Not another video about HIV? Yes! Here’s why.

 

In less than a month, on 11th October 2017, a new and I think ground-breaking resource will be launched which tells the story of people living with and affected by HIV.

What, another one?  I hear some of you ask.  Yes, and I’ll tell you why.

Why another resource?

This resource is different. Funded by Public Health England, through their HIV Prevention Innovation Fund, this new resource will feature people prepared to talk despite the stigma.  It privileges the voices of people living with and affected by HIV above other voices. Multiple people living with HIV and affected by it are in the resource, have co-produced the resource and have been in workshops considering, commenting on, augmenting and amending the resource. This has been, in and of itself, a powerful experience.

This resource has a series of videos, accompanied by a website of resources, blogs and other materials. It features people with HIV prepared to share how they thrive, cope and how HIV, their health and the deepest issues of their lives come together, and the problems and the positives of that.

And I have been privileged to be the sponsor of that project, at PHE’s request.

This will be a tool to combat stigma.  It will be a tool to show people the nuanced reality of living with HIV. It is a tool for people with and affected by HIV.  And it is a tool for celebrating people with and affected by HIV.

The changing nature of life with HIV

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We are in a time when virological suppression is a major success story (People I work with, people I love who ten years ago would have died are still alive and well and every day I cherish that and them.)

We are in a time when we could achieve the end of new HIV transmissions, and tools like PrEP are further resources in the long travail which has been the journey since the first people I knew and loved with HIV died. Today, many people with HIV are thriving , some in jobs vital to our society, others quietly living and working and relating, living out their gifts and their talents.

But, others still aren’t thriving. And it’s not just about biology. Far from it. With the success of virological suppression – where the virus is essentially regarded as undetectable – come a range of opportunities, choices and still many challenges. Stigma, ongoing challenges of living, new health threats to people with HIV, and the need to renew our efforts to cherish those with and affected by HIV while reducing new infections.

People live longer, they contribute their talents and gifts to their loved ones and our society.  Great.   For some, cognitive decline, however subtle, diseases of ageing in an ageing cohort of people with HIV, negotiating social support, relationships and just coping with life alongside a lifelong health condition, remain psychological, social, practical and – dare I say it – spiritual and existential challenges.

Negotiating life with HIV still takes skill. For every person who accomplishes it with panache, there is a story of sheer hard work behind it.

In a world where Pre exposure prophylaxis is becoming more available (though I notice our trial in England is still dragging its heels) and undetectable status means different issues for negotiating intimate relationships than it once did, we need more than ever to reaffirm people, reduce stigma, and most of all, learn from our friends, colleagues, loved ones, partners and residents with HIV.  One of the world’s foremost HIV resources, Aidsmap has a great post on why it endorses the prevention access statement for HIV which makes you realise just how much has changed, and how much we still have to achieve.

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http://www.aidsmap.com

 

So come on, what’s special about this, really?

Well, two things.  First, the people in it.  Secondly, the people in this resource, and the resource itself, will address HIV through the context of Faith. Specifically, Christian faith in this resource, but other faiths may follow suit.

I want to tell you why, and why health professionals should take notice.

But let me say this first: this resource is not an exercise in Christian exclusivism. It’s an exercise in affirming the particularity of faith and producing a model others can use and follow. A one size fits all approach to faith is an immature approach to diversity. In the same way most of us have multiple protected characteristics. Seeing people through the lens of one shows how poor the imagination of much of our diversity policy and the assumptions around it still are.

The Project will be called Positive Faith (Launches late October 2017.) The resource features people from a range of Christian churches. I’ll speak about why later.

A few thanks to the people who’ve worked hard

The project is being managed and led by Catholics for AIDS Prevention and Support.  The wonderful Vicki has project managed it.  CAPS are a small charity which provides direct support and care including supporting Positive Catholics.    Our local Hertfordshire HIV Voluntary agency, HertsAid, has given significant support and effort to supporting this programme. And Public Health England have, of course, funded it.

