MEETING REPORT UNDERSTANDING THE IMPACT OF SMART PHONE APPLICATIONS ON MSM SEXUAL HEALTH AND STI/HIV PREVENTION IN EUROPE

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1 UNDERSTANDING THE IMPACT OF SMART PHONE APPLICATIONS ON MSM SEXUAL HEALTH AND STI/HIV PREVENTION IN EUROPE Stockholm, 4-5 February 2015 Key issues emerging from the meeting There is evidence that use of mobile apps by MSM is common and has increased significantly in recent years. There is little quantitative data on the extent to which apps are influencing the source or number of sexual partners or sexual networks. Mobile apps have significant reach and offer considerable potential for public health in terms of health promotion and data generation. Experience suggests that approached correctly, apps can help promote the uptake of HIV testing and other services when linked to specific events such as testing week or through push messages about nearby services. Available evidence suggests that patterns of recreational drug use have changed, although patterns vary between countries. There is little data on the link between apps and recreational drug use, although apps do appear to be playing a role in organising and finding group gatherings of MSM for sex which include the use of recreational drugs. Existing harm reduction services are generally not well placed to provide services for MSM or to address recreational and sexualised drug use. Key actions to be considered include the need to: Improve understanding of how apps are being used and the effects on sexual health, behaviour and networks. Establish a platform for sharing information and experience about smart phone apps and MSM sexual health, recreational drug use and develop practical guidance on effective approaches to using apps for public health interventions. Take coordinated action across Europe and in partnership with organisations in the US to engage with app owners and developers and to identify what works in STI/HIV prevention and health promotion. Identify ways in which apps could be used for public health, for example, testing reminders and messages about local services, and as a data source.

2 Introduction The European Centre for Disease Prevention and Control (ECDC) in collaboration with Terrence Higgins Trust (THT) held a meeting in Stockholm on 4-5 February 2015 to discuss the implications of smart phone applications for MSM sexual health and STI/HIV prevention. Participants, representing public health, research, service delivery and community organisations, were welcomed by Teymur Noori (ECDC) and Cary James (THT) (see Agenda in Annex 1 and Participant list in Annex 2). Following introductions and an overview of the work of ECDC by Andrew Amato (ECDC), Teymur Noori provided the background to the meeting. There has been a proliferation of digital platforms geared towards facilitating finding sexual partners amongst MSM. Grindr is the largest all-male GPS-based mobile app, bringing together more than 5 million active monthly users in 192 countries and with 10,000 new members joining daily. Studies show that a significant proportion of MSM who are not in a closed monogamous relationship use online platforms to source sexual partners and the use of apps increased for those with higher numbers of partners. 1 Given this, ECDC identified the need for a better understanding of the use of mobile apps and their impact (e.g. on how MSM communicate and meet, on sexual partners, on mixing of sexual networks and on organisation of private sex parties involving recreational drug use) as well as to explore their potential role in STI/HIV prevention. THT was contracted to implement a project to explore the importance and impact of mobile apps on MSM sexual health in Europe through a literature review, in-depth stakeholder interviews, survey of HIV professionals, and MSM in-depth interviews. The main objectives of the meeting were to: Share the preliminary findings of the ECDC/THT project and seek further expert input. Provide a platform to discuss the impact of apps on MSM sexual health. Share information on recreational drug use and its relationship to private sex parties and MSM phone apps. Share experiences of using mobile apps for STI/HIV prevention among MSM. Identify priorities for research and for action in the area of mobile apps, MSM sexual health and sexualised recreational drug use. This report summarises the main issues and action points from the meeting presentations and discussions. (Presentations were made available separately to the participants.) STI/HIV epidemiology among MSM in Europe Gianfranco Spiteri and Anastasia Pharris (ECDC) presented an overview of STI/HIV epidemiology among MSM in the EU/EEA. Data is reported annually to ECDC for syphilis, chlamydia, gonorrhoea, lymphogranuloma venereum (LGV) and HIV. In 2013, 6% of reported Chlamydia cases, 43% of reported gonorrhoea cases and 54% of reported syphilis cases in the EU/EEA were in MSM. Rates of Chlamydia, gonorrhoea and syphilis are increasing among MSM. Data across countries are difficult to compare due to differences in availability of diagnostics, testing practices and guidelines and surveillance systems. 1 Mowlabocus et al, Reaching out online: Digital literacy and the uses of social media in health promotion. Working Papers of the Communities & Culture Network+ Vol.3 (April 2014). 2

3 MSM are the population most affected by HIV in Europe. Sex between men is the predominant mode of HIV transmission in the EU and MSM accounted for more than 40% of reported cases in 2013 (see below). The number of new HIV diagnoses among MSM increased by 33% between 2004 and 2013 (see below); this increase has been particularly marked in many countries in the Centre and East of Europe. Available data show that rates of HIV testing among MSM are low and that, although late diagnosis may be decreasing, more than one-third of MSM are diagnosed late. 3

