Viremic – Cases in HIV

Announcer:
Welcome to Viremic–Cases in HIV, hosted by Dr. Eileen Scully and Dr. Christopher Hoffmann, both HIV specialists at Johns Hopkins, who explore quandaries in adult HIV care. Each case discussion includes medical history and diagnoses, challenges in care and treatment, and key evidence and guidelines that inform clinical decision making.

Cases are presented as a composite from the hosts’ clinical practice, with all identifying details removed to protect the privacy of patients. Case discussions are for informational purposes only and not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use only, not an endorsement.

Dr. Christopher Hoffmann:
Welcome to Viremic. I’m Chris Hoffman, and I’m joined today by a special guest, Dr. Jeremy Kidd. Regular listeners may notice that my voice is a bit off today, but I’m so excited about my discussion today with Jeremy that I wanted to continue to record.

Before we start, if you like this podcast, please share with a colleague and follow us wherever you access podcasts. Please send questions or future topic suggestions to us at viremicpodcast@jh.edu.

Dr. Jeremy Kidd is a psychiatrist, addiction medicine specialist and authority on the intersection of mental health, substance use and HIV. He is faculty at the Icahn School of Medicine and the Medical Director of Outpatient Addiction Treatment at Mount Sinai West in New York City. He wrote the very informative, readable, and useful New York State AIDS Institute’s Questions and Answers on Chemsex [see Show Notes] and is a member of the Adult HIV Guidelines Committee of the New York State AIDS Institute Clinical Guidelines Program. Welcome, Jeremy.

Dr. Jeremy Kidd:
Hi Chris, it’s great to be here. Thanks for having me.

Chris:
Thanks so much for joining. Before we discuss the case at hand, tell me a little bit about what led you to clinical practice and research at the intersection of substance use, mental health, and HIV.

Jeremy:
For a long time before undergrad, I was involved in a lot of organizing efforts and then a lot of research efforts separately in LGBT mental health and in substance use treatment. Over time, I started to see how there were numerous intersections in these two fields that weren’t being always coherently and cohesively addressed.

Working with LGBTQ youth who were struggling with substance use to manage internalized stigma, working with people who were using drugs, who were also engaging in chemsex, the topic we’re going to talk about today, but they were often being talked about, like sex and drugs were often being talked about in separate spaces by separate people. It’s been really fun and a privilege to get to work at this intersection to help promote harm reduction and treatment for both mental health and substance use disorders in people who are affected by all these issues.

Chris:
Well, I really look forward to learning more about this intersectionality from you and hopefully perhaps some frameworks that we can use as clinicians to better serve each of these issues.

We’ll be discussing optimizing management of a patient who is new to my practice. I’d especially like to hear about how you would approach that intersectionality of substance use, potential negative consequences of the substance use, HIV, stigma, and how we can apply a harm reduction approach.

So, to get started, a 27-year-old man transferred his HIV and primary care to me. He was diagnosed with HIV about 5 years ago and prescribed ART soon thereafter. He states that his viral load is usually suppressed as far as he remembers. He’s a gay man, engages in oral sex mostly as a bottom partner for anal or butt sex. He has been treated for syphilis and rectal LGV and episodically for perirectal HSV. He has no known other medical conditions. His only med is Biktarvy. He does not smoke. He drinks alcohol on the weekends mostly. And while not considering himself to be a drug user, he does use methamphetamine almost always when having sex. He has multiple regular sex partners. They do not usually use condoms, and he does not use doxy-PEP.

He had blood work done before seeing me that was notable for normal kidney and liver function, negative hepatitis B surface antigen, positive hepatitis B surface antibody, negative HCV antibody, RPR reactive but only undiluted, and a viral load of 840 copies/mL.

He has not had any insurance gaps to explain adherence challenges or access to antiretroviral therapy but does acknowledge a recent episode of missed doses.

An immediate concern of mine is his elevated viral load, both for the health consequences he may suffer and the risk of onward HIV transmission to his sex partners.

