Drug use strongly associated with sex, condomless sex and STIs in gay men living with HIV in England

ASTRA study first of its kind for ten years
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A large survey of gay and bisexual men living with HIV and attending eight sexual health clinics in England has found that half of them had used recreational drugs in the last three months and a quarter had used more than three drugs.

The ASTRA (Antiretrovirals, Sexual Transmission Risk and Attitudes) study was conducted in sexual health clinics in central, north and east London, Sussex and Manchester in 2011 and 2012. All clinic attendees living with HIV had a viral load test and screening for sexually transmitted infections (STIs) and were asked to fill out a behavioural questionnaire: 64% of them completed it. Of these, 2248 people (69%) were men who had sex with men (MSM), most of whom defined as gay.

The 2248 men formed an ageing group: the median age was 46, 11% were over 50 and only 5% were under 30. The median time since their HIV diagnosis was ten years, 85% were on antiretroviral therapy (ART) and 73% had a viral load under 50 copies/ml at their most recent test.

Who used drugs and which ones?

The most popular drugs (excluding alcohol and tobacco) were nitrites (poppers), used by 27% of study participants, and cannabis, cocaine and erectile dysfunction drugs (e.g. Viagra¸ Cialis), which were each used by about 20%. Ketamine and MDMA (ecstasy) were used by about 12% of participants, GHB or GBL by 9% and methamphetamine and mephedrone by 7%. All other individual drugs including various opiates, psychedelics, crack and anabolic steroids were used by less than 4% of study participants. Three per cent of the sample reported injecting drug use (68 people) of whom four reported sharing injecting equipment with persons of unknown serostatus.



Having sex without condoms, which used to be called ‘unprotected’ or ‘unsafe’ sex. However, it is now recognised that PrEP and U=U are effective HIV prevention tools, without condoms being required. Nonethless, PrEP and U=U do not protect against other STIs. 


Amyl, butyl or isobutyl nitrite, are recreational drugs sniffed during sex to both intensify the experience and relax anal sphincter muscles.


In HIV, refers to the act of telling another person that you have HIV. Many people find this term stigmatising as it suggests information which is normally kept secret. The terms ‘telling’ or ‘sharing’ are more neutral.


The use of recreational drugs such as mephedrone, GHB/GBL and crystal meth before or during sex.


Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

The pattern for which drugs were most used stayed the same as the number of different drugs increased; in men who had used just one drug in the last three months, poppers were the most popular, closely followed by cannabis; in men who had used three, these two drugs plus cocaine and erectile dysfunction drugs predominated, and in men who had used more than five drugs there was more or less equal use of these drugs plus ketamine, GHB, MDMA and, to a slightly lesser extent, methamphetamine.

Any drug use was especially strongly associated with younger age, smoking, having disclosed they had HIV to other people, and being non-adherent to antiretroviral therapy (ART). Men who reported drug use were also somewhat more likely to have sex with other HIV-positive rather than HIV-negative partners or partners whose HIV status was unknown. 

Men who reported using four or more drugs were more likely than other men who used drugs or men who did not use drugs to either not be on ART or to have a viral load over 50 copies/ml, and also to be young and to have a higher proportion of partners who also had HIV.

Compared with men over 60, men under 40 were 70% more likely to use any drug, 50% more likely to have disclosed to partners that they had HIV, 40% more likely to smoke and 30% more likely to be non-adherent to ART. 

Drug use and sex

Drug use was strongly associated with having had sex at all in the last three months, having sex without a condom and having higher-risk sex without a condom, having an STI diagnosed, and having had group sex or more than ten new partners in the past year.

For instance, whereas 64% of the whole group had had any anal or vaginal sex in the last three months, this rose to 79% among men who had used recreational drugs. While 38% of the whole group had had sex without a condom, this rose to 52% for men who had used drugs; and while 21% of all the men had participated in group sex, 32% of those using recreational drugs had done so (and only 10% of men who took no drugs).

The definition of ‘higher-risk condomless sex’ in this study was sex with a partner of different HIV status while not on ART, or while having a viral load over 50 copies/ml, or while having a diagnosed STI. The study did ask about sex roles, i.e. whether men took the insertive or receptive role during sex, but this wil be reported in another paper.