4 Key points raised by participants included: The need for caution in interpreting data, as countries use different approaches to testing MSM for STIs and, with the exception of syphilis, STI data is not comparable across countries. The significant increase in reported cases of gonorrhoea and syphilis among MSM from The reasons for this are not clear, although increased testing and improved reporting may be a factor. Some participants suggested that it may also reflect the impact of the economic crisis on health services. The need for better analysis of mode of transmission for cases where this is reported as unknown. In some Eastern and South-eastern European countries it is likely that many of these cases are in MSM. ECDC is currently exploring the potential to apply an imputation approach to cases where mode of transmission is unknown. Project methodology Cary James provided an overview of the project methodology which included a literature review, in-depth stakeholder interviews with HIV prevention professionals, a stakeholder survey, and MSM in-depth interviews. Literature review A literature review was conducted in June Findings from the literature review were used to create the interview script and survey questions for the stakeholders. In-depth stakeholder interviews After an initial analysis of the literature review against the original research questions, a set of questions were created for stakeholder interviews with workers and volunteers who undertake HIV prevention work with MSM. These questions covered: The importance of apps and other online spaces to MSM in their area. Historical shifts in terms of the importance of online spaces and more traditional gay physical meeting spaces. HIV prevention work by the stakeholder which has used online MSM spaces, including apps. What their opinions are on the impact of MSM smartphone apps on the sex lives of MSM. Stakeholder survey The online survey was created based on the interview data and questions, and circulated to stakeholders across Europe via existing LGBT and sexual health/hiv stakeholder networks. The survey was completed by 195 stakeholders from 36 different countries. Of those, 159 were from 26 EU/EAA countries. These stakeholders comprise a convenient sample and is therefore not a representative sample from across all EU/EEA countries. ECDC and THT will approach stakeholders from the four EU countries currently missing; Cyprus, Hungary, Lithuania and Latvia. 4

5 MSM in-depth interviews The stakeholder interviews and surveys established hypotheses on the potential impacts of smartphone apps on MSM social-sexual practices. These were conducted over Skype or smartphone. Interview participants were recruited via Facebook advertising across EU countries. Content from the interviews do not provide definitive answers to the hypotheses, but rather add some personal experiences to show the depth and complexity of each issue, and its importance for future research. Preliminary project findings Cary James presented an overview of the preliminary project findings: Mobile apps are the latest in a series of methods and media used by MSM to source sexual partners. Their use has increased dramatically since 2010, as smart phones and internet access have become more widely available. Although websites are still the most popular platform, apps are the second most popular across Europe (see below). There are differences between sub-regions: smart phone apps are more popular than websites in Western Europe but the reverse is the case in Central and Eastern Europe. 5

6 There are also differences between sub-regions in the popularity of specific platforms. Although Grindr is the most popular overall in the region and in Western Europe, Gay- Romeo is the most popular platform in Central and Eastern Europe (see below). The following plenary session discussed specific findings for some of the project hypotheses. Hypothesis 1: Smart phone applications have increased partner numbers and frequency of partner change among MSM Responses to this question are shown below. More than two-thirds of respondents agreed or strongly agreed that apps have increased partner numbers and frequency of partner change. However, individual responses from MSM interviewed suggest the impact may depend on the country context. For example, a respondent in Malta said that apps had made a difference to the number of partners he had, but another in the UK said that it had not. Answer Options Strongly Disagree Disagree Unsure Agree Strongly Agree Rating Average Response Count 0% (0) 5.17% (6) 28.45% (33) 37.93% (44) 28.45% (33) Key points raised in the subsequent discussion included: The need to avoid framing the number of partners and frequency of partner change in relation to use of apps as a moral debate. The advent of the internet generated the same debate about numbers of sexual partners. Anecdotal evidence suggests that apps may be replacing other media, such as websites, as well as gay venues, in some settings. Apps do offer a number of advantages. They can be used more easily and more often than websites. The benefits may be greater in areas outside cities where there are fewer opportunities to find sexual partners, although websites also provide this facility. They enable MSM to interact and to find partners without needing to go to a venue; this is particularly important for MSM who cannot afford to go to gay venues and in places where MSM infrastructure is limited or MSM face high levels of stigma and discrimination. However, participants also noted concerns about the authorities using platforms to identify MSM in countries with restrictive legal and social environments. 6

7 Anecdotal evidence suggests that there has been little change in the average number of sexual partners among MSM. Participants suggested that the overall impact of phone apps on increasing the number of sexual partners may be limited; it is those who would have had many sexual partners anyway who are using apps to source partners. Project feedback also suggests that there is a lot of seeking but less finding of sexual partners and that phone apps may not necessarily increase success in sourcing partners. Hypothesis 2: Smart phone applications provide new opportunities for MSM to communicate, meet and form non-sexual connections Responses to this question are shown below, overall and broken down by sub-region. The majority of respondents agreed or strongly agreed that apps provide new opportunities for communicating and meeting with other MSM. Key points raised in the subsequent discussion included: The way in which apps are used, and the popularity of apps, varies between countries as well as within countries. The need to differentiate between apps. Some are used only for finding sexual partners while others are used by those looking for friends or a boyfriend; some address social and political issues; some are used specifically by HIV-positive or by HIV-negative men. Hypothesis 4: Smart phone applications facilitate the mixing of sexual networks which may have previously been separated by age, identity or sexual practices Responses to this question are shown below. Although most respondents agreed that apps do facilitate mixing of sexual networks, a significant minority were unsure or disagreed. Answer Options Strongly Disagree Disagree Unsure Agree Strongly Agree Rating Ave Count 0.85% (1) 14.53% (17) 27.49% (29) 44.44% (52) 15.38% (18) Key points raised in the subsequent discussion included: There is limited evidence about the role of apps in facilitating mixing of sexual networks and there was no consensus on this issue. Some participants suggested that apps are unlikely to influence MSM preferences and allow people to maintain separation. Some also highlighted racist, anti-older gay men and anti-hiv-positive MSM content on some 7