I’m going to start with a general question for you, Jeremy. From what you’ve heard, is his drug use consistent with chemsex, and how do you define chemsex?

Jeremy:
It might be consistent with chemsex. We need to know a little bit more.

I’m curious, when you got these labs, how did this patient react to that viral load? I totally get why it’s a concern of a clinician, a physician, but how did he react when he saw that number after it usually being undetectable?

Chris:
Well, he acknowledged that he does miss doses sometimes. He feels like he tries to be adherent but occasionally has these lapses. I like to get a better understanding of why my patients may have these lapses, and it seemed like there were probably multiple factors going on.

He sometimes avoided taking medications to not disclose his HIV status or his medication-taking to others. In addition, as a coping mechanism for internalized stigma, sometimes avoided medications. And then also at times, he said the methamphetamines interfered with his ability to remember or remain adherent to his antiretroviral therapy. He described himself as usually being very good about it, but obviously was a little bit ashamed, perhaps, first meeting me and then also trying to explain to me that although he cared about his health, his viral load was not where he knew a doctor would want it to be.

Jeremy:
Thanks for that additional information. I think that’ll be helpful. come back to that when we think about ways to engage this patient in a motivational conversation to address both what’s the biggest concern for the physician but contextualizing that within what might be the biggest concerns for a patient.

You asked about chemsex. Chemsex is a term that is generally defined as somebody using drugs before or during sex with the intention of positively affecting the experience of having sex. So, it’s different than just having sex while high; it’s really that intentionality piece that makes something chemsex and not just the combination of sex and drugs. It sounds like that’s probably what this patient is doing, but I might ask a little bit more, and it sounds like you did ask a little bit more about what was motivating him to use drugs in that way. That could definitely be contributing to his missed ART doses.

Chemsex sessions can last a day or a night, but sometimes they can go on in these marathon ways for days at a time, and people lose track of everything else that’s going on in their lives, including their medications. Four or five days here and there without taking his antiretrovirals could certainly explain that viral load. It’s something I see a lot in my practice where I’m treating folks who are coming into treatment for methamphetamine use disorder but often have these same challenges.

Chris:
What are some of the questions that I should be asking him to better understand whether this is chemsex and to perhaps clarify his use and potential risks related to his use of methamphetamines when he’s having sex?

Jeremy:
You’ve done the hard part already because you’ve gotten a patient who feels comfortable and has an alliance with you to share with you that they are having chemsex in the first place. That’s often the hardest part.

In the question-and-answer document, we pose a few questions that providers can use to screen patients in their practice for chemsex because this is so common. But you can imagine it’s something people may be reluctant to bring up on their own for fear of stigma or being judged. So generally, I’ll ask people if they’ve used drugs before or during sex in the past 6 months. If they have, then tell me what they’ve used and how often they’ve used it. That gives me a sense right away, again, we’re not equating use with sex as use during sex with chemsex, but that is a necessary part—you can’t have chemsex without sex and drugs. So that tends to be a good screening question.

Getting a sense over the past 6 months gives you a sense of if this is something people have done once or twice, or if this is a more regular thing, which would be necessary to explain the kind of viral load abnormalities that you’re seeing. So, if somebody says that they have, then I’ll generally ask them about the last time they use drugs or alcohol to make sex enjoyable. There, we’re inserting that intentionality piece, and we’re also making it specific. So, we’re asking, “Tell me about that time. What did you use? What did you do?” I’m listening for opportunities to insert harm reduction messages. I’m listening for things that might explain the labs that I’m seeing or the health problems that I’m seeing or the psychiatric problems that I’m seeing that I can then draw on later. Because it’s a specific episode of chemsex, it’s going to be a bit more salient for the patient.

