Findings from the Flux Study
Garrett Prestage
HIV Epidemiology and Prevention Program
Kirby Institute, UNSW Sydney
Body Positive
Treatments Update
Auckland
25th August 2017
Drug use among gay men:
How does it compare?
2
www.flux.org.au
Recent illicit drug use among Sydney gay men
3
Any drug
use
Ecstasy Cocaine Speed LSD Heroin Amyl Marijuana Any
injecting
100%
75%
50%
25%
0%
Sydney Periodic Survey Health in Men National Household Survey
Prestage, G. et al. (2009). Use of illicit drugs and erectile dysfunction medications and subsequent HIV infection among
gay men in Sydney, Australia. The journal of sexual medicine, 6(8), 2311-2320.
HIM Study: Risk of HIV seroconversion
4
Odds Ratio 95% CI P value
No drugs
1 - .001
Both Methamphetamines and EDM 8.1 2.74 – 23.71
Erectile Dysfunction Medication (EDM) 4.1 1.30 – 12.81
Methamphetamines 1.8 0.46 – 7.30
The Flux study:
What it is and how we do it
5
www.flux.org.au
- Cohort study of over 2500 gay & bisexual men
- Focus on drug use broadly
- Includes sexual behaviour
- Increasingly including sexual health measures
- Individuals complete online survey every six months
- About 80% provided follow-up data
- About 70% full retention at 12 months
- Additional 700 provided baseline data anonymously
Flux study
6
Results:
Some key baseline results
7
The Flux Study: Baseline data
www.flux.org.au
Characteristics
8
Total participants
Consented to follow-up 76.1%
Mean age (SD) 33.0 (12.6)
Socio-economic details
University educated 52.4%
Managerial or professional occupation 61.5%
HIV Status
HIV positive 7.6%
HIV negative 72.1%
Don’t know 20.6%
Sexual Identity
Gay 88.4%
Bisexual 8.8%
Heterosexual 0.3%
Other 2.4%
History of illicit drug use
Amyl Cannabis Cocaine Ecstasy GHB Heroin LSD Ketamine Speed Crystal
100
90
80
70
60
50
40
30
20
10
0
Ever used Past 6 months Monthly use
The Flux Study: Baseline data
www.flux.org.au
Methamphetamine use
10
History of use
Never used 76%
Used >6 months ago 12%
Used in previous 6 months 12%
Frequency of recent use (269)
< monthly 56%
~monthly 29%
~weekly 15%
Method of use
Smoked 82%
Injected 31%
Swallowed 13%
Snorted 11%
Shafted 7%
The Flux Study: Baseline data
www.flux.org.au
Demographics & methamphetamine
11
No meth Use History of meth
use
Recent meth
use
Mean age (SD) 26.0 25.1 25.6
%
University educated 52.9 53.4 50.9
HIV Status %
HIV positive * 2.9 13.7 22.7
HIV negative * 70.9 80.9 71.7
Don’t know * 26.2 5.3 5.6
The Flux Study: Baseline data
www.flux.org.au
Sexual Behaviours
12
No meth use* History of meth use* Recent meth use*
100%
75%
50%
25%
0%
Condomless sex with casual partners
Group sex with casual partners
>10 partners
The Flux Study: Baseline data
www.flux.org.au
Party n play networks
13
No meth use* History of meth use* Recent meth use*
100%
75%
50%
25%
0%
Any friends that use crystal
Used drugs for sex
Any partners only have sex with crystal
The Flux Study: Baseline data
www.flux.org.au
Social & psychological measures
14
Gay social engagement Depression Anxiety
0
1
2
3
4
5
6
7
8
No meth use* History of meth use* Recent meth use*
The Flux Study: Baseline data
www.flux.org.au
Highs of methamphetamine use
15
100%75%50%25%0%
Had better sex
I felt happy
Had some great parties
Gained more confidence
Met new friends
Brought me closer to people
Highs and Lows of Methamphetamine Use
www.flux.org.au
16
Self Report SDS
0%
25%
50%
75%
100%
Addiction No addiction
Dependence
Frequency of crystal use, dependence, and mental health
Depression Anxiety
Concern about own drug use
Yes 39% 25%
No 28% 15%
Dependence
Dependent users 34% 28%
Non-dependent users 15% 9%
Frequency of use
Weekly users 38% 20%
<weekly users 24% 12%
The Flux Study: Baseline data
www.flux.org.au
• 6.3% indicated ever overdosed.
• 2.8% indicated overdosing more than once.
• Those most likely to overdose:
• Methamphetamine users (31%).
• GHB users (33%).
• Injecting drug users (36%).
• Main factor associated with overdose was frequency of use.