8 apps and websites. However, others suggested that apps are reducing the separation between genres, by allowing certain practices to be more visible. In the US, there is some evidence that apps are increasing mixing between MSM who would be unlikely to meet in venues, for example MSM of different races and age groups. The impact is likely to be context specific. For example, apps will have little effect on mixing in places where there is little separation between sexual networks. The impact of increased mixing between MSM of different ages needs to be monitored. Hypothesis 6: Smart phone applications influence MSM tourism within Europe, functioning as a common way for MSM travelling to a new country to meet other MSM in that location Responses to this question are shown below. The majority of respondents agreed or strongly agreed that apps enable MSM travelling to another country to meet other MSM there. For example, one respondent from the UK said that he definitely used apps when he was on holiday in another country. Another, from Romania, said he used apps to chat to other MSM when he was in cities in other countries. Answer Options Strongly Disagree Disagree Unsure Agree Strongly Agree Rating Average Response Count 0% (0) 5.13% (6) 12.82% (15) 51.28% (60) 30.77% (36) Key points raised in the subsequent discussion included: There was agreement that phone apps have enhanced the sociability of travel, making it easier to meet other MSM. It is no longer necessary to take a laptop or to find an internet café. Apps have also facilitated meeting other MSM during business travel. Some noted that otherwise heterosexually-identified men are using Grindr when they are away on business. In some countries and cities, escorts and sex workers are using apps such as Grindr. Using apps for STI/HIV prevention The project found that although 89% of those working in HIV prevention surveyed reported that they are doing prevention work online, only 58% reported that they are doing prevention work through smart phone apps. This reflects a number of challenges, in particular in working with app owners. These challenges include lack of cooperation and the high cost of advertising. 8

9 Nevertheless, organisations are using apps for a range of public health-related activities including outreach, advertising campaigns and services, and recruitment for research. The following summarises project findings on the type of support from app owners that organisations would find useful. 9

10 Specific experiences described by participants included: In the UK, THT has used apps successfully to promote postal HIV testing services; each Grindr message has generated around 1,000 orders for tests. THT in Brighton has used apps, mainly Grindr, for push messages on syphilis, during HIV testing week and during the Shigella outbreak, as well as to create a profile and to promote THT services. This has increased the number of MSM using walk in services and there is evidence that use of apps is reaching MSM who were previously not in contact with services. THT has experienced some challenges, for example, information being removed or blocked by app moderators. Apple devices are also more problematic than android devices; THT has switched to android devices which allow it to fake GPS location in order to reach people in a wider area and inform MSM in advance about outreach testing services. The Dean Street clinic in London has had some success in engaging with Grindr, allowing people to receive a push message when they are in the vicinity of the clinic. In the Netherlands apps have been used to promote websites and HIV testing. In Greece apps have been used to provide general information about Checkpoint location and opening times; experience suggests that MSM do not respond well to reminders about HIV testing. In Croatia, paid for advertising on Grindr has been used during HIV testing week, but this is expensive. Gay-Romeo has provided free ad space. Likewise, in Slovenia, Gay-Romeo is reported to be the only app owner with a sense of social responsibility. However, in Germany, Deutsche Aids Hilfe has used Gay-Romeo to provide information and peer support but has found Gay-Romeo difficult to engage with. In Spain, SMS is used to remind people about testing but there is no experience as yet of using apps for STI/HIV prevention. Lack of funds for ads and for staff to respond is the main problem. Lack of funds is also a problem in Hungary. In Sweden, RFSL has recently started advertising on Grindr to raise awareness but does not yet have a profile; an SMS chat service was not successful. It has been difficult to engage with Grindr; its response to approaches has been that RFSL should buy ads. Likewise there are issues with Scruff; ads are bought via Google ads and there are difficulties due to Google rules about content. RFSL does have a good relationship with Cruiser and hope that this will allow it to set up a specific app. Cruise has also been used to recruit MSM for a survey by the Swedish public health agency. In Denmark, some advertising has been done on Grindr, although this is very expensive; messages during HIV testing week have resulted in increased uptake of testing. In France, a prevention app has been developed, but this has not been very effective; apps have been used for ads during HIV testing week. Similarly in Belgium, apps have been used for ads during HIV testing week. In both France and Belgium, apps are not seen as suitable for outreach work due to lack of trained staff. In Australia, the New South Wales AIDS Council runs workshops on how to use apps for peer education, linking health and digital literacy; there has been high demand in particular from young men of Asian origin. Issues highlighted included: The need for a coordinated approach to collaboration with app owners. More specifically, for example, to allow push messages about sexual health services in the immediate location. The need for better coordination between organisations providing information and services in engaging with app owners. 10