Then I’ll also ask patients, “When was the last time you had sober sex or sex without drugs? Have you ever had sober sex? Would you like to have sober sex?” This gives me a sense of what’s the direction of this conversation. Somebody who’s never had sober sex before, it’s a very different situation than somebody who had a largely sober sex life up until their mid-20s or 30s and then began to use meth versus somebody who’s maybe never had that experience of having sex without drugs before. That’s going to be a very different goal.

If somebody doesn’t want to have sober sex, we’re going to think of that as maybe more pre-contemplative, and we’re going to think about harm reduction messages more. If somebody really wants to have sober sex, then we can start talking about goal-setting and potential treatment referrals. It gives me a sense of where the conversation might head. “So, have you had sex with drugs in the past 6 months? When’s the last time? Tell me about that. And have you ever had sober sex before? Do you want to have sober sex?”

Chris:
Well, some of the questions that you asked, I should probably refer him to drive up to New York and see you. Some of them I may be able to answer: He has not had sober sex recently but has had it in the past, really feels that he depends on using drugs to have an enjoyable and uninhibited sex experience with his partners. I did not ask about whether he wants to have sober sex.

Any further reflections on this new information?

Jeremy:
I think what he cited as his motivations are pretty common among what I hear and what’s in the literature. There’s a great ethnographic study by Cathy Reback from the early 90s called The Social Construction of a Gay Drug [see Show Notes]. She interviews people—in-depth ethnographic interviews with gay and bisexual men in Los Angeles—about their motivations for use, how they use. What is remarkable is that even though the context has changed, the landscape of what it means to have HIV, the landscape of treatments, the drug use landscape, the reasons cited by people for using drugs during sex, for engaging in chemsex, are remarkably consistent.

That’s some of what you brought up— patients, or people, they’re not patients because they might not be in treatment, but people who engage in chemsex talk about managing stigma. That might be managing multiple kinds of stigma. It might be homophobia, might be HIV-related stigma, might be stigma as a person who uses drugs. So, there’s a lot going on there that you can obliterate and check out from if you use drugs.

It’s also a way to meet people. There’s a shared goal there and a community and a language and a culture or subculture that people can get really wrapped up in in a way that can feel validating.

People can feel sexually desired either as the person who’s providing drugs or the person who is being pursued for sex. People also talk about lack of inhibitions or reduced inhibitions. So being able to do things sexually that they might be less likely to do when they were sober, either because they feel inhibited, or because it hurts, or because they just don’t have the stamina. Having sex for 4 days is not something many people can do without some assistance from a drug. People might engage in kinds of sex—bottoming or fisting or group sex or BDSM or more fetish play—that they might feel like they can’t do if they were sober. That gets into this conversation around what do people imagine they might be giving up or having to figure out how to integrate into their sober lives if they were trying to be sexual in that way without drugs?

Chris:
How do you get into some of these issues to understand the underlying motivation on that side with some of the sex activities that they value and then on the other side, some of the perhaps stigma and other traumas they may be fleeing through the use of chemsex?

Jeremy:
It’s a layered conversation and often evolves and unfolds over time. The initial conversation might start out very much like your interaction with this patient. He’s disclosing for the first time that he is engaging in chemsex and realizing for the first time that it’s having an impact on his health. The conversation might stay pretty surface with what can he do to be more adherent to medications while engaging in chemsex or to change the way that he’s engaging in chemsex to make it less impairing of his ability to take medications or exploring alternatives to chemsex for him and outlets that he has in that way.

Over time, as people begin to tell us more about the reasons they’re engaging in chemsex, it can often give me a better sense of what other supports might be helpful to them. Maybe this is the sum total of their social network, and they don’t know anyone who’s having sober sex or who wants to hang out with them when there’s not drugs involved. There, the intervention often is helping people make those connections and develop those sorts of communities where there is an alternative. It doesn’t mean everybody stops having chemsex, but it means that chemsex isn’t as central to the way that they go about organizing their lives.