Overdose
18
The Flux Study: Baseline data
www.flux.org.au
Factors associated with anxiety & depression
19
Anxiety Depression
None Any aOR None Any aOR
% 82% 18% 72% 28%
Aged <25 78 22 60 40
University education 85 15 77 23
HIV-positive 84 16 75 25
Over 10 partners 84 16 74 26 0.7
Condomless sex (cas.
partners)
82 18 72 28
Not in workforce 73 27 2.0 60 40 1.9
In relationship 86 14 0.6 80 20 0.7
Feels masculine 87 13 0.7 76 24 0.9
Mean
Gay soc. engagement 3.6 3.3 3.7 3.3 0.7
Supp from gay friends 3.1 2.9 0.8 3.2 2.9 0.8
The Flux Study: Baseline data
www.flux.org.au
Drug use in prev 6 months: anxiety & depression
20
Anxiety Depression
None Any aOR None Any aOR
% 82% 18% 72% 28%
Amyl 83 17 74 26
Cannabis 80 20 69 31
Cocaine 85 15 78 22
Ecstasy 83 17 74 26
GHB 86 14 78 22
LSD 84 16 68 32
Ketamine 82 18 74 26
Methamphetamine 86 14 0.7 73 27
Legal drugs
EDM 86 14 77 23
Daily tobacco 81 19 1.2 70 30 1.1
Alcohol AUDIT-c 2.1 2.2 2.1 2.1
Results:
1-year follow-up
21
The Flux Study: 12 months follow-up data
www.flux.org.au
Prevalence of illicit drug use
22
Round 1 (baseline) Round 2 (6m) Round 3 (12m)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Speed Crystal GHB
Drug Initiation in FLUX
23
Incidence by age
24
Drug Initiation in FLUX
The Flux Study: 12 months follow-up data
12-month follow-up
6-month follow-up
Baseline
www.flux.org.au
Crystal methamphetamine changes over time
25
Never used
82.3%
Ceased after round 2
0.2%
Started at round 3
1.9%
Continued use after initiating
2.2%
Stopped after round 2
0.4%
No use after round 1
1.0%
Initiated after ceasing
8.9%
Continued use
3.0%
Never used
84.2%
Started at round 2
2.6%
Ceased after baseline
9.9%
Continued use
3.2%
Never used
86.9%
Recent use
13.1%
Overall incidence:
2.6% at 6 months
4.5% at 12 months
The Flux Study: 12 months follow-up data
www.flux.org.au
Baseline characteristics of crystal initiators
26
Never used Initiated after
baseline
p value
%
Condomless sex with casual partners 30.3 33.9 -
Group sex 28.1 35.5 -
PrEP at baseline 1.4 0.0 -
Mean
Age 34.8 35.2 -
Socially engaged with other gay men 3.67 3.79 -
Socially engaged with other gay men who
use crystal
0.8 1.7 <0.001
Number of partners 14.4 16.3 -
The Flux Study: 12 months follow-up data
www.flux.org.au
Follow-up characteristics of crystal initiators
27
Never used Initiated after
baseline
p value
%
Condomless sex with casual partners 26.4 46.8 0.002
Group sex 21.6 41.9 <0.001
PrEP at follow-up 4.3 11.3 0.011
Mean
Socially engaged with other gay men 3.71 3.89 -
Socially engaged with other gay men who
use crystal
0.73 2.22 <0.001
More sexual partners 15.03 34.43 0.002
The Flux Study: 12 months follow-up data
12-month follow-up
6-month follow-up
Baseline
www.flux.org.au
PrEP incidence rates
28
Never used
93.6%
Ceased after round 2
0.0%
Started at round 3
2.9%
Continued used after initiating
2.3%
Stopped after round 2
0.4%
No use after round 1
0.2%
Initiated after ceasing
0.4%
Continued use
0.2%
Never used
96.5%
Started at round 2
2.7%
Ceased after baseline
0.6
Continued use
0.2%
Never used
99.2%
Recent use
0.8%
Overall incidence:
2.7% at 6 months
5.6% at 12 months
The Flux Study: 12 months follow-up data
www.flux.org.au
Baseline characteristics of PrEP initiators
29
Never
used
Initiated after
baseline
p value
%
Condomless sex with casual partners 29.2 55.6 <0.001
Group sex 26.7 61.9 <0.001
Crystal at baseline 13.5 25.4 0.015
Mean
Age 34.76 36.73 -
Socially engaged with other gay men 3.64 4.33 <0.001
Socially engaged with other gay men who
use crystal
0.83 1.74 <0.001
Number of partners 13.73 28.92 0.019
The Flux Study: 12 months follow-up data
www.flux.org.au
Follow-up characteristics of PrEP initiators
30
Never
used
Initiated after
baseline
p value
%
Condomless sex 24.6 82.5 <0.001
Group sex 20.8 57.1 <0.001
Crystal use 12.2 33.3 <0.001
Mean
Social engagement with gay men 3.71 4.72 <0.001
Social engagement with gay men who
use crystal
0.74 1.92 <0.001
Number of sexual partners 14.43 41.58 <0.001
The Flux Study: 12 months follow-up data
Reasons:
Why start? Why stop?