11 The challenge of providing targeted information through apps that have a wide and diverse audience. The need for a clear approach to using apps for sex and drug-related health promotion and prevention work. The need to work through apps with MSM who host private sex parties. The need to evaluate the effectiveness of ads and provision of information through apps. Experience in the US David Purcell (CDC) presented a summary of available evidence on the impact of apps on sexual health of MSM in the US. Following an overview of the epidemiology of HIV in the US where, as in Europe, MSM are the population most affected by HIV, he described developments in use of the internet and mobile platforms during the last two decades. The 1990s saw the advent of the internet, in particular the use of chat rooms, which changed how MSM connected socially and sexually, allowing non-gay identified and rural men to connect and reducing the risk of physical harm or arrest. Between 2000 and 2009, the use of the internet expanded, as broadband and wireless services became more widely available, with an increase in MSM-specific sites with personal profiles and images and a shift from physical to digital communities. Since 2010, there has been a significant shift to use of mobile platforms with high use of dating apps by MSM. The increase in STI/HIV among MSM in the US was evident prior to the availability of mobile platforms. While it is possible that there is a link to the expansion of gay websites, other factors context, personal factors and venues have also affected sexual behaviour and HIV risk. Available data on the impact of the internet and mobile platforms is limited. In summary: Meta-analyses comparing online and offline recruitment or use for partner selection suggest that unprotected anal intercourse (UAI) is more likely among participants recruited online and MSM who sought partners online. Another study, of men coming for STI screening in Los Angeles found that men who used apps to meet sex partners were more likely to have new chlamydia and gonorrhoea diagnoses but were not more likely to have new syphilis or HIV diagnoses. In another study, of MSM who did not have a main partner, app users compared with non-app users reported more recent sex partners, more lifetime partners, and rates of STIs that were twice as high despite no differences in STI testing. In a qualitative study of young MSM, themes mentioned in relation to HIV acquisition were, in order of importance: lack of HIV prevention education, use of marijuana with sex, use of alcohol with sex, lack of family support and internet partner hook ups. Men recruited from Grindr for a microbicide study, compared to other recruitment methods, were more likely to be younger, white and to have had more recent sex partners; 70% perceived themselves to be at low risk of HIV but 46% had had UAI in the past 3 months. In another study of HIV testing among MSM in New York City recruited from Grindr, a higher proportion had never been tested and had recently been tested compared with community samples, suggesting that Grindr may be useful for promoting testing to those never tested (especially young) and reinforcing testing to those already testing regularly. The internet and apps are critical media for public health. There is a range of initiatives in the US including communication and information campaigns, health education interventions, and apps and games to promote sexual health. CDC is also working with app owners to advocate for allowing key features such as sero-status disclosure and push messages and advertising on 11

12 sites when ads are free. Key challenges include rules limiting explicit content and preventing federal funding of ads. Following this, Jennifer Hecht (San Francisco AIDS Foundation) described the experience of a study (see that aimed to find strategies to reduce HIV and STD transmission that will be supported by and incur low costs for website owners and public health and that are likely to be used by website users. It surveyed three stakeholder groups (see below) in The study identified eight strategies that the majority of each of these groups supported: filtering partners by profile information; online STI testing directory searchable by zip code; sub-section of sites for specific sexual interests; including safe sex as a profile option; access to sexual health experts; access to sex-positive videos; automatic STI/HIV testing reminders at users choice of intervals; and online partner notification about exposure with e-cards. In September 2014, SFAF and amfar held a meeting that brought together eight major website and app owners and public health representatives from all US states, CDC and other institutions. It is important to note that, in the time between the 2009 survey and the meeting, there were significant developments, including the emergence of smart phone apps, the rollout of PrEP, and improvements in HIV testing technologies. The meeting aimed to: evaluate current strategies for online STI/HIV prevention and generate new ideas; develop an action plan for implementing strategies and establish productive relationships between website and app owners and public health representative working in STI/HIV prevention. It also provided an opportunity for website and app owners and public health representatives to share their perspectives. Key issues for website and app owners include: lack of coordination among those engaging with website and app owners, resulting in multiple requests from health and community organisations, and difficulties in distinguishing who is and is not legitimate; negative media reports that blame websites and apps for spreading HIV and STI; limited understanding among public health staff of new technologies and the potential to leverage website and app features. Key issues for public health representatives include: lack of evidence about what works; and inability to coordinate and prioritize requests of app owners. The meeting focused on the positive benefits of partnership. From a public health perspective these include the opportunity to expand outreach, promote awareness of outbreaks, improve partner notification and generate data for surveillance and research. 12

