Slamming, drug injection in sexual contexts: increased HIV and HCV exposure for MSM points to a need for intersectional approaches to harm reduction

Background

In the last decade, European cities saw the development of “slamming”, a practice related to chemsex that combines three elements: sexual context, psychostimulant drug use, and injection. Epidemiological data on this practice is still sparse and media attention might have unintentionally distorted the size of this phenomenon. Therefore, we aimed to estimate the prevalence of men practicing slamming in France and to identify factors associated with this practice.

Methods

Prevagay is a cross-sectional study of HIV and HCV prevalence conducted in several French cities among MSM (Men who have Sex with Men) who spend time in gay social spaces, using Time Location Sampling. Participants filled out surveys and handed in blood samples. The survey explored sociodemographic profiles; sexual habits over the last 12 months (number of partners and types of practices); HIV, HCV and STI prevention; mental health; and substance use in sexual contexts including slam practices (in lifespan and in last 12 months). Blood samples provided data on HIV and HCV status. We applied a weighting mechanism to enhance the generalizability of the estimates.

Results

We recruited 2 646 people in Prevagay-Study. Among participants, 3.1% of the 2,646 participants practiced slamming in their lifetime. 21.5% reported sharing injection equipment (7.3% for syringes and 15.5% for paraphernalia). 1.6% practiced slam in the last 12 months. In univariate analysis, MSM involved in slamming in the last 12 months were younger (33.6 average vs. 40.7), tested positive more frequently for HIV (48.8% vs. 14.4%) and HCV (8% vs. 0.7%), reported more unprotected anal penetrations (66% vs. 27%) and BDSM (bondage, discipline, and sadomasochism) practices (35.5% vs. 12.2%), and used PrEP (Pre-exposure prophylaxis) more frequently in the last 12 months (32.9% vs. 3.9%). MSM involved in slam reported financial difficulties (36.6% vs. 7.5%) and pourer mental health (66.5% vs. 51.8%). In multivariate analysis, after adjusting for age, factors related to slamming were seropositivity for HIV (OR=13,2) and HCV (OR=4.2), financial difficulties (OR=3.56%), and pourer mental health (OR=1.36).

Conclusion

Even though slamming seems to involve a relatively small proportion of MSM, the vulnerability of this sub-group is high enough to justify setting up harm reduction measures and specific care. Indeed, slamming practices are worrisome from the point of view of HIV and HCV exposure among MSM. Slamming appears to involve populations at-risk in multiple respects, particularly MSM who have tested positive for HIV but also, more surprisingly those who are still negative. Slam's propagation transforms the way we think about harm reduction intervention. It requires an intersectional approach that goes beyond traditional epidemiological categories that marked a clear distinction between HIV and HCV transmission through sexual relations and through drug use. Training health professionals and creating services combining sexual health and drug dependence could be an effective response.