Chris:
Perhaps you can walk me through harm reduction around chemsex in a little more detail. But before you do, some of the other potential risks of chemsex beyond lack of viral load suppression, perhaps some of the physical drug-related STI and psychological risks.

Jeremy:
Absolutely. It gives me a chance to also emphasize that when I have these conversations with people, I put the risks second, and I ask them why they engage in it, and why they like having chemsex, and why they like using the drugs, because I think it’s often very disarming for people, because they’re not used to a doctor and a physician acknowledging that drugs make people feel good and that there’s often some upside, even if short term and limited. So, I think asking that first can really help put a patient at ease and help them feel like this is somebody who I can talk to about this.

Then I bring in the risk conversation with people. Some of the risks, I think of them falling into 2 buckets. One is risks related to the drugs that people are using and then sexual health and related medical risks. Drug use risks vary by substance. We might be thinking about things like overdose prevention, or if somebody is using a stimulant, we might be thinking about risks of overdoing it, sometimes that’s known as “over-amping,” the negative effects that come from unintentionally using too much of the substance and becoming anxious and paranoid and having perceptual disturbances like hallucinations.

Then on the HIV side, we’re going to tailor that more to the kind of sex somebody is having. We might be talking about using PrEP or in this case, ARVs. Maybe we’ll have a chance to talk about long acting antiretrovirals later as well. We might be talking about different PrEP and PEP options. We might be talking about drug refusal skills if there are certain drugs somebody doesn’t want to use because they know that it makes them make choices around sexuality that they wouldn’t otherwise make. We might be talking about ways that they can sequence drug use and particular kinds of sex to minimize their risk. For instance, trying not to engage in rectal use of substances before bottoming because that’s a particularly high-risk scenario for HIV transmission and other STIs and also puts people at risk for fissures and other kinds of complications.

Sometimes just having those kinds of conversations can help people make more informed choices about the ways that they’re engaging in chemsex, even if they’re not at a place where they’re ready to embrace sober sex as a goal.

Chris:
That’s a really helpful overview. Is there a specific group of drugs or a specific drug that you are most concerned about with overdose or people engaging in chemsex may be most concerned about?

Jeremy:
In the U.S., methamphetamine still tends to be the backbone of most chemsex, and then there are other drugs that people add on. That’s a different story if we look at some of the data out of Europe or Southeast Asia, where it’s a much more heterogeneous mix of drugs. So, I always start with that in mind.

Some things that people will sometimes bring into chemsex experiences either to potentiate the effects of methamphetamine or to get around some of the negative side effects, if you will, of meth might be things like sildenafil or tadalafil to overcome erectile dysfunction, GHB or GBL, which are 2 sedative hypnotics that can be used, I think, in an effort to have a more balanced experience. Even though alcohol is not itself considered a chemsex drug, many people will engage in chemsex after they’ve been drinking prior, and that’s obviously still in their system.

In terms of acute overdose, we’re often worried about methamphetamine in combination with either opioids or things like GHB or GBL, where people could have unintentional overdoses. If people are using things like GHB or GBL or benzodiazepines regularly, they can develop a physiologic dependence that can be life-threatening that can result in seizures. In my world, sometimes people even need to go inpatient for a medically managed withdrawal from those in order to space out their use or stop using.

With methamphetamine, some of the risks that I worry about are around over-amping—people ending up in the ED with hallucinations and paranoia that can persist for quite a while sometimes after use. But also, people are sometimes using these drugs intravenously, and that obviously carries its own risks as well. So, some of the conversations are around “How do you use with sterile supplies? Or how do you switch to non-injection forms of use to minimize those risks?” It can be a pretty tailored conversation, but I always go into it assuming that the first thing I’m going to hear is probably that somebody’s using meth plus some other things.

Chris:
Okay, so going back to our case, perhaps we can sketch out a harm reduction approach. We already understand one harm, which is his viremia. Certainly, there may be other harms with risks of overdose or other risks that you’ve outlined. But as a starting point, can you describe harm reduction and then describe how you would apply that to my patient?