13 From the perspective of website and app owners these include positive public relations, providing resources for users, and enabling owners to be responsive to user needs. The meeting addressed five main topics: stigma reduction, partner notification, disclosure, promotion of STI/HIV testing, and coordination between public health and site/app owners. There was unanimous support for promoting testing. Reactions concerning partner notification from owners were mixed. Some were willing to and already offer this to users, others were not interested in interfacing with health departments and viewed this as potentially intrusive for users; there were also concerns about technology issues on apps. On disclosure, reactions were not uniform. Some owners were concerned about whether including information about status in profiles would increase stigma and also about whether users would be honest about their status. Yet all owners were addressing disclosure in ways that were most relevant to their users. With regard to coordination between site/app owners and public health, the meeting attendees decided to create a consortium for future partnerships. Other key issues highlighted by owners were the need for well-written messages and engaging graphics, the need to link messages to action, and requests for organizations using apps for outreach to follow terms of service. In summary, website and app owners are willing to support STI/HIV prevention and many have already taken action to do this. Promoting testing is a high priority for all stakeholders, as is promoting a culture of respect to reduce stigma. Next steps will include: identifying what works through piloting and research; expanding and supporting the newly-created consortium; providing clear recommendations to owners e.g. on disclosure options; and improving coordination and streamlining requests and communication with web and app owners. In December 2014, the consortium, with strong partnership from CDC, was able to undertake its first effort by coordinating eight sites to participate in promoting STI/HIV testing as part of World AIDS Day. Key points raised in the subsequent discussion included: The challenges of partner notification include: the lack of a standard approach across Europe and the need for approaches that are appropriate and respectful. Strong support for using apps to promote STI/HIV testing, with recognition that to do so would require compiling a European-wide database for testing sites. The need for coordinated engagement with app owners, in particular those who have very few staff. The difficulties of engaging with app owners, many of which are based in the US, for European organisations. Sexualised recreational drug use and apps This session included four presentations. The first, by Adam Bourne (London School of Hygiene and Tropical Medicine), provided an overview of research from the UK on MSM, sex and drug use. Key points included: Gay men have been known to use drugs, especially stimulants, more than the general population. Drug use has changed over time; currently in the United Kingdom, the most commonly used substances are mephedrone, GHB/GBL and crystal meth. In addition to stimulant properties, these drugs also enhance sexual arousal, and there is growing evidence that they are used for intentional and specific sexual purposes. 13

14 Chemsex is defined as sex between men that occurs under the influence of drugs taken immediately preceding and/or during the sexual session. (In the US and Australia it is sometimes referred to as Party and Play or PnP.) It typically occurs in private homes and is often associated with group sex. It has been portrayed negatively in the media, based on the assumption that it is a factor in increased HIV incidence among MSM, but there is no evidence of this. Data on the prevalence of chemsex is limited. There is some clinic data and some data from Public Health England. Available data, based on substances self-reported as problematic, indicates that in the UK, there has been an increase in use of mephedrone, GHB/GBL and crystal meth. There has also been a rise in injecting; in 2011, 20% of clients to English GUM clinics using crystal meth injected, in 2012, 80% did so. Public Health England enhanced surveillance to investigate the lifestyle and sexual behaviour of MSM diagnosed with Shigella flexneri included interviews conducted between October 2012 and February The findings showed that 60% of Shigella cases were HIV positive, 76% of cases had used recreational drugs and one-third of these reported injecting drugs (slamming), and 40% said that drugs had affected their judgment with respect to risk behaviour (see also below). In addition, HIV-positive men with Shigella were more likely to use recreational drugs than HIV-negative men. 14

