Michael Cassell, FHI 360, EpiC/Vietnam
Matt Avery, FHI 360, EpiC/Thailand

The link between drug use and HIV risk is well documented across a wide range of substances, modes of administration, and contexts. While there are now proven, highly effective interventions to reduce the risk of HIV and other diseases associated with injecting drug use, additional solutions are needed to mitigate the risks specific to the global expansion of sexualized drug use, or “chemsex.”

Chemsex refers to intentionally taking drugs before or during casual or group sex to facilitate, initiate, prolong, sustain, and intensify pleasure. It is a growing public health concern, particularly among men who have sex with men (MSM), who globally are more likely to use illicit drugs than the general population. Several studies have estimated chemsex participation among MSM across Asia to range from 3.1% to 30.8%.

Combining sex and drugs can impair capacity to make informed decisions about sexual behavior. It can also contribute to sexual risk-taking, condomless sex or unnoticed condom breakage, sharing of injecting and other ingesting equipment, and missed antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP) doses. In turn, these HIV risks may contribute to other negative outcomes, including sexually transmitted infections, poor mental health, and addiction.

People who engage in chemsex also face substantial barriers to health service access. To overcome these barriers, HIV programs need to offer differentiated solutions, including client-centered counseling and case management support that are tailored to this population and responsive to the wide range of risks associated with different drug administration practices, including ingestion, smoking, and snorting.

Given this need, the Meeting Targets and Maintaining Epidemic Control (EpiC) project funded by PEPFAR and USAID recently published Chemsex, MSM, and the HIV Cascade – A Guide for Program Planners in Key Population Led HIV/Sexual Health Programs in Southeast Asia, developed collaboratively by FHI 360 and regional partner APCOM. This guide is distinct from existing resources in focusing on strategies public health practitioners can employ to minimize the impact of chemsex on participants’ HIV risks, rather than on controlling the drugs themselves.

The guide uses EpiC’s HIV cascade as an organizing framework to help program planners develop and implement HIV prevention, testing, and treatment activities that are more attractive, relevant, and responsive to individuals who engage in chemsex (Figure 1). At each step across the cascade (i.e., identify, reach, test, prevent, and treat), the guide discusses the following:

  • Characteristics of chemsex participants that may affect risk and service delivery
  • Implementation strategies for both face-to-face and online/virtual interventions
  • Programmatic examples and resources where relevant and available

Examples of the interventions described in the guide include mapping and social listening approaches to identify and reach chemsex participants via dating apps and social network platforms, interpersonal communication models and tools (such as motivational counseling) to engage chemsex participants in conversations about reducing or eliminating risk, and considerations for “chemsex-aware” HIV treatment and support services.

Figure 1. Specific chemsex interventions in the cascade

Source: EpiC, APCOM. Chemsex, MSM, and the HIV Cascade – A Guide for Program Planners in Key Population Led HIV/Sexual Health Programs in Southeast Asia. Version 1. Durham (NC): FHI 360; 2021.

EpiC’s cascade framework recognizes and responds to the dynamic nature of the risks and service access barriers that individuals may face over time. The Chemsex, MSM, and the HIV Cascade guide offers integrated, community-based, and key-population-led service delivery and referral approaches that provide clients with convenient connections to additional services—such as those related to substance use—as their individual risks evolve. Since HIV services are not delivered in a vacuum, the guide emphasizes the importance of a supportive environment that addresses stigma and discrimination, consensual sex, sexual violence, and potential legal risks for program clients and service providers.

Chemsex, MSM, and the HIV Cascade is not intended to be an exhaustive resource for all contexts and populations, nor is it intended to be the last word on the subject. Rather, the guide aims to serve as a touchstone for ongoing conversation on how to meet the needs of chemsex users, who include transgender people, sex workers, and potentially other populations, in addition to MSM.

To advance this conversation and inspire practical action, the guide draws upon the experience of EpiC partners and collaborators, including APCOM, Mainline, Asia Catalyst, the Terrance Higgins Trust, and the International Network of People who Use Drugs. Although many of the examples in the guide focus on the Asian context —such as the efforts of Hope Clinic in Taiwan to create a safe environment for chemsex users—we believe they have broader relevance and can be adapted, informed by local expertise, to meet the needs of chemsex participants around the world.

We hope that as program implementers adapt the tools and approaches described in the guide, they will also prioritize safe, routine collection and analysis of client data about their participation in chemsex. Better, richer, and more representative data are essential to improve the quality of HIV programming. Practitioners need to expand their efforts to provide HIV services for chemsex participants, including by collecting data to inform the continued development of impactful, client-centered programming.

Together, by combining vigorous local action and regional and global exchange, clinical and community providers can improve the quality and impact of services for chemsex participants and play a leading role in accelerating HIV epidemic control.

Photo Credit: APCOM