Jeremy:
Harm reduction is both a movement and a philosophy. It’s become a bit of a lightning rod recently. You’ll hear euphemisms used for it. The basic idea is that it’s a philosophy that respects the rights of people that use drugs. It simultaneously recognizes that drugs carry risk and that drug use is a reality in our society, that it pretty much always has been, and that while it might not be accurate to say that there’s a completely safe way to use drugs, there are safer ways to use drugs. And people have a right to be aware of all of the different harms that might be coming their way and to be able to make choices based on that information in a way that can protect their health and safety.

This was not a physician-led movement. This is a movement that came out of queer communities and people who used drugs during the height of the HIV epidemic and was people trying to take care of themselves. In many ways, we owe a huge debt of gratitude to those folks for giving us this frame to think about drug use and helping our patients.

With this patient, I might think about first what drugs he’s using. Can you remind me what drugs he was using?

Chris:
Pretty much crystal meth is his main drug, GHB.

Jeremy:
Okay. So, I would ask him what drugs he’s using. I might also ask, “Have you ever been in a situation where you didn’t really know what drug you were using?” That sometimes happens too, where people are just given stuff at a party and they don’t necessarily know and that might lead us down a different path. So, I’d ask how is he using? Is he smoking it? Is he injecting it? Is he able to keep up in terms of the G? Does he know how much G he’s using? Has he ever had an overdose in the past?

I don’t know if you know any of that information about your patient.

Chris:
I should have had you in the room meeting him. I don’t yet have those answers, but let’s hypothesize that he is not ready to give up chemsex, but there are times that he would like to have more control over his use of methamphetamines.

Jeremy:
That actually is a really great place to start and an even better place to start than me thinking of all the harm reduction strategies to get a sense of what does this person want, because the most successful strategy is going to be the one that actually gets implemented by the patient.

If he wants to cut down on his use of methamphetamine and he is injecting, that’s a much more potent way to experience the drug and may lead him to get high faster, puts him at greater risk of over-amping, so experiencing some of these untoward side effects of meth that he probably has experienced and doesn’t want to. Any of those experiences might help us begin to have a conversation about how he could move away from injection or at least move away from injection sometimes.

In terms of his ARV use, we might talk about how/when does he take his Biktarvy in relation to chemsex? How many days are we talking about that he’s missing? How many days is he engaging in chemsex? Are there particular strategies that he can employ to maybe help him be more successful? If he’s having chemsex at night, being sure that he took his Biktarvy that morning. Is there any predictability to when he’s going to be having chemsex? Is there a particular party he goes to every month that he tends to go home with guys afterward? Those might be times where he wants to really strategize how is he going to remember to do this.

Or if he feels like he just can’t keep up with it and it’s a pretty regular occurrence for him, then that may lead you into thinking, “Is a long acting injectable an option for him?” That would certainly help him get around some of these adherence issues. Those are some of my initial thoughts based on at least his goals.

Chris:
Yeah, I like that. I think long acting cabotegravir/rilpivirine would be a good option. I did raise the issue with him, described the pros and cons, and expect to have continued conversation around that, but certainly would seem like a step towards harm reduction for him at this point.

Jeremy:
Totally. In terms of his GHB use, that’s often something we don’t talk enough about, and I think it is the elephant in the room in terms of withdrawal risk.

We have detailed and nuanced information about GHB in the guidelines in terms of maximum dosages people should be thinking about, but it comes down to understanding first that that is a very different substance than meth, and that there is an overdose and a withdrawal risk. It’s not responsive to naloxone. Some people will think, “Because I have naloxone, I’m covered.” But as you and I know, GHB and GBL aren’t opioids, so, they’re not going to be reversed by naloxone and helping people understand that that risk persists.