15 Other data sources also suggest a rise in the use of recreational drugs in the UK. For example, 2012 data from the CODE clinic in London showed that 19% had used GHB/GBL, 10% had used crystal meth and 21% had used mephedrone within the previous 6 months. The ASTRA study, based on clinic data on HIV-positive men in two cities in , found that 9% had used crystal meth and GHB/GBL and 7% had used mephedrone in the previous three months. The South London chemsex study conducted 30 in-depth interviews with MSM, 13 of whom were HIV positive, to better understand the motivations for and context of chemsex and experience of harm reduction services. Key findings were as follows: Trends in drug use are related to cost and availability; mephedrone and GHB/GBL are cheap and widely accessible relative to cocaine and ecstasy. Crystal meth remains relatively expensive and only about half of the men interviewed used it on a regular basis. Often where such use did occur it was in exchange for sex, particular with older, wealthier gay men. Injection of mephedrone and/or crystal meth was reported by onethird of men interviewed. Mobile apps have increased access to sexual partners and sources of recreational drugs and facilitating organising and finding sex parties. Chemsex was also commonly reported in saunas, sex clubs and other sex-on-premises venues. Mephedrone, GHB/GBL and crystal meth are easily accessible in such venues, as are a large number of casual or anonymous sexual partners. Reasons reported for using drugs included increasing sexual confidence, desire and libido, sexual longevity and partner turnover, and facilitating sexual adventure. The relationship between drug taking and sexual risk behaviour is complex. The study found that the association could be grouped into several categories. Around 25% of those interviewed engaged in chemsex but always maintained strict safe sex behaviour; around 25%, all of whom were HIV positive, engaged in pre-determined condom-less anal intercourse, having actively made the decision to always or nearly always have sex without condoms with other men they thought were also positive; and around 33% had engaged in unintentional condom-less anal intercourse, they had intended to use condoms but drugs had diminished their capacity. In terms of sexual health, among those interviewed, two attributed their HIV infection to chemsex and more than 30% had been diagnosed with an STI in the past year; there was also widespread reporting of penile abrasions and rectal trauma. There were also mixed feelings about sexual satisfaction and happiness, with some reporting that drugs had been beneficial for their sex life, but others reporting that sex associated with drugs was mechanical and lacked intimacy. Chemsex was also associated with other health risks, of which overdosing was the most pressing; overdosing also left men vulnerable and three participants reported that they had been victims of non-consensual sex. The majority of men interviewed who used recreational drugs had not sought professional support for drug issues and were wary of using generic harm reduction services, which are associated with opiate users. More research is needed to assess the prevalence of chemsex among MSM in Europe, to assess the impact of chemsex over time on sexual health and wellbeing, and to develop and evaluate interventions. In the second presentation, Axel J. Schmidt (The EMIS project, London School of Hygiene and Tropical Medicine; Swiss Federal Office of Public Health), provided an overview of the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS) findings on drug use among MSM across 44 European cities. EMIS data is from 2010 and the amount and type of drugs 15

16 used by MSM may have changed in the intervening period. In this analysis, drugs associated with chemsex included ketamine in addition to GHB/GBL, mephedrone and crystal meth. Use of drugs associated with chemsex varied substantially across European cities. Only a minority of MSM had experience with use of chemsex drugs. Less than 20% in all European cities had used chemsex drugs in the four weeks preceding the survey, and less than 4% had used crystal meth. The city of residence was the strongest predictor for recent use of chemsex drugs. The ranking order was largely consistent when controlling for age, HIV testing history, and the number of sexual partners. In multivariable regression, HIV positive MSM as well as MSM with 10 or more sex partners in the last 12 months were nearly five times more likely to report use of chemsex drugs in the past four weeks. An age beyond 40 years was slightly protective. Recency of chemsex drug use in 44 European cities, displaying the top 10 and the city with the least consumption. (EMIS-2010) Key points included: As the city of residence was the strongest demographic predictor of chemsex drug use, drug use patterns appear to be culturally determined. In 2010, mephedrone use was predominantly a UK phenomenon. In the UK, it has replaced Ketamine in In continental European cities, mephedrone use was substantially lower, with less than 5% of MSM having used it in the previous 12 months. Less than 10% of MSM in all cities had used crystal meth in the previous 12 months. Crystal meth use particularly common in English and Spanish cities, Amsterdam, as well as in central/eastern European cities such as Berlin, Riga and Prague. In the third presentation, Fred Bladon (AIDES) discussed drug injecting in a sexual context in the French gay community. This is based on research conducted in 2012, in response to emerging evidence that slamming was becoming more widespread, to identify the determinants of risk taking and the needs of MSM. Interviews were conducted with 23 informants including ten slammers and four ex-slammers. Key findings were: All of the slammers reported that they had used other drugs before slamming. Although they define slamming in terms of injecting psycho stimulant products in a sexual private setting, slammers did not perceive themselves as injecting drug users. The most commonly used substances were mephedrone derivatives, which are cheap and easily available, cocaine and crystal meth. Mephedrone derivatives were reported to 16

17 produce intense sexual desire and pleasure, as well as strong cravings which increased the frequency of injecting. Most reported that they were injected initially done by someone else with experience and did not want to learn to self-inject to avoid addition, but this changed over time and some reported that slamming had replaced sex. Some also reported that they had lost control over their drug use and had sought professional help or decided to stop. The interviews identified two types of needs. First, information, for example, on both sex and drugs, about self-injecting and harm reduction and access to injection kits. Second, health care, for example, non-discriminatory services, trained health workers, and support. In the final presentation, Kane Race (University of Sydney) provided insights into the Australian experience, based on an ethnographic study among MSM in Sydney and Melbourne. Findings concerning growing use of multiple apps to seek sexual partners and of recreational drugs at private sex parties were similar. In Sydney, 15-20% of MSM had participated in chemsex in the past 6 months. Although some have a negative view of online and mobile devices for hook ups, in particular their impact on social interaction, apps do provide a safe space for, for example, exploring fantasies and desires, and sero-sorting and disclosure of status. Apps, websites and recreational drug use may be regarded as giving rise to a specific sphere of sexual sociability and sexual pleasure in some contexts, the investment in which participants may have difficulty acknowledging 'in public, due to stigma around nonnormative intimacies and substance use. Key points raised in the subsequent discussion included: The need to expand further the data on drug use among MSM in Europe; in France mephedrone is not used. The need to keep the issue in proportion; although apps appear to be facilitating the organisation of private sex parties, only a specific sub-set of MSM engage in chemsex. The need to also consider the role of alcohol in sexual risk behaviour. In San Francisco, drug use appears to have declined but alcohol use is highly prevalent and may be a bigger factor in HIV transmission than chemsex drugs. The issue of injecting is a concern and it will be important to monitor sexual networking among those injecting and those not injecting. The need to increase awareness of the risk of other STIs and of hepatitis C; sero-sorting may reduce HIV risk but it will not address the risk of other STIs; some MSM are sharing syringes even if they are not sharing needles. The need to increase awareness of interactions between recreational drugs and HIV and HCV medications. The need to monitor the impact of the wider environment on drug use. For example, reduced availability of legal highs has resulted in their replacement replaced with new synthetic drugs, and the economic crisis has contributed to the switch from opiates to stimulants. The need to repeat EMIS to obtain up to date data on drug use and monitor trends. The need for sexual health services for MSM to also ask about and address drug use. 17

