Prevalence and correlates of recent injecting drug use among gay and bisexual men in Australia: Results from the FLUX study

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Abstract

Background

While illicit drug use is prevalent among gay and bisexual men (GBM) in Australia, little is known about the factors associated with injecting drug use among GBM.

Methods

The Following Lives Undergoing Change (FLUX) study is a national, online prospective observational cohort investigating drug use among Australian GBM. Eligible participants were men living in Australia who were aged 16.5 years or older, identified as gay or bisexual or had sex with at least one man in the last year. We examined baseline data for associations between socio-demographic and behavioural characteristics and recent (last six months) injecting using log-binomial regression.

Results

Of 1995 eligible respondents, 206 (10.3%) reported ever injecting drugs and 93 (4.7%) had injected recently, most commonly crystal (91.4%) and speed (9.7%). Among recent injectors, only 16 (17.2%) reported injecting at least weekly; eight (8.6%) reported recent receptive syringe sharing. Self-reported HIV and HCV prevalence was higher among recent injectors than among other participants (HIV: 46.2% vs 5.0%, p < .001; HCV: 16.1% vs. 1.2%, p < .001). Recent injecting was associated with lifetime use of more drug classes (adjusted prevalence ratio (APR) = 1.31, 95% Confidence Interval (95%CI) 1.21–1.41), longer time since initiating party drug use (APR = 1.02, 95%CI 1.01–1.04), greater numbers of sex partners (2–10 sex partners: APR = 3.44, 95%CI 1.45–8.20; >10 sex partners: APR = 3.21, 95%CI 1.30–7.92), group sex (APR = 1.42, 95%CI 1.05–1.91) and condomless anal intercourse with casual partners (APR = 1.81, 95%CI 1.34–2.43) in the last six months.

Conclusions

Observed associations between injecting and sexual risk reflect a strong relationship between these practices among GBM. The intersectionality between injecting drug use and sex partying indicates a need to integrate harm reduction interventions for GBM who inject drugs into sexual health services and targeted sexual health interventions into Needle and Syringe Programs.

Introduction

Illicit drug use is prevalent among gay and bisexual men (GBM) in Australia as well as other settings, such as Europe (Schmidt et al., 2016) and the United States (US) (Reback, Shoptaw, & Grella, 2008; Yu, Wall, Chiasson, & Hirshfield, 2015). In Australia, illicit drug use in the last six months among Gay Community Periodic Survey (GCPS) participants 2004–2015 ranged between 57% and 72% (Hull et al., 2015; Lea, Prestage et al., 2013). In Europe, prevalence of illicit drug use in the past four weeks among participants in the 2010 European MSM Internet Survey (EMIS) ranged between 6.2% and 28.3% for poppers, 4.9% and 13.8% for cannabis and 2.3% and 10.6% for party drugs (Bourne, 2012). In a 2004–2005 online survey in the US, levels of drug use before sex among 8717 US men who have sex with men (MSM) ranged from 15.3% for amphetamine, 14.4% for ecstasy, 10.5% for gamma-hydroxybutyrate (GHB), and 7.6% for ketamine (Yu et al., 2015). According to behavioural surveillance in Los Angeles, between 1996 and 2007 prevalence of methamphetamine use among GBM in the last 12 months ranged between 11% and 53% (Reback et al., 2008).

Australian GBM use amyl nitrite, methamphetamine (including crystal) and oral erectile dysfunction medications (EDM) (Prestage, 2009) to enhance sexual pleasure and performance (McCabe, Hughes, Bostwick, West, & Boyd, 2009; Prestage, Grierson, Bradley, Hurley, & Hudson, 2009). European GBM also report using GHB, ketamine, crystal and mephedrone with sex (an activity referred to as ‘chemsex’) (Schmidt et al., 2016). In the US, GBM also report the use of illicit drugs, most commonly methamphetamine (Reback et al., 2008), within the context of ‘circuit parties’ (Halkitis & Palamar, 2008; Halkitis, Palamar, & Mukherjee, 2007; Morgenstern et al., 2009; Pappas & Halkitis, 2011).

