Challenges in defining Chemsex. Answers for surveillance from EMIS-2017
Axel Jeremias Schmidt M.D. MPH Assistant professor of sexual health and STIs, Sigma Research, LSHTM, London, United Kingdom Division of Infectious Diseases and Infection Control, Cantonal Hospital St. Gallen , Switzerland Swiss Federal Office of Public Health, Bern, Switzerland
STI & HIV 2019 World Congress, 15 July 2019 Outline
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
1. Brief introduction to EMIS-2017.
2. Data items on sexualised drug use and chemsex.
3. Introduction to recency curves.
4. Ranking of 15 cities with respect to three measures of chemsex: Amsterdam, Barcelona, Berlin, Brussels, Istanbul, London, Moscow, Paris, Prague, Stockholm, Tel Aviv, Toronto, Vancouver, Warsaw, Zurich. Acknowledgements
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
EMIS 2017 core team: Axel J. Schmidt, Ford Hickson, David Reid, Peter Weatherburn (Sigma Research, London School of Hygiene & Tropical Medicine, UK) in association with Ulrich Marcus and Susanne B. Schink (Robert Koch Institute, Berlin, DE)
Primary Funding: As part of ESTICOM, EMIS 2017 was carried out under the service contract 2015 71 01 with The Consumers, Health, Agriculture and Food Executive Agency (Chafea), acting under powers delegated by the Commission of the European Union. Other international financial contributions: Swedish Ministry of Health for recruitment in the Nordic Countries; The Arctic University of Norway and University Hospital of North Norway for Russia; Israel Ministry of Health for Israel; Public Health Agency of Canada for Canada; Office of the WHO Representative in the Philippines for the Philippines.. Acknowledgements: We begin by thanking all of the men who took part in EMIS 2017 and our partners who recruited 17% of all respondents through activities on Facebook and other social media and by placing EMIS banners on their websites. We thank all our partners for being part of something huge! Europe: PlanetRomeo, European AIDS Treatment Group (EATG), Eurasian Coalition on Male Health (ECOM), European Centre for Disease Prevention and Control (ECDC), European Monitoring Centre for Drugs & Drug Addiction (EMCDDA), European Commission (DG SANTE). AL: Arian Boci. AT: Aids Hilfe Wien, Dr Frank M. Amort. BA: lgbti.ba, Masha Durkalić. BE: SENSOA, exaequo, Observatoire du SIDA et des sexualités. BG: HUGE, GLAS Foundation, Dr Emilia Naseva, Petar Tsintsarski. BY: Vstrecha. CA: Health Initiative for Men, Rézo, Gay Men’s Sexual Health Alliance of Ontario, CATIE, Université du Quebec & Montréal, University of Toronto, Ryerson University, University of Windsor, University of Victoria, Public Health Agency of Canada, Rob Gair. CH: Swiss AIDS Federation, Cantonal Hospital St. Gallen, Centre Hospitalier Universitaire Vaudois, University Hospital Zurich, Swiss Federal Office of Public Health. CY: AIDS Solidarity Movement. CZ: AIDS pomoc, National Institute of Public Health, Tereza Zvolska, Dr Michał Pitonak. DE: Deutsche AIDS-Hilfe, Robert Koch Institute, BZgA, Dr Michael Bochow, Dr Richard Lemke. DK: AIDS-Fondet, Statens Serum Institut, François Pinchon, Jakob Haff. EE: Eesti LGBT, VEK LGBT, Estonia National Institute for Health Development, Dr Kristi Rüütel. ES: Stop Sida, CEEISCAT, Ministerio de Sanidad. FI: Positiiviset, Hivpoint, SeksiPertti, Trasek. FR: AIDES, Coalition PLUS, SexoSafe, Santé Publique France, INSERM. GR: Ath Checkpoint, Thess Checkpoint; Positive Voice. HR: Iskorak, gay.hr, Zoran Dominković, Vjeko Vacek. HU: Háttér, Tamás Bereczky. IE: Gay Health Network, Man2Man, HIV Ireland, Outhouse, GOSHH, Sexual Health Centre Cork, AIDSWEST, Gay Community News, Health Service Executive, Gay Men's Health Service, Sexual Health and Crisis Pregnancy Programme, Health Protection Surveillance Centre. IL: Israel AIDS Task Force, Israel Ministry of Health, Dr Zohar Mor. IS: Samtökin '78. IT: Arcigay, Fondazione LILA Milano ONLUS, University of Verona, Dr Raffaele Lelleri. LB: SIDC, Dr Ismaël Maatouk. LT: demetra, LGL, Gayline. LV: Testpunkts, Baltic HIV Association, Dr Antons Mozalevskis, Indra Linina. MD: GENDERDOC-M. ME: Juventas. MK: Subversive Front, Dr Kristefer Stojanovski. MT: Malta LGBTIQ Rights Movement, Allied Rainbow Communities, Infectious Disease Prevention and Control Unit (Malta), Silvan Agius, Russel Sammut. NL: Results in Health, Maastricht University, Amsterdam Pink Panel, Soa Aids Nederland, Rutgers, Dr Wim Vanden Berghe. NO: Helseutvalget, Norwegian Directorate of Health, Folkehelseinstituttet, Dr Rigmor C. Berg. PH: Bisdak Pride-Cebu, Cebu Plus, HASH, Pinoy Plus, UP Babaylanes, YPEER, TLF, Natasha Montevirgen, Mikael N. Navarro. PL: Spoleczny Komitet ds AIDS, Kampania Przeciw Homofobii, Lambda Warszawa, Dr Łukasz Henszel. PT: GAT Portugal, CheckpointLX, Associação ABRAÇO, rede ex aequo, SexED, dezanove, ILGA Portugal, Trombeta Bath, ISPUP. RO: PSI Romania, ARAS Romania, Tudor Kovacs. RS: Association Duga, Association Red Line, Omladina JAZAS-a Novi Sad, Institute of Public Health of Serbia, Sladjana Baros, Dr Marija Pantelic. RU: LaSky. SE: RFSL, University of Gothenburg, Folkhålsomyndigheten. SI: ŠKUC, Legebitra, LJUDMILA. SK: PRIDE Košice, Light-House Slovakia, Trnavská univerzita, Slovenská zdravotnícka univerzita, Dr Zuzana Klocháňová. TR: Pozitif Yaşam, Sami Sarper Yazıcılaroğlu. UA: Alliance for Public Health, alliance.global, msmua.org, Oleksii Shestakovskyi. UK: Terrence Higgins Trust, NAM, PrEPster, Antidote, Horizon Drugs and Alcohol Support, LGBT Foundation, Yorkshire MESMAC, MESMAC Newcastle, Derbyshire LGBT+, Trade Sexual Health, London Friend, GMFA, Spectra, International HIV Partnerships, International Planned Parenthood Federation, Bristol University, University College London, Sigma Research, Raul Soriano. Other: Dr John Pachankis, Dr Mark Hatzenbühler, Dr Valeria Stuardo Ávila, Dr Michael W. Ross. Contact: [email protected] EMIS 2017: 50 countries, 33 languages, 137,358 respondents
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
Number of respondents 1 1,000 10,000 Crude recruitment rate per country
≤ 3/10,000 men ≤ 7/10,000 men ≤ 12/10,000 men ≤ 20/10,000 men Sample sizes & response rate
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
Number of respondents 1 1,000 10,000
Crude recruitment rate per country ≤ 3/10,000 men ≤ 7/10,000 men ≤ 12/10,000 men ≤ 20/10,000 men 105 cities…
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019 4-chems
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
-2010
“4-chems: GBH/GBL, Crystal Meth, Mephedrone, & Ketamine “ Sexualised Drug Use and Chemsex
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
1. Description of the last new sexual partner each man had.
2. Questions about how recently the participant had sober sex and how recently they had sex under the influence of stimulant drugs.