18 Summary and priority actions The final session summarised the main issues that emerged during the meeting and priorities for action. Key issues included: There is evidence that use of apps by MSM is common and has increased significantly in recent years. There are some issues that are common across countries, but there are also differences, for example, in the popularity of certain apps. There is little quantitative data on the extent to which this is influencing the source or number of sexual partners or sexual networks. Regardless, it is important to avoid over-reaction and to take a proportionate view of the potential impact of this technology on sexual behaviour. Mobile apps have significant reach and offer considerable potential for public health, in terms of health promotion and data generation. Organisations in some countries are already using online and mobile platforms for STI/HIV prevention, although there are questions about how to do this most effectively. Experience suggests that approached correctly, apps can help promote the uptake of HIV testing and other services when linked to specific events such as testing week or through push messages about nearby services. Experience of working with app owners is mixed. Although some are cooperative, organisations have encountered a range of challenges including limited willingness to collaborate, being banned or blocked by moderators, and the high cost of advertising. Available evidence suggests that patterns of recreational drug use have changed, although patterns vary between countries. Recency analysis is a useful tool for identifying trends. There is little data on the link between apps and recreational drug use, although apps do appear to be playing a role in organising and finding group gatherings of MSM for sex which include the use of recreational drugs. Existing harm reduction services are generally not well placed to provide services for MSM or to address recreational and sexualised drug use; most services are not MSMfriendly and have traditionally focused on opiate use. Equally, MSM organisations and others providing sexual health services for MSM may not be equipped to address use of drugs commonly associated with sexualised use. There are particular concerns about the lack of service infrastructure in some countries in the region. Key actions to be considered are: Improve understanding of how apps are being used and the effects on sexual health, behaviour and networks, through a repeat of EMIS and other studies, and of the potential role of mobile platforms in reaching young MSM who may not access information though more traditional media. The next pan-european MSM internet survey could include questions about use of apps and use of recreational drugs. Establish a platform for sharing information and experience about smart phone apps and MSM sexual health, recreational drug use and develop practical guidance on effective approaches to using apps for public health interventions. Existing networks and platforms could also be used to share experience. Take coordinated action across Europe and in partnership with organisations in the US to engage with app owners and developers and to identify what works in STI/HIV prevention and health promotion. Improve monitoring and analysis of the dynamics of recreational drug use among MSM. 18

19 Strengthen the capacity of, and promote collaboration between, harm reduction services, sexual health services and MSM organisations to meet the sexual and drug-related health needs of MSM. Identify and scale-up of effective interventions addressing sexual health and drug harm reduction among MSM using drugs in sexual settings. Identify ways in which apps could be used for public health, for example, testing reminders and messages about local services, and as a data source. Consideration could be given to registration of STI/HIV clinics such as the MSM Checkpoints in various EU cities (GPS location, opening times and drug counselling available) and integration of this information into app widgets. Several participants encouraged ECDC to explore further the links between public health and the use of mobile apps. Strengthen second generation surveillance, evidence on the determinants of health in MSM and qualitative research on drug use in sexual contexts. Next steps The ECDC/THT project report will incorporate key points from the meeting and additional inputs to be solicited from stakeholders in countries that were not surveyed and will be finalised by late spring ECDC will consider producing a consensus statement/short summary based on key issues and priority actions identified by the meeting, establish further collaboration with EMCDDA in the area of chemsex and its relationship to mobile apps and other online platforms, ongoing collaboration with US partners on engagement with app owners and developers, establishing an informal network to continue dialogue on digital platforms and MSM, sexual health and recreational drug use, and other ways in which it can take forward the issues raised by the project and this meeting. Teymur Noori and Cary James closed the meeting by thanking all the participants for their contribution to productive, interesting and useful discussions. 19