Some reasons why we need this

First, we know from ever greater scientific evidence that for people of faith, their understanding of health challenges, their coping, even their health behaviour, is profoundly influenced by and mediated through their faith. People of faith – even those who feel excluded by it – greatly understand their health experience, even down to their efforts to live with HIV or stay free from it, in a way linked to their faith. We still lag behind in the UK with that understanding in many of our health services, despite it being a commonplace of Health Psychology for decades. We cannot do health without encountering faith in dialogue for people of faith. Ellen Idler’s 2016 book Religion as a social determinant of Public Health (Oxford University Press) is a lucid presentation of the evidence for this.

Second, health services sometimes still seem to remain squeamish, embarrassed or discomforted by the presence of faith. It’s the protected characteristic of the equality act many feel uncomfortable with. But over 40% of people in the UK still confess a religious faith of some kind. NICE guidance, NICE standards and more and more scientific evidence affirms that to personalise health care, we must recognise that we cannot treat faith as something totally private and separate from it. If a person of faith is in the clinical encounter, so is the issue of faith.

Churches struggle with HIV, Health services struggle with Faith

Faith is not going away. It is not dying. Even if you think it’s a minority pursuit, it’s important to that minority, which is still one of the largest in the country. And this resource is an attempt to redress an inequity in health – that of faith and HIV.

We must do better on this as a health system. This new resource speaks actively into that. If churches are sometimes uncomfortable about HIV, health services still feel uncomfortable about faith. This resource seeks to bridge that gap. To that extent this is a series of interventions about reducing stigma to build health equity for a population which still faces many challenges.

Why only a Christian resource so far?

Thirdly, this resource seeks to build inclusion of people with and affected by HIV in churches. To that extent, this clearly is a public health intervention. And this is why we haven’t produced a multi-faith resource. To understand HIV in the context of a particular faith, there needs to be dialogue in the language of that faith for people who have it. Yes, we need Islamic, Judaic, Hindu and more resources. And I hope people will use this approach as a template. But for a Christian black African woman to understand her HIV and her faith or for a gay male Christian to understand his faith and HIV prevention for himself or others, we and they need to relate that Christian faith specifically to health.

Is this really about prevention?

How will this prevent HIV? Well, by affirming and including people and pointing to them how much their health is something to be cherished and how much their faith acknowledges this. And we need to find a way to keep ourselves healthy and resilient to get the best from life. And health doesn’t mean a blissful state of freedom from any problem. It means adjustment to the realities of our physical, psychological and social challenges and limitations.

This resource sits firmly in the tradition of public health interventions to strengthen individuals and change communities.

More in-depth reflection

Nearer the time the Catholic Press are expected to cover this with some significant space. Articles have already been commissioned by The Tablet and The Catholic Universe .  The Catholics in Healthcare Blog will obviously carry a post. The Pastoral Review will carry a more in-depth article on the pastoral, theological and church issues around this.

The resource will be launched on 11th October 2017 by the RC Archbishop of Southwark and the Anglican Bishop of Southwark at an event in London in which people with HIV in the Video will speak. Fr Timothy Radcliffe, OP, the Master of the Dominicans, will speak alongside people with HIV.  For invitations contact Vicki Morris the Project Manager or Jim McManus the sponsor.

 

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Chemsex: Why should it be a Public Health issue?

 

I don’t know about anybody else, but I can’t help thinking that the issue of chemsex is one we are still not really getting our act together on.  I claim no specific expertise here, but what I do know is this issue is impacting on the health of our population, and an already vulnerable one at that, so we need to act. And I have several friends and colleagues from across the country -the youngest 24 and a student, the oldest 50 and a professional in the City, whose processes of getting out of the harm they’ve come to I have helped with.