3. A question on stimulant drug use and sex in a group.
4. Recency of use of 16 recreational drugs across the whole sample. Combining sex and drugs
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
“In the last 12 months, how much of the sex you’ve had with men has been under the influence of alcohol or any other drug?”
7% said almost all or all
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% None Almost none Less than half About half More than half Almost all All Cumulative recency of sober sex & chemsex
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
100 92% 84% 90
80 64% 70
60 “When was the last time you … 50 • … had sober sex (that is, NOT under the influence of alcohol or any other drug)?” 40 • … used stimulant drugs to make sex more intense or last longer?” • 30 … combined stimulant drugs & sex with > one man at the same time ?” (dotted line) 15% 20 10% 5% 10 0 24 hrs 7 days 4 wks 6 mths 12 mths 5 yrs Ever Chemsex* last 4 weeks
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
* In the last four weeks, “used stimulant drugs [including ecstasy/ MDMA, cocaine, amphetamine (speed), crystal methamphetamine (Tina, Pervitin), mephedrone and ketamine], to make sex more intense or last longer?”
Canada … make sex more intense or last longer
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
1. “Sex last longer” longer exposure.
2. “Make sex more intense” different set of sexual practices different exposures Cumulative recency of …
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019 Stockholm (#15, 2%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Stockholm: 4-chems (any)
35% Stockholm: Stimulant drugs
30% Stockholm: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Prague (#14, 3%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Prague: 4-chems (any)
35% Prague: Stimulant drugs
30% Prague: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Warsaw (#13, 3%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Warsaw: 4-chems (any)
35% Warsaw: Stimulant drugs
30% Warsaw: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Vancouver (#12, 4%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019 40% Vancouver: 4-chems (any)
35% Vancouver: Stimulant drugs
30% Vancouver: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Moscow (#11, 5%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Moscow: 4-chems (any)
35% Moscow: Stimulant drugs
30% Moscow: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Istanbul (#10, 5%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Istanbul: 4-chems (any)
35% Istanbul: Stimulant drugs
30% Istanbul: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Tel Aviv (#9, 5%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019 40% Tel Aviv: 4-chems (any)
35% Tel Aviv: Stimulant drugs
30% Tel Aviv: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Toronto (#8, 9%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Toronto: 4-chems (any)
35% Toronto: Stimulant drugs
30% Toronto: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Brussels (#7, 11%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Brussels: 4-chems (any)
35% Brussels: Stimulant drugs
30% Brussels: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Zürich (#6, 11%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Zürich: 4-chems (any)
35% Zürich: Stimulant drugs
30% Zürich: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Berlin (#5, 11%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Berlin: 4-chems (any)
35% Berlin: Stimulant drugs
30% Berlin: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever London (#4, 11%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019 40% London: 4-chems (any) 35% London: Stimulant drugs 30% London: Combined stimulant drugs & sex 25% with >1 man
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Paris (#3, 12%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Paris: 4-chems (any)
35% Paris: Stimulant drugs
30% Paris: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Barcelona (#2, 14%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Barcelona: 4-chems (any)
35% Barcelona: Stimulant drugs
30% Barcelona: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Amsterdam (#1, 17%)
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
40% Amsterdam: 4-chems (any)
35% Amsterdam: Stimulant drugs
30% Amsterdam: Combined stimulant drugs & sex with >1 man 25%
20%
15%
10%
5%
0% 24h 7d 4w 6m 12m 5y Ever Summary
Schmidt AJ: Challenges in defining Chemsex (EMIS-2017). STI & HIV 2019 World Congress , Vancouver, 15 July 2019
Not all sexualized drug use is use of stimulant drugs for sex, not all use of stimulant drugs for sex is Chemsex. The “4-chems”, despite including GHB (not a stimulant) and Ketamin (can be debated), seem to be a good proxy for sexualized use of stimulant drugs. However both overestimate sexualized drug use with more than one man. EMIS-2017 data provides an excellent opportunity to compare different ways of measuring Chemsex across a range of countries and cities.