without fear of being kicked out. This dovetails with results from Earl Nowgesic’s Red Ribbon study, in which participants called for needle exchange programs developed in consultation with HIV-affected Indigenous populations.

Current studies are also testing whether changing the schedule for social assistance payments can help reduce drug-related harm. Kerr explained that income-generating activities like sex work and selling drugs are associated with a lower likelihood of viral suppression, but that many sex workers and drug dealers would be willing to give up this work for other low-threshold employment.

Kerr also explained that legalizing marijuana is sometimes considered a path toward harm reduction, since many people who use crack, heroin, or methamphetamines also use cannabis as a substitute to reduce their reliance on hard drugs. He emphasized the need to prioritize harm reduction frameworks above stopping drug use.

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