Only 7% of the men had had sex of this ‘higher-risk’ type in the last three months, or 10% of those who had used at least one recreational drug.

There was also a strong and consistent correlation between the numbers of different drugs used in the last three months and the various sexual behaviour indicators: the more different drugs people used, the more sex, condomless sex, risky sex, STIs, group sex and partners they had. For instance, whereas 10% of men who had any drug use had higher-risk condomless sex, 16% of the men who had used five or more different drugs in the last three months had done so (39 individuals), and whereas 15% of men who had any drug use had been diagnosed with an STI in the last three months, 24% of men who had used five or more drugs had had an STI. This correlation was particularly strong the measures for group sex and number of new partners in the last year. 

In general, men who used drugs were about 40 to 70% more likely to have high-risk sex than men who did not use drugs, while users of ‘club drugs’ like GHB and mephedrone, erectile dysfunction drugs, nitrites (poppers) and cocaine were 90% more likely to have higher-risk sex. Methamphetamine stood out as the drug most likely to be associated with high-risk sex: men who reported using ‘meth’ were 2.7 times (170%) more likely to have high-risk sex than non-drug-users, suggesting, the researchers suggest, that it has a specific disinhibitory effect.

Comparisons, comments, conclusions

How do these findings compare with others? These data correlate well with those from a community study reported at the Melbourne International AIDS Conference in July that found that among a group of gay men surveyed, 25% had condomless sex when no drugs were used, 50% with three drugs and 75% when more than five drugs had been taken.

In terms of changes in drug use over time, ASTRA is the first study to look at the HIV transmission risk and drug-using behaviour of gay men living with HIV in England for ten years. In a series of studies of MSM living with HIV and attending outpatient clinics and using gyms in 2002-03, the prevalence of drug use in the previous three months was 54% – similar to the present study. But drug fashions change, and while the use of MDMA among men who report using drugs has gone down from 17% to 11%, the percentage of  drug users who use cocaine has increased from 14 to 23% and the proportion who use methamphetamine from 4 to 10%.

The authors emphasise that having up-to-date date information about the frequency of polydrug use among gay men taking ART is important for clinical care. They highlight the potential cardiovascular risk of consuming nitrites and erectile dysfunction drugs together, the potential for increased toxicity of GHB when consumed with alcohol, and the potential for impact on the effectiveness of antiretroviral therapy - although the study found no evidence of an increase in non-adherence when using more drugs.

The researchers conclude that polydrug use and HIV and STI risk in gay men living with HIV are “inextricably linked”. They urge long-term longitudinal research to find out more about men’s episodic patterns of drug use, and urge cross-agency collaboration between HIV treatment and substance misuse services to provide “tailored, judgement-free harm reduction advice and support” to men living with HIV who use drugs. They say that national HIV prevention campaigns should more explicitly address drug use.

In an accompanying comment, Martin Holt of the University of New South Wales in Sydney, Australia advises readers and public health workers not to “panic” about the ASTRA study. He points out that in the recent “Chemsex” study in London, the majority of men interviewed saw their drug use as relatively unproblematic. He praises ASTRA for adopting a new and more rigorous definition of ‘risky’ sex and comments that it is relatively encouraging that only 7% of men overall had this kind of sex and that most gay men living with HIV take steps to avoid transmission.

However, he acknowledges that a small proportion of MSM do have difficulty in “negotiating sex, drugs and HIV treatment” and urges that studies like ASTRA include measures of drug-related harm and dependence in the future.


Daskalopoulou M et al. Recreational drug use, polydrug use, and sexual behaviour in HIV-positive men who have sex with men in the UK: results from the cross-sectional ASTRA Study. Lancet HIV, early online publication, 2014. doi:10.1016/S2352-3018(14)70001-3. Full text available at http://download.thelancet.com/pdfs/journals/lanhiv/PIIS2352301814700013.pdf?id=gaayYgD4v_8d0f6gd3QHu

Holt M Sex, drugs and HIV: let’s not panic. Lancet HIV, early online publication, 2014. Full text available at http://download.thelancet.com/pdfs/journals/lanhiv/PIIS2352301814700074.pdf?id=gaayYgD4v_8d0f6gd3QHu