To have a meaningful conversation about HIV status, people should corner intentions and sexual partners in the realm of actuality, by keeping it to-the-point and asking the following questions: “When did you last test for HIV? What was the test result?” Equally important is to open minds to reality by remembering that the time of binary HIV statuses is pretty much over.
I can count five HIV statuses, plus a new one. They entail different responsibilities, possibilities and risks.
Every single day we all face countless situations that could, potentially, expose us to harm. In most instances the potential harm can be mitigated to some extent by our following a specific action. A driver can choose not to speed, not to overtake on a solid line and to wear a safety belt to limit injury in the event of an accident. Such harm reduction strategies generally include an element of protecting both ourselves and others from potential harm, as is the case with responsible sex: using condoms and appropriate lube when we bonk protects ourselves and our partners from spreading or contracting HIV and STIs. Harm reduction does make sense and has been proven to be effective.
In the field of sexual health, harm reduction is often closely associated with the use of recreational drugs. We certainly can’t stop people from using street drugs and instead of moralising about it and making drug users feel alienated, we need to implement programmes designed to mitigate the harm associated with this behaviour. Such harm reduction programmes are certainly not new – their importance is recognised by international bodies such as the WHO, UNAIDS and USAID – but they’re certainly new to South Africa. Health4Men, a project of the Anova Health Institute, already at the forefront of providing innovative free sexual health services for gay and bisexual men, has initiated an innovative harm reduction programme in Cape Town.
We’re all aware of high levels of recreational drug abuse among gay men, especially for the enhancement of sexual pleasure. If we don’t use drugs ourselves, we have friends, partners or colleagues who do. Health4Men conducted local surveys on the interface between recreational substance use and sexual risk-taking, HIV and STIs and, in partnership with Amsterdam-based project Mainline, has developed a carefully crafted harm reduction project for gay and bisexual men in Cape Town. The project is funded by AidsFonds, a Dutch donor organisation.
The multi-faceted programme is inclusive of men who use different drugs in different ways and in diverse contexts. The overarching aim is to develop and refine a harm-reduction model that can be replicated elsewhere. It is designed to limit HIV and STI transmission and to prevent non-injecting drug users from adopting this exceptionally high-risk behaviour. The programme includes the dissemination of topical information to gay and bisexual men, with referral points for treatment and care and free harm reduction packs for people who use drugs.
A main concern is the high-risk grouping of gay men who inject their drugs (colloquially referred to as slamming or spiking). In addition to HIV, sharing needles exposes drug users to blood infections such as hepatitis C which is prevalent among gay men in several Northern hemisphere countries and is yet to become prevalent locally. Injecting also stimulates rapid onset of addiction.
The free harm reduction packs, with different contents for injecting and non-injecting users, all contain brochures entitled Drugs and Sex and Drugs and ARVs. Following is an extract from one of the booklets:
“Many gay men associate drugs with sex. Some guys use drugs to make them feel more horny or to give them added confidence, others use drugs to make the sex feel more intense. Many guys use drugs to make the sex last much longer and some use drugs to get into kink, such as fisting or extended edging. Some guys even avoid having sex unless they’re wired on chems. Drugs often influence who we have sex with, what sex acts we get into, how roughly we play and the duration of the sex. Irrespective of whether you’re HIV positive or negative, the sex you have when you’re using chems can be very risky for your health.”
In addition, the pack for injectors includes a 16-page booklet on safer injecting techniques (including information on preventing an overdose) plus new syringes and needles, alcohol swabs, plasters, a teaspoon and candle for cooking, cotton filters and sterile water. The non-injecting pack includes straws for snorting, chewing gum to stimulate saliva, tin foil and a candle, lip balm to sooth burns from smoking and a card for cutting lines. All packs contain Health4Men condoms and sachets of water-based lubricant and contact numbers in the event of a medical emergency such as an overdose, plus contact numbers for Narcotics Anonymous (NA) and drug-related counselling and treatment services in Cape Town. Clients need to register with the programme, and used needles need to be returned in order to receive a fresh batch.
Health4Men is emphatic that the programme, which is being very carefully monitored and evaluated, does not in any way encourage non-drug using men to start taking recreational drugs. On the contrary, we believe that by acknowledging the scale of drug abuse among gay and bisexual men, and addressing this by providing appropriate information to men who are already using recreational drugs we are encouraging responsible sex and better health outcomes. In the same way that it would be totally irrational to tell gay men to stop having anal sex because of HIV, it is unrealistic to expect gay men to simply stop using drugs. We address HIV by providing topical information on responsible anal sex plus condoms and lube; we can limit the impact of drug use by providing gay-appropriate topical information and the equipment needed by drug users to reduce their risks. Research has shown that harm reduction services as planned by Health4men have the potential to decrease drug use over time.
I personally think it may take a while for drug-using gay men to start utilising the harm reduction project fully. Initially gay men had to develop trust in Health4Men when we launched our free sexual health services in Woodstock during 2009; we’ve successfully gained the gay community’s trust and respect, and this process needs to happen again. Recreational substance use remains illegal but I firmly believe that gay men will trust us to respect their confidentiality in this regard.
Please call 021 421 6127 or click here to view Health4Men's Drug harm reduction fact sheets.