We seem to have depressingly little in the way of national leadership or action on this from the Public Health community, with the work of some dedicated individual clinicians and community activist -step forward David Stuart and 56 Dean Street, Greg Owen, Matthew Hodson, GMFA , James Wharton, MenRUs, Burrell Street Clinic for their Safer Chemsex Kit and a few others being most visible. I have provided links to several pieces of this work in the footnotes, but let me also direct you to  London Friend’s work on LGBT drug use and recommendations for treatment services .  I hope anyone I have missed off will forgive me.

It is simply unacceptable for the skills and resources of the Public Health profession to be absent from this issue.

I was discussing this today at another meeting. I said to a colleague from another agency “people say we don’t have a problem locally” and before I could continue to say “and they’re wrong” he interjected, “they should just open grindr, it’s everywhere.”

The use of some kind of substance to enhance sex is known and common throughout history (drinks while dating?) And if people are fine about that and use without harm, then I don’t feel it’s my business.  But recently the phenomenon of chemsex has become a bit better known than it was. A search of MEDLINE and PSYCARTICLES when I was doing a quick review to inform this blog, after removing duplicates, found in 2014 3 papers, a search for 2017 found 48 papers so far in the health and psychological literature.

Chemsex is a term for a complex of behaviours – use of dating apps to have parties where sustained group use of drugs happens, particularly drugs like cocaine, crack, GHB (gamma hydroxybutyrate) and crystal methamphetamine. Sex is often but not always a given at some of these parties. Slamming – injection of drugs for quicker highs, sometimes happens, and with it sometimes sharing needles.

While it may be more of a scene for gay men, bisexual men and heterosexuals do it too. What will that pattern will be in two years time? We know that trends started by gay men sooner or later get picked up by the wider heterosexual world, or am I just remembering disco through rose tinted (glitter encrusted) spectacles? (Showing my age there.)

Increasingly, use of chems or drugs is reported by men using dating apps for 1-1 encounters too. Recent work has shed more light on the multiple motivations and issues at play.  From the many paper available, I have a few which I think resonate. Weatherburn et al[1] identify a range of motivations linked to “enhancing the qualities valued in sex” including enhancing attraction, heightening sensation, intensifying intimacy and connection and, for some men, overcoming lack of libido. Media attention[2] and the interest of the scientific press[3] seems to have been somewhat limited to date.

The increasing intelligence from reporting by clinicians and community groups of problems presenting from chemsex is concerning. From understandable motives – socialising, feeling good, enjoying sex and coping with life pressures are reported as factors, certainly in GHB use for some time[4] , the drug use is primarily intended as a facilitator of these. But clinicians are reporting a range of harms including addiction and other sequelae.

Dedicated professionals like David Stuart and others working on this issue[5],[6] have brought greater light on chemsex. The publication by James Wharton of his chemsex experiences[7] in Something for the Weekend and the associated meda reporting[8],[9]have gone some way to cast some light on this as an issue which needs addressing.

Parties are not the only places, however, where chemsex is becoming an issue. Increasing use of chems with sexual hook ups means some men may rarely have sex sober. It’s not just physical risk, but psychological. Intimacy may become associated with being high, and for some, dependent on it.

Prevalence

A 2014 BMJ editorial suggested a minority of men engage in chemsex[10] but community reports suggest this is growing and becoming more prevalent. There are as yet no robust epidemiological estimates. Weatherburn et al report up to 18% of men from three London Boroughs uses cocaine and 10.5% GHB compared to 4.8% and 1.6% respectively of men elsewhere in England[11].

Wharton quotes estimates that a gay man dies in London from GHB overdose every 12 days but very few have been high profile[12]. Estimates of prevalence vary in recent reports[13] but what is clear is that this is becoming an increasingly prevalent presenting problem in sexual health clinics, and few services as yet seem prepared to address it effectively.

Harm

There are also some people who seem to be able to use drugs regularly without seeming to come to harm. If people genuinely can do that safely, and we can help them successfully avoid harm, then my interest ends there. But many do come to harm, and it’s those who experience harm in any form I’m interested in here. And the harms from chemsex can be wide.