20 Annex 1: Agenda Wednesday 4 February 2015 SESSION 1: INTRODUCTION (Cary James and Teymur Noori) 09:00 09:20 Welcome and introduction (Andrew Amato) 09:20 09:40 Objectives and project overview (Teymur Noori and Cary James) 09:40 10:00 Overview of STI/HIV epidemiology among MSM in the EU/EEA (Gianfranco Spiteri and Anastasia Pharris) SESSION 2: PROJECT FINDINGS (Anastasia Pharris and Teymur Noori) 10:00 10:15 Phone apps, MSM and HIV prevention in Europe preliminary findings of the project (Cary James) 10:15 10:45 Plenary discussion: For each hypothesis: What is the evidence? What are the challenges and opportunities? What action needs to be taken? 11:15 12:30 Plenary discussion SESSION 3: Hypothesis 1: Do you believe that smart phone applications have increased partner numbers and the frequency of partner change among MSM? Hypothesis 2: Do you believe that smart phone applications provide new opportunities for MSM to communicate, meet and form non-sexual connections? Hypothesis 3: Do you believe that the short nature of conversations on smart phone applications can have an impact on successful negotiation of sex or sexual health practices? Hypothesis 4; Do you believe that smart phone applications facilitate the mixing of sexual networks which may have previously been separated by age, identity or sexual practice? Hypothesis 6: Do you believe that smart phone applications influence MSM tourism within Europe, functioning as a common way for MSM travelling to a new country to meet other MSM in that location? Hypothesis 7: Do you believe online platforms and, increasingly, smart phone applications will often be the first point of contact for young MSM with other MSM or MSM culture? EXPERIENCE OF USING APPS FOR STI/HIV PREVENTION (Andrew Amato) 13:30 15:15 Roundtable discussion: Use of mobile apps in STI/HIV prevention SESSION 4: BUILDING HEALTHY ONLINE COMMUNITIES: THE US EXPERIENCE (Cary James and Teymur Noori) 15:45 16:15 Overview of impact of apps on sexual health/practices of MSM in the US (David Purcell) 20

21 16:15 16:45 Experiences from building a coalition to address healthy online communities in the US including engaging with app owners (Jennifer Hecht) 16:45 17:30 Plenary discussion Thursday 5 February 2015 SESSION 5: 09:00 11:00 Presentations: 11:30 12:00 Plenary discussion SESSION 6: 12:00 13:15 Future priorities: SEXUALISED RECREATIONAL DRUG USE IN MSM AND MSM APPS (Alessandro Pirona and Adam Bourne) Overview of research from the UK on gay men, sex and drug use (Adam Bourne) Differences in chemsex use among MSM in selected European cities EMIS results (Axel J. Schmidt) Injection in a sexual context in the French gay community (Fred Bladou) Wired Play logics and practices (Kane Race) Hypothesis 5: Do you believe smart phone applications facilitate the organisation of private sex parties involving recreational drug use? Sexualised drug use among MSM in Europe: What are the common issues? What services are needed to address sexualised drug use among MSM and what should our approach be to addressing these needs? PRIORITIES GOING FORWARD (Andrew Amato and David Purcell) What actions are needed to better understand the impact of mobile apps on MSM sexual health and STI/HIV prevention? What actions are needed to better understand and address the issue of sexualised recreational drug use among MSM? 13:15 13:30 Summing up and next steps (Cary James and Teymur Noori) 21

22 Annex 2: List of participants Name Affiliation/Country Cary James Terrence Higgins Trust, UK Tom Boyt Terrence Higgins Trust, UK Francois Pichon Tamás Bereczky The Danish AIDS Foundation, Denmark European AIDS Treatment Group, Hungary Dirk Sander Deutsche AIDS-Hilfe, Germany Vicky Gilbart Public Health England, UK Adam Bourne London School of Hygiene and Tropical Medicine, UK Félix Pérez HISPANOSIDA, Spain Zoran Dominković Iskorak, Croatia Miran Šolinc SKUC Association, Slovenia Massimo Mirandola Verona University Hospital, Italy Ulrich Marcus Robert Koch Institute, Germany Koenraad Vermey Soa Aids Nederland, Netherlands Chantal den Daas Lucile Bluzat Thomas Ronti National Institute for Public Health and the Environment (RIVM), Netherlands Institut National de Prévention et d Education por la Santé, France Observatoire du sida et des sexualités, Belgium chantal.den.daas@rivm.nl lucile.bluzat@inpes.sante.fr thomas.ronti@fusl.ac.be Nikos Dedes Positive Voice, Greece nikos.dedes@me.com Axel J. Schmidt EMIS project, LSHTM, UK; Swiss Federal Office of Public Health axel.j.schmidt@emis-project.eu Kane Race University of Sydney, Australia kane.race@sydney.edu.au Fred Bladou AIDES, France fbladou@aides.org Jennifer Hecht San Francisco AIDS Foundation, USA jhecht@sfaf.org David Purcell Centers for Disease Control, USA dhp8@cdc.gov Nicklas Dennermalm Carolina Orre Kristina Ingemarsdotter Persson Swedish Federation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL), Sweden Swedish Federation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL), Sweden Public Health Agency of Sweden, Sweden nicklas.dennermalm@stockholm.rfsl.se carolina.orre@rfsl.se kristina.id.persson@folkhalsomyndigheten.se Alessandro Pirona EMCDDA alessandro.pirona@emcdda.europa.eu 22