Injecting drug use is more prevalent among Australian GBM than among heterosexual people (Roxburgh, Lea, de Wit, & Degenhardt, 2016). In a 2013 nationally representative sample, 6.2% of participants who identified as lesbian, gay and bisexual (LGB) reported ever injecting drugs compared to 1.3% of heterosexual participants (Roxburgh et al., 2016). Between 2001 and 2009, 4.3%–7.0% of participants in convenience samples recruited in the national GCPS reported injecting drugs in the last six months (Holt, Mao, Prestage, Zablotska, & de Wit, 2011). An online cross-sectional survey of 474 Australian GBM conducted in 2013 found that among the 15.0% of respondents who reported injecting drug use in the previous six months, 8.5% reported receptive syringe sharing (RSS) and 38.0% reported sharing ancillary injecting equipment (swabs, water ampoules) (Hopwood, Lea, & Aggleton, 2015). Previous studies in Australia have reported associations between recent drug injection (in the last six months) and being less likely to be employed full-time, more likely to be HIV positive and HCV positive, to have used party drugs for sex and to have engaged in esoteric sexual practices among GBM (Lea, Mao et al., 2013) and dropping out of school among regular ecstasy users (White et al., 2006).

Unsafe injecting practices by GBM in the context of sex are of particular concern, because they may faciliate HIV transmission and, especially among men living with HIV, hepatitis C virus (HCV) transmission (Ghanem et al., 2011; Jin, Matthews, & Grulich, 2017). Drug use has been implicated in HIV transmission via its association with high-risk sexual practices, particularly condomless anal intercourse among GBM (Berg, 2012; McCabe et al., 2009; Prestage, 2009; Prestage, Grierson et al., 2009; Rawstorne, Digiusto, Worth, & Zablotska, 2007; Sewell et al., 2017). In Australia, 3.8% of new HIV infections are estimated to be among GBM who inject drugs, although the exposure cannot be precisely determined as sexual or injecting (The Kirby Institute, 2015).

Despite the growing body of research on drug use among GBM, most quantitative studies in this population (including the paper from the Australian GCPS (Lea, Mao et al., 2013) only collected incidental data about injecting and, therefore had little capacity to investigate recent injecting and its correlates in detail. The Following Lives Undergoing Change (FLUX) study was specifically designed to investigate drug use and injecting among Australian GBM. The substantial number of variables related to this issue provided a unique opportunity to investigate in detail prevalence and correlates of recent injecting using baseline data from a large prospective observational study specifically designed to examine drug use among GBM. Such findings will be of use to harm reduction, sexual health and gay men’s community organisations as they target and tailor their interventions for this population.

Section snippets

Data source and measures

The FLUX study is an ongoing online prospective observational cohort of Australian GBM which examines the prevalence and incidence of drug use and associated harms, and risk factors for uptake and changes in drug use over time. The study protocol and procedure have been reported elsewhere (Hammoud et al., 2017). The study protocol was approved by the UNSW Human Research Ethics Committee (HC14075).

We used baseline data collected in 2014–2015. Recruitment was conducted online using popular GBM

Results

Between August 2014 and July 2015 2943 men consented to participate, 2705 commenced the baseline survey and 2250 fulfilled the minimum data requirements. We excluded 255 participants who did not provide sufficient information about drug use. Compared to the 1995 men included here, the 255 men excluded were older (mean age of 36.1 vs 32.6; p < .001), more likely to be social engaged with gay friends (mean score of 5.6 vs 5.4; p = .032), more likely to be living with HIV (12.9% vs. 6.9%;

Discussion

Prevalence of recent injecting in our study (4.7%) was similar to that reported by GBM in Sydney in the 2015 GCPS (4.6%) (Hull et al., 2015). However, both estimates are higher than in the general Australian population (0.3%) (Australian Institute of Health and Welfare, 2014). Injecting was most common among recent crystal users (17.2%), a finding similar to that reported by the GCPS. In contrast, opioids are the most commonly injected drugs among the predominantly heterosexual injectors

Conclusions

Our findings confirm that the prevalence of lifetime injecting drug use among Australian GBM (10.3%) is high, with 4.7% reporting injecting in the last six months. Recent injecting was independently associated with high-risk sexual practices such as having multiple sex partners, having group sex with casual partners and recent CLAI-C. While in the Australian context, unsafe sexual practices are the major contributor to HIV and HCV transmission among GBM, the potential contribution of injection

Author agreement/declaration

All authors certify that they have seen and approved the final version of the manuscript being submitted. All authors warrant that the article is the authors’ original work, has not received prior publication and is not under consideration for publication elsewhere.

Disclosure statement

No potential conflicts of interest were reported by the authors.

Acknowledgements

We are grateful to the study participants and to our colleagues Colin Batrouney, Brent Mackie, Marcus Pastorelli and Giang Le. This study was funded by the Australian Research Council (ARC #RG132750). The Kirby Institute and the Centre for Social Research in Health receive funding from the Australian Government Department of Health. Lisa Maher is supported by a National Health and Medical Research Council Senior Research Fellowship and Hao Bui is supported by an Australia Awards Scholarship.

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