Whether or not this is a minority phenomenon in terms of the population, the harms to some users are significant and the barriers to accessing services also important disablers of helping men deal with harms arising from chemsex[14].

What we don’t know reliably is how many men engage in chemsex without coming to some form of harm. Most data from clinics and the small amount of research to date identifies some kind of harm. A spectrum of harms across physical, psychological and social health is possible. Some of the documented and reported harms are shown in Table 1 below. But this isn’t exhaustive.

Table 1: Harms from chemsex

Physical Health ·      STIs, HIV and other Blood borne viruses

·      Physical effects of comedowns

·      Risks to circulatory system from injection

·      Respiratory risk from frequent use

·      Risk of death from overdose

·      Disrupted sleep patterns, anorexia, weight loss

·      Impaired immune function

 

Psychological/Mental Health ·      Use of chemsex to facilitate social contact and overcome loneliness, isolation

·      Coping mechanism for stigma and homophobia

·      Impact on coping skills, sleep, employment, cognitive functioning

·      Impact on relationships of becoming habituated on having sex while using drugs

·      Psychological impact of financial problems from financing habit

·      Impact on identity integration and acceptance

·      Bereavement from people in social networks dying as a result of G

Social health ·      Group identification

·      Coping with stigma

·      Holding down a job and responsibilities

·      Risk of debt and homelessness

·      Criminalisation for possession of drugs and sometimes dealing

 

Public Health Issues

Chemsex is not just a drugs or an HIV or a sexual health issue. For most men it seems to be linked to a complex manifold of issues. From the physical risks to health, to the psychological risks and impact on lifecourse development, there are significant issues which impact on the populations and individuals who use it.

I have spoken, written and presented elsewhere on how the need to ensure LGBT populations are able to live happily and successfully across the lifecourse must be a public health issue[15],[16]. So I won’t repeat that here. One of my worries is that chemsex for some can hamper or impair that process.

The mental health impact of being unable to have sex or be intimate unless high presents a number of challenges. But there is another set of issues. If some gay men use chemsex to cope with stigma or feelings about being gay, that must be seen as potentially problematic. It is a commonplace in psychology of LGBT populations that a key task is identity integration and acceptance[17]. Theory and evidence assumes that identity integration and assimilation is crucial to health and wellbeing outcomes for gay men across the lifecourse[18],[19],[20]. It is assumed to be especially important to ensure inclusion for LGBT people in education and employment. If chemsex disrupts such processes, or means a population or sub-population of gay men can only feel good enough about themselves where mediated through drug use (either individual or in groups), there may be significant avoidable psychological morbidity as a result. If what Wharton says about younger gay men finding it easy to get into this scene is true, then that has worrying implications about the ability of those men to form attachments and integrate their identity as they grow, with potential maladaptation and poor coping and mental health across the lifecourse[21].

Policy frameworks and action

While chemsex is mentioned in the new UK Drugs Strategy, there has been much criticism of the lack of commitment on what to do about it[22]. There remains no coherent public health response. Community harm reduction approaches[23] including safer injecting kits[24] are most visible interventions with the best available frameworks for clinical response being those developed by David Stuart[25] There is as yet no clear national policy framework or consensus guideline on what can or should be done. Community intelligence is still crucial to developing action on this, and we need to find ways of making sure we capture and factor that into response planning, on a more agile basis than we sometimes do.

What can be done?

A range of action is needed, and this needs to be revised as we know more. I group suggested actions under domains here.

Domain 1: Establishing prevalence and incidence

  1. We need as clear a picture of prevalence, service use, harm, morbidity and mortality as can be compiled, nationally and locally
  2. Including and using community intelligence in this development will be crucial
  3. Asking about chemsex use should become a routine question in sexual health services on the electronic patient record

Domain 2 : Harm Reduction strategies

  1. We need to work with providers of dating and sex hook-up apps to target information on harm reduction to users engaging in chemsex
  2. The current good practice (chemsex care plan and harm reduction information and kits) should be rolled out to those areas who identify they have a developing issue
  3. Support harm reduction including continued information and kits to reduce harm
  4. Agencies could consider safer chemsex courses as a way of helping reduce harm including teaching people skills of what to do about GHB overdoses
  5. Agencies should combine efforts to make available a single reliable source of information on reducing harm from chemsex and where to get help
  6. Sex venues should consider placing information on chemsex and where users can get help.

