hemsex has led the French community-based HIV organisation AIDES to bring two previously separate strands of its work together, Fred Bladou told the recent European Chemsex Forum in Berlin. AIDES began to talk about drug use with gay men and to talk about sexuality with people who inject drugs, he said.
The first part of its strategy was to develop a new approach to sexual health promotion and education. On the edge of Paris’ gay district le Marais, AIDES has opened a community health centre called ‘Le Spot’ that provides HIV testing, easy access to condoms and other prevention materials, and helps develop community understanding of pre-exposure prophylaxis (PrEP) and undetectable = untransmittable (U=U). There is also a strong emphasis on peer support, including weekly peer-to-peer meetings for men involved in chemsex – described as a space that allows men to be listened to and supported, recreating social connections for men who have become isolated.
The second part of the strategy was to develop a new approach to harm reduction, including adapting it to a new population who are taking different substances. Education is provided on safer injecting practices, including staff observing an individual’s injecting practice and giving feedback on how it could be safer. Users can bring substances they have purchased in for testing, to better understand what drugs they are actually taking. Sterile equipment is provided.
A similar approach has been taken in 15 French cities where AIDES works and where chemsex is an issue. Outreach is done at private sex parties, saunas and sex clubs. The organisation also moderates a private Facebook group with around 1200 participants and a WhatsApp group, both of which allow men to share information and feel less isolated.
Stephan Vernhes of AIDES said that the weekly Paris meetings were attended by around 15 men each time, with a total of around 180 men attending in the past year. Establishing ground rules was crucial to creating a safe space, Vernhes said. Each week, participants are reminded of guidelines on non-judgement, confidentiality, active listening and related issues.
To maintain interest, different themes are addressed each week, such as sexuality and pleasure; dealing with cravings; screenings of documentaries on drug issues; and presentations by sexologists, psychiatrists and addiction specialists. As an increasing number of participants now have a goal of abstinence, some sessions now address life without drugs or sex without drugs.
There’s often a tension in the drugs field between proponents of harm reduction (aiming to reduce immediate harms related to drug use without necessarily changing the underlying drug use) and proponents of abstinence (programmes which have the aim of helping the person completely stop using). However many at the forum felt that this was a false dichotomy. David Stuart of the 56 Dean Street clinic in London said that what was most important was to work in a person-centred way, helping the client work towards whatever goal he had set himself.
For many people at the beginning of the process, abstinence is over-ambitious, he suggested. “It’s a very big goal, very heroic,” he said. “It might be wiser to take it in small steps.”
He outlined the ChemSex Care Plan he has developed, an online tool which men can use on their own, but which is also designed to be used by a healthcare professional together with a client. For a worker who has limited knowledge or experience with chemsex, the care plan provides a structure for a conversation and an intervention. It is available in 15 different languages.
The care plan aims to help people identify a goal and work towards it. It asks men to reflect on what they like and dislike about chemsex and what they want to change. The tool helps men identify ‘trigger’ situations when they may have cravings and to think about how they will manage them.
Ingrid Bakker described how the Dutch harm reduction organisation Mainline developed services for men injecting crystal meth in Amsterdam. Around four years ago and through their connections with the gay community, staff members realised that ‘slamming’ was an emerging issue but were not aware of other professionals responding to chemsex or the situation in other countries.
They didn’t have time to have in-depth discussions about the nature of the problem or to develop detailed plans, she said. Instead they took a pragmatic approach. “We prefer to waste as little time as possible, roll up our sleeves and get to work,” she said. “We did some ground work to find out what’s happening and what are the biggest needs, and took the first steps.”
Many men knew little about crystal meth when they had their first experience. They often had poor injecting techniques that they had learnt from each other. Men also reported that the only information they had been able to find online was American and took a ‘just say no’ approach that they did not find appropriate. Mainline therefore developed web and booklet resources to meet these needs.
As the population were already engaged with sexual health clinics and often talked to staff about their sex lives, training efforts were focused on sexual health professionals. As Mainline is a harm reduction organisation that works with people who use drugs, they developed a collaboration with Soa Aids Nederland, an organisation which has the infrastructure and relationships to deliver training to clinicians.
Bakker said that it’s important to identify ‘co-responders’ who can address the issue in different ways. “The multi-sectoral response in the Netherlands grew organically, with various organizations working hard and working together to make a change, each taking responsibility for various parts of the response,” she said.
Jan Großer of Schwulenberatung Berlin said that the complex and fragmented structure of health services in Germany made it challenging to provide joined-up services. Because of different funding streams and divisions between prevention and healthcare, it is difficult to provide holistic services under one roof. This is particularly problematic in relation to chemsex, which requires competencies in sexual minority cultures, drug use in a sexual setting, psychology and sexual health. The way forward is to build networks that can plan and co-ordinate services, he said.
Großer said that men may present with problems in a wide variety of settings. The issue that a man is seeking professional help with – such as relationship or work difficulties – may appear to be unrelated to drug use. But with sensitive questioning, it often becomes apparent that chemsex is part of the problem.
“When people present with some difficulty, have chemsex in the back of your mind,” he advised. “And when you are working with chemsex, think about sex first.”
Services for this population have to be able to deal with the sex as well as the chems. Udo Beckmann of the rehabilitation organisation Tannenhof Berlin-Brandenburg said that he sees too many cases of men relapsing after having been treated at treatment centres where staff have skills in dealing with addiction, but are not comfortable talking about sex.
“Gay sex is at the very centre of this,” commented David Stuart. “It’s all about gay hook up culture.”