Then a lot of it comes down to timing and keeping track of how much GHB and GBL people are using. There have been innovative strategies developed. Again, this is a subculture, so people sometimes take on the role of a timekeeper and a dose-keeper to keep track of how many doses people have had and how much they’ve been using. I’ve had people tell me that they put food coloring in their GHB, because it’s a clear liquid, so that it doesn’t get mixed up with water because they’re often really attuned to staying hydrated. Somebody told me they had been in a situation where somebody grabbed the container of GHB, they were high and drank it and overdosed. Oftentimes, our patients can be the best sources of harm reduction strategies because they’re the ones living it and managing the risks all the time.

Chris:
A lot to think about. I’m going to summarize, and you fill in and correct. First of all, chemsex is using drugs while having sex to enhance or enable a sexual experience. From a person’s perspective, it may have some value in both enhancing the sexual experience and building that community that may be engaging in similar practices. Then also risks. It sounds like some of the patients you have may be aware of those risks, some may be less aware, but something to identify which are of concern to them, and then to work on a harm reduction strategy to minimize those risks while allowing them to continue to benefit from ways that they feel like they’re benefiting from chemsex. Is that a reasonable summary?

Jeremy:
Yeah, I think that’s a great summary. If people want a more visual experience of this world, there are 2 documentaries [see Show Notes] that I would recommend. One is called party boi, B-O-I, directed by Michael Rice. It’s a really great portrayal of meth and chemsex use, particularly in the black and LatinX community, and there’s another documentary called Crystal City, that’s specifically about this scene in New York City. I think that those can also kind of bring this issue to life for people who maybe aren’t as familiar with it.

Chris:
Thanks for those tips. Anything else you want to add regarding chemsex, mental health, HIV, optimizing care for your patients or harm reduction?

Jeremy:
Well, I’d be remiss if I didn’t mention trauma and didn’t mention substance use disorder treatment as well.

It’s beyond the scope of our discussion today to talk about trauma-informed care and all that that means, but I think to keep in mind that many of our patients who are coming to us with chemsex experiences have had a history of trauma, either within or outside of the context of chemsex. That might be sexual trauma, that might be violence, or some really scary situations that people have been in, and they might be reluctant to talk about these experiences. So, creating that environment where people feel comfortable to share and then having resources at the ready for folks if they want to spend some more time processing and working through some of those traumatic experiences.

Then not everybody who engages in chemsex has a substance use disorder, but many people have lost control of their meth use or other drug use and want to seek treatment for the drug use itself. There are treatments available, including some newer research suggesting that things like long-acting naltrexone plus high-dose bupropion might be helpful for folks who are struggling with meth use and may be particularly helpful for people who are struggling with meth use in the context of chemsex in helping them reduce their use. I think keeping an eye on that too, because sometimes people really want sober sex, but that requires them to get treatment for their substance use in order to do that.

Chris:
Thanks so much for this discussion, Jeremy. I certainly feel better prepared to discuss combining sex and drug use or chemsex with my patients. Also, I’m relieved to know that there are experts like you out there that I can refer my patients to who need more expert care than I’m able to provide.

Jeremy:
Thanks so much for having me, Chris. Thanks so much for devoting this episode to this topic.

Chris:
Yeah, definitely. It’s been a real pleasure.

To our listeners, thanks for joining in to another episode of Viremic. You’ll be able to find links to the articles as well as to the 2 documentaries in our show notes. Please send any comments or questions to viremicpodcast@jh.edu. We’ll be back in 2 weeks with a case involving HIV management considerations for a patient with long history of various ART regimens who may need a switch.

Announcer:
Viremic is sponsored by the Clinical Guidelines Program, a collaborative effort of the New York State Department of Health AIDS Institute and the Johns Hopkins University Division of Infectious Diseases.

Visit the program’s website at: HIVguidelines.org.

Viremic’s case discussions are for informational purposes only and not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use only, not an endorsement

The podcast is produced and edited by Mary Beth Hansen and Brian Hatcher with assistance from Jesse Ciekot and Laura LeBrun Hatcher.