Domain 3: Service response and readiness

  1. Most chemsex users don’t find drugs services resonate with them on the whole. We need to identify what drugs services and sexual health services can to do address this and roll it out
  2. Sexual health and drugs services should identify what they can to do ask gay men about, identify and respond to chemsex issues, and develop collaborative approaches to sharing skills
  3. Those services should become skilled in particular identity and lifecourse issues facing gay men
  4. Services should consider whether they can recruit people recovering from chemsex harm to work with those seeking support
  5. Drug services should consider as part of this work both the LGBT supplementary guidance of the NEPTUNE programme work on NPS ,the London Friend work on drugs services and LGBT populations and the work of David Stuart

Domain 4: Developing consensus on interventions

  1. Agencies working on this should convene with experts on drug use, sexual health and LGBT development to develop some consensus guidelines on harms and issues, and intervention strategies, and keep this under review.
  2. Learn from the work being developed by the London Chemsex Network as part of this

Domain 5: Community resilience

  1. LGBT community groups who provide social groups or counselling facilities should consider what they can do to continue to support gay men with lifecourse identity development
  2. Employers with large numbers of gay men in population centres likely to be affected should consider what resilience and support packages they can put in place for employees with performance issues arising from chemsex

 

[1] http://sti.bmj.com/content/93/3/203

[2] http://www.newstatesman.com/politics/health/2016/04/what-chemsex-and-how-worried-should-we-be

[3] https://www.newscientist.com/article/2140756-what-is-chemsex-and-why-is-the-uk-government-worried-about-it/

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3611333/

[5] https://gregowenblog.wordpress.com/2015/10/17/chemsex-the-film/

[6] http://www.davidstuart.org/

[7] Wharton, James (2017) Something for the Weekend: London : Biteback Publishing

[8] http://attitude.co.uk/exclusive-former-british-soldier-james-wharton-opens-up-about-addiction-chemsex-culture-is-now-gay-culture/

[9] http://www.telegraph.co.uk/men/the-filter/11942081/Nine-things-you-should-know-about-GHB.html

[10] http://www.bmj.com/content/351/bmj.h5790

[11] http://sigmaresearch.org.uk/files/report2014b.pdf

[12] http://www.bbc.co.uk/news/magazine-35976705

[13] https://www.lambeth.gov.uk/sites/default/files/ssh-chemsex-study-final-main-report.pdf

[14][14] http://www.bmj.com/content/351/bmj.h5790

[15] https://www.slideshare.net/jamesgmcmanus/british-psychological-society-sexuality-and-wellbeing-symposium-a-public-health-perspective-on-lgb-populations

[16] https://www.slideshare.net/jamesgmcmanus/lgbt-public-health-agenda-idahot-2016

[17] https://msu.edu/~renn/BilodeauRennNDSS.pdf

[18] https://pcilab.ucsc.edu/wp-content/uploads/sites/472/2017/06/Hammack-et-al-2017.pdf

[19] Hammack, P.L (2009) The Story of Sexual Identity: Narrative Perspectives on the Gay and Lesbian Life Course New York: Oxford University Press

[20] https://www.ncbi.nlm.nih.gov/pubmed/12666737

[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215279/

[22] http://www.independent.co.uk/news/uk/home-news/drugs-treatment-strategy-government-criticism-problems-campaigners-a7841986.html

[23] https://www.gmfa.org.uk/Pages/Category/safer-chems

[24] https://www.menrus.co.uk/drugs/introduction/

[25] http://www.davidstuart.org/care-plan