Club drugs, or recreational drugs, as they are sometimes called, have only recently been associated with increased high-risk sexual behaviours which, in turn, may cause higher incidence of HIV/AIDS. The most significant new drugs of the past twenty years have been crack, ecstasy, crystal meth and Viagra. Crack played a significant role in spreading HIV in the inner cities of the United States, whereas ecstasy has played a more ambiguous role in North America, Europe and Australasia. More recently, crystal meth and Viagra are playing a significant role in the spread of the HIV epidemic amongst gay scene attendees in North America and Europe.

Crack is a highly addictive derivative of cocaine (see the A–Z of drugs), and has become widely available in inner city areas in the US and Europe. Some researchers attribute the spread of HIV amongst women in the US to the practice of trading sex for drugs. Users are reported to trade sex for the next hit of crack in what are known as crack houses, locations where dealers sell the drug to addicts and make pipes available to smoke the drug. Crack houses often appear to bring uninfected women into contact with HIV-positive injecting drug users acting as dealers.

Crack appears to play a significant role in the spread of HIV in the United States because of its role in encouraging high rates of partner change in communities where HIV is already prevalent. A high incidence of other sexually transmitted infections amongst crack users compounds this problem by increasing the chances of transmission. Researchers in Florida found that women who used crack were more likely to be black, to have had more than five sexual partners per month, and that women were more likely to have exchanged sex for money and to have more than five sex partners per month after initiating crack use (Schoenfisch et al. 1993). It has also been noted that crack use may increase the risk of oral transmission of HIV due to burns and sores in the mouth caused by crack smoking, and because at least one study has shown that the sex sold by male and female crack addicts is predominantly oral sex. Sharing crack pipes is also contributing to the spread of Hepatitis C. It has also been noted that prostitution by crack users has led many non–crack users to seek out crack using prostitutes because they offer cheaper sexual services (Genser et al. 1992).

Crack is now prevalent in the UK, chiefly in larger cities, and it seems that the links between crack use and HIV which have appeared in the US will be replicated in the UK. A recent study, looking at the prevalence of recreational drug use in a group of club-goers in Scotland, found that crack use was less than 5%, compared with 80% use of ecstasy and amphetamines. (Riley et al. 2001). However, police figures from 2002 show that the numbers of those arrested for trafficking and possession of crack in Britain have risen by more than 200% since 1999.

Ecstasy has been linked to unsafe sex by a number of studies of sexual behaviour amongst gay men. This suggests a possible link between ecstasy use and the increase in risk behaviour which could lead to HIV infection.  An American study of 169 gay and bisexual men who were mostly club goers, published in July 2000, found that men who used ecstasy were more likely to have unsafe sex than men who drank or used other drugs. Overall, 57% of the men reported having had unprotected sex at least once during the past year- with the odds being higher among those who used ecstasy frequently (Klitzman et al. 2002).

Drugs such as MDMA have become increasingly popular within a significant drug-using subset. A large probability telephone sample of urban men who have sex with men (MSMs) taken at four large American cities found a 52 percent prevalence of recreational drug use (Stall et al 2001). A separate study in New York City found that 13.7 percent of a sample of MSMs reported using MDMA within the past six months, using it an average of 6.24 times in that period. Compared with non-users, MDMA users were found to have more male partners, have more one-night stands with men, and have more unprotected anal sex with men. (Klitzman et al. 2002). There was clearly an association between club drug use and high-risk sexual behaviours.

Although there have been no further recent studies on the link between Ecstasy and unsafe sexual practices, the use of ecstasy amongst gay men in the UK has not declined. In 2001, twice as many people suffered from ecstasy-related deaths (40 vs. 20) than in 2000 (Stall et al. 1999). Some ecstasy users argue that since the drug relaxes blood vessels, making erections difficult to maintain, unsafe sexual practices are being reduced by the drug.  However, this does not prevent an ecstasy user being the receptive partner. Furthermore, the anti-impotency drug Viagra, which became more widely available in the UK since 1998, is being combined with ecstasy and other drugs increasing the possibility of sexual risk-taking amongst club-going gay men in the UK.

Since HIV-positive men are more likely to suffer from sexual dysfunction than their HIV-negative counterparts, many HIV-positive men receive prescribed Viagra from their clinicians. However, Viagra is easily available through illicit sources, either on the internet or through adverts in the gay and club-scene press, and increasing numbers of men are using it recreationally.

A study presented at the 13^th International AIDS Conference in July 2000 in Durban, conducted quite soon after the licensing of Viagra, among both HIV-positive and HIV-negative gay men using one of five central London gyms found that 15% of all men had ever used Viagra (Sherr et al. 2000). The overwhelming majority (83%) had used it recreationally, without prescription and 63% had combined it with other recreational drugs. HIV-negative men were found to be more likely to report serodiscordant unprotected anal intercourse (UAI) in the previous three months, while actually taking the drug, than those who had never taken it (4.0% v 3.8%). Rates of serodiscordant UAI in the previous three months among the HIV-positive men who were taking the drug were barely different to those recorded among HIV-positive men who had never taken the drug (4.0% v 3.8%). The authors concluded that both HIV-positive and HIV-negative men may have added Viagra to their risk-taking repertoire, rather than Viagra causing the increase in risk behaviour.

A more recent study from San Francisco (Kim et al. 2002) found similar incidences of unprescribed Viagra use, high rates of STIs, and use of Viagra with other recreational drugs. Worryingly, 17% of Viagra users had combined the drug with poppers (amyl/butyl nitrate) which can lead to dangerously low blood pressure, stroke, heart attack or death. The authors were unable to differentiate whether these MSM were experiencing higher rates of STIs and unprotected sex because Viagra enables men to have more partners, Viagra increases the length of sexual exposure, or that these men simply added Viagra to their risk-taking repertoire.

References

Genser SG et al. Sex for crack as an AIDS risk behaviour: an ethnographic study. VIII International AIDS Conference, Amsterdam, abstract WeC 1032, 1992.

Kim AA et al. Increased risk of HIV and sexually transmitted disease transmission among gay or bisexual men who use Viagra, San Francisco 2000-2001, AIDS 16(10): 1425-1428, 2002.

Klitzman RL, Greenberg JD, Pollack LM, Dolezal C. MDMA ("Ecstasy") use, and its association with high-risk behaviours, mental health, and other factors among gay/bisexual men in New York City. Alcohol and Drug Dependence 66: 115-125, 2002.

Riley SC et al. Patterns of recreational drug use at dance events in Edinburgh, Scotland, Addiction 96(7): 1035-1047, 2001.

Schoenfisch S et al. Risk of HIV infection and behavioural changes associated with crack cocaine use in prenatal patients, IX International AIDS Conference, Berlin, abstract PoC 15-2920, 1993.

Sherr L et al. Viagra use and sexual risk among HIV-positive and HIV-negative gay men in London. XIII International AIDS Conference, Durban, abstract WePpD1409,  2000.

Stall R, Paul JP, Greenwood G, Pollack LM et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: The Urban Men's Health Study. Addiction 96: 1589-1601, 2001.