31
The Flux Study: 12 months follow-up data
www.flux.org.au
Why have you stopped since last time?
32
I have not been able to locate a dealer
Ian, GHB, 44 y/o
It's a horrible drug. I end up in emergency wards …wanting to
kill myself. It's easier not to do it. I've been sober 4 months
Ben, Crystal. 34 y/o
I don't have the time to stay awake for 2 days then feel like crap
for three days afterwards now
Phillip, Crystal, 38 y/o
The Flux Study: 12 months follow-up data
www.flux.org.au
Why have you started since last time?
33
My best friend had some. I was drunk and thought why not.
Steve, Crystal, 37 y/o
It started showing up more on gay chat apps and sites I use
to obtain amateur porn like twitter and tumblr, and that made
me curious about trying it.
Jack, Crystal. 39 y/o
… helps to remove any inhibitions, and helps to relax you into
the group you are in
Peter, GHB, 26 y/o
Summary
• Initiation of illicit drugs was very high
– Over 10% ppy for amyl to about 2% ppy for GHB
– Nearly 5% for methamphetamine
• Mental health only associated with frequent/dependent drug use
• Main predictor of crystal initiation was having friends that use crystal
• Most crystal use was purposefully to enhance sex
• Uptake of crystal use was accompanied by intensive sex partying
• Men who used crystal & men who commenced PrEP were similarly
engaged in intensive sex partying
Flux-on, Flux-off:
What’s happening next?
35
Future enrolments and funding: possibilities
• Currently able to maintain cohort through 2019
• Funding applications under review
– NHMRC focus on mental health
– ARC focus on drug and sex cultures and PrEP
• FAME methodology being applied to other cohort studies
– EPIC & PrEP-It (NSW and WA PrEP trials)
– New HIV Seroconversion Study
• Expansion & extension of cohort to other settings
– Separate & parallel
– Direct enrollment into existing cohort (easy extraction of separate data)
The Flux Study: What’s next
www.flux.org.au
New enrolments
37
www.flux.org.au
www.facebook.com/fluxstudy
Thank you
The Flux participants
.
Study staff:
Mohamed Hammoud.
Chief Investigators:
Garrett Prestage, Jeff Jin, Lisa Maher,
Louisa Degenhardt, Jeffrey Grierson,
Toby Lea, Adam Bourne, Bridget Haire.
Associate Investigators:
Brent Mackie, Marcus Pastorelli,
Colin Batrouney, Nicky Bath.
38
The Study Team:
Jack Bradley, Stefanie Vaccher, Team
HEPP
The Funders:
Australian Research Council.
39
Mo Hammoud | +61 (02) 9385 9972 | mhammoud@kirby.unsw.edu.au
www.flux.org.au | www.facebook.com/fluxstudy | flux@kirby.unsw.edu.au
www.flux.org.au
www.facebook.com/fluxstudy
EDM
HIV
Status
Crystal
history
40
FAME: Automation of a cohort study
Attitudes
Crystal
history
EDM
HIV
Status
Recent
Drug
Use
Baseline Responses Follow-up Questionnaires
Recent
Drug
Use
Why did you
start/stop using
crystal?
Why did you stop
injecting drugs?
Injecting
history
Injecting
history
www.flux.org.au
www.flux.org.au
Automation
41
The Flux Study: Baseline data
www.flux.org.au
Tobacco & alcohol use
42
%
Tobacco use
Never used 33%
Over 6 months ago 28%
Less than daily use 19%
Daily use 20%
Level of risk from alcohol use
Low/no risk 27%
Moderate 39%
High 22%
Severe 13%
The Flux Study: Baseline data
www.flux.org.au
Steroids & erectile dysfunction medication
43
%
Steroid use in previous six months
Not used 98.5%
Less than weekly use 0.7%
Weekly use 0.7%
EDM use in previous six months
Never used 78%
Less than monthly use 12%
Monthly use 6%
Weekly use 5%
The Flux Study: Baseline data
www.flux.org.au
Steroids & erectile dysfunction medication
44
%
Steroid use in previous six months
Not used 98.5%
Less than weekly use 0.7%
