Ford Hickson of the London School of Hygiene and Tropical Medicine reflects on the findings of the Gay Men’s Sex Survey.
Blame has always been the key note of the HIV epidemic among gay men. In the 1980s the self-righteous blamed gay people, the promiscuous and sex workers.
They in turn blamed the government and the churches. The old blamed the young and the young blamed the old.
The natives blamed the foreigners, the British blamed the Americans and the humans blamed the monkeys. No one wanted to be seen as part of the problem.
Recently the finger has been turned to point to certain drugs such as mephedrone and the emergence of smartphone apps such as Grindr that make it easier for people to hook up – the powerful combination of stronger, cheaper stimulants and the means to contact a lot of “up-for-it” men in a short period of time.
The result is a chemsex scene. But how common is it? And are our fingers pointing in the right direction?
We’ve just released the results of the latest gay men’s sex survey, the largest and longest running survey of its kind in the world.
This time more than 15,000 men answered an online survey about sex, drugs, prevention needs and health services.
Drink and drugs
In the preceding four weeks of the survey, 89% said they had drunk alcohol and 39% had smoked tobacco – alarming but not surprising.
The use of the drugs typically associated with chemsex was relatively rare. In the last four weeks only 5% had used mephedrone, 3% had used GHB and 2% had used crystal meth – somewhat surprising given chemsex is such a hot topic. It shouldn’t be.
The use of these drugs is highly concentrated in particular groups and networks. While 7% of all men had used any of these three drugs in the past four weeks, 22% of men living with diagnosed HIV and 33% of men living with HIV in London had done so.
In some networks, almost all men use these drugs. Among the men using them the risks of harm are very high. But the needs of men engaged in chemsex are not best served by suggesting chemsex is universal.
In fact, suggesting that it is universal runs the risk of giving the impression that it is both inevitable and impossible to escape. Most gay men in Britain, even in its gay centres, are not having chemsex.
But many men are still acquiring HIV during gay sex. For the first time, the survey asked men with HIV whether they thought drugs or alcohol had played a part in their acquiring the infection.
A quarter felt they played a large part, while three quarters felt they played little or no part. Drugs are part of the story but far from the whole story.
Testing, testing …
The number of HIV tests taken in the UK each year by men who have gay sex has increased ten-fold in the past ten years.
Unsurprisingly, the number of diagnoses has also increased and the length of time men spend with undiagnosed infection, a key parameter for their prognosis, is thankfully getting shorter.
But there has not been a surge in new HIV infections. Estimates from Public Health England suggest that the number of men being infected has stayed flat over the last ten years at about 2,600 infections each year.
The contexts in which men are getting infected might be changing but the number doing so isn’t. Who is to blame?
The finger is currently pointing at the NHS for refusing to provide pre-exposure prophylaxis, or PrEP, for HIV, an effective but expensive preventative drug – expensive to the NHS, who must buy Truvada, the branded drug, and expensive to all those individuals who cannot afford the generic version online.
This finger is accompanied by justified community anger at being strung along in an 18-month process to develop NHS guidelines that was summarily terminated – and which raised well-founded suspicions of deception and misdirection.
But it is a mistake to put everything into PrEP when it comes to prevention. In our survey, 20% of respondents were not confident that kissing never transmits HIV.
Thinking of HIV prevention only one topic at a time impedes our ability to provide education across the demonstrably wide range of needs in the community.
Over the years, attention has shifted from promiscuity, to not using condoms, to HIV treatment optimism, to the internet, to not enough testing, to chemsex, to PrEP-refuseniks.
No doubt in five or ten years’ time, if PrEP is widely available and there is still an epidemic, the finger will be pointing at something else.
Looking for singular solutions has not got us ahead of the curve on HIV infections among men having sex with each other. It is a complex multifaceted problem that requires sustained systemic change in a wide range of social institutions.
One agency alone cannot end HIV, but all individual institutions can recognise the part they play in promoting risks and inhibiting precautions – and to reverse them. Finger pointing should play no part.