KUALA LUMPUR, Dec 8 – The rising use of psychoactive drugs during sex involving mostly, but not exclusively, among gay men in Asia could pose an increasing risk to public health, a new report by Harm Reduction International (HRI) shows.
The rising popularity of “chemsex” – the practice of using specific drugs to enhance and prolong sex, often involving group sex among gay men and other men who have sex with men (MSM) – is pushing the need for a wider offering of harm reduction services, as those who engage in chemsex are at higher risk of contracting HIV than the general population, including in Malaysia.
Scholars, advocates and people from the chemsex community acknowledge that “traditional harm reduction services are [often] not appropriate for [the] needs” of people who engage in chemsex, according to HRI’s Global State of Harm Reduction (GSHR) 2022 report released today.
“For instance, while certain chemsex settings may involve injecting drugs, meaning some risks can be mitigated by NSPs (needle and syringe programmes), many others, such as the risks arising from orally consumed drugs like methylenedioxymethamphetamine (MDMA), require tailored interventions that pre-existing programmes do not cover.
“There is, in other words, a need to innovate and tailor programmes to meet the specific needs of the communities in question,” the report stated.
While policies for chemsex remain scarce in the region, researchers have documented ways in which individuals and communities can limit the harms of chemsex.
In the Philippines, people engaging in chemsex have been found to actively bring their own syringes to “party n play” sessions to reduce the possibility of sharing needles, to pay for pre-exposure prophylaxis (PrEP) and sexually-transmitted infection (STI) tests and medicines where available, and limit polydrug use.
PrEP is medicine that reduces a person’s chances of getting HIV from sex or injection drug use. When taken as prescribed, PrEP is highly effective in preventing HIV.
Organisations in Argentina, Brazil and Colombia are also carrying out exploratory studies to characterise sexualised drug use in the Latin America and Caribbean region, with the intention of designing harm reduction services.
A separate report by the International Drug Policy Consortium (IDPC) found that the prevalence of chemsex among MSM in Asia ranges from 3.1 per cent to 30.8 per cent.
Several reasons influencing the decision of MSM in Asia to practice chemsex include the direct benefit of using the drug to enhance sexual pleasure, persuasion from peer network, and external prejudice directed towards MSM existence.
Common drugs used in chemsex in the region include methamphetamine, MDMA, poppers (alkyl nitrites), ketamine and gamma-hydroxybutyrate or gamma-butyrolactone (GHB/ GBL). People who engage in chemsex often use more than one type of drug during their chemsex sessions.
Malaysia’s Health Ministry announced on World AIDS Day the launch of a two-year programme to provide PrEP for free at selected public health clinics in states with high HIV prevalence, starting January 2023.
Harm Reduction Services Continue To Improve
One of the key highlights from the GSHR 2022 report is that harm reduction interventions, such as safe injection rooms, needle exchange services, or opioid agonist therapy (OAT), as well as the use of medications such as methadone and buprenorphine to treat opioid addiction, are rising, especially in sub-Saharan Africa.
Many harm reduction services also stayed open during the pandemic and continued to do so in conflict zones such as Ukraine and Afghanistan, the report stated.
In Malaysia, efforts to expand hepatitis C testing and treatment services within primary health care and harm reduction facilities have been successful in reaching and treating people.
Malaysia decentralised hepatitis C care in 2019 by enabling primary health care facilities to test and treat hepatitis C. Now the country is focusing on improving hepatitis C care for populations most affected by HIV and people in prison.
To address co-infections, policies are now in place for the integration of hepatitis B and C screening, treatment and care in HIV clinics. In 2021, the government announced it would conduct a study on the impact of using hepatitis C self-testing as part of its commitment to eliminate hepatitis C by 2030.
Several countries across Asia, including Bangladesh, India, Indonesia, Myanmar, Thailand, the Philippines, and Vietnam, however, have reported that many drop-in centres offering NSPs have remained closed long after lockdown measures eased due to lack of funding
Malaysia has also reported a decline in NSP sites, which the country officially attributes to decreased demand for needle exchange services.
Sexual transmission has been the major risk factor for HIV infections in Malaysia since 2011, a shift from the initial stages of the HIV epidemic which saw sharing of needles among drug users as the main risk factor for infection.
Despite the shifting trend, the report stated that there is continued significance of injecting drug use in the region, including in Malaysia where HIV infections continue to rise despite a global decline.
According to the UNAIDS Global AIDS Update 2022 report, HIV infections have increased since 2015 in 38 countries, including Malaysia and the Philippines.
The report cited Malaysia and the Philippines as being among the countries with rising HIV epidemics among “key populations”, defined by UNAIDS as gay men and other MSM, sex workers, transgender people, people who inject drugs, and prisoners and other incarcerated people as the five main key population groups that are particularly vulnerable to HIV and frequently lack adequate access to services.
From 2017 to 2021, Malaysia recorded the second highest proportion of new HIV infections among key populations in a sample of 11 countries at 78 per cent, behind the Philippines’ 93 per cent.
Shift In Drug Choice: From Heroin And Other Opioids To Meth
The GSHR 2022 report also highlighted the continuing shift in the drug of choice or drug of concern in many countries from heroin and other opioids to methamphetamine.
In China, the government now reports that a majority of people who use drugs use methamphetamine, leading to a revised official estimate of 556,000 people who inject drugs.
Factors that are causing this shift include the wider availability and accessibility of methamphetamine and the widespread perception of its relative safety compared to heroin, with most public health campaigns focusing on the harms of using heroin.
The United Nations Office on Drugs and Crime (UNODC) had previously described 2021 as a record year for methamphetamine seizures in the region, totalling 171.5 tons.
The general price of methamphetamine has continued to decrease, making it more widely accessible and available – trends that have been attributed primarily to the shift of methamphetamine production to tablet form and the use of non-controlled substances in the lower Mekong sub-region in Southeast Asia.
Mandatory Death Penalty Abolishment Far From Reform
In June, Malaysia announced its intent to abolish mandatory death penalty sentencing, which has been disproportionately meted out to people charged with drug offences. The report, however, states that indicating this intention does not necessarily signify progress in overall policy reform.
Elsewhere in the region, countries including the Philippines, Japan, Bangladesh, and Singapore continue to subscribe to hardline approaches and “drug-free” paradigms.
Rodrigo Duterte’s “war on drugs” persisted up to the end of the former Philippines president’s term. The country’s political climate remains tilted toward punitive approaches under the current administration, including to restore the death penalty for drug offences.
In Japan, under its zero-tolerance drug regime, the government has proposed amendments to existing laws that would criminalise the personal consumption of cannabis.
In Bangladesh, an association has been made between drugs and the Rohingya crisis, which has contributed to negative attitudes and punitive responses toward Rohingya refugees. Bangladesh has seen a rise in extrajudicial killings of people associated with the drug trade, and the country’s drug policy has become increasingly militarised.
Despite significant vocal opposition, Singapore has resumed executions of people convicted of drug trafficking, cementing its classification as a “high application state” – alongside China, Malaysia, Indonesia, North Korea, and Vietnam – in imposing the death penalty for drug offences.
Countries such as Thailand have undertaken efforts to depart from punitive approaches. Thailand legalised kratom, a plant that has stimulant properties, resulting in the release of thousands of people jailed for related offences and the expungement of their records.
In 2022, the country became the first in Asia to legalise cannabis, including consumption, possession, sale, cultivation, and importation. Thailand’s latest report shows that NSPs have been managed exclusively by civil society organisations, not the government, due to what it describes as “controversy within the public sector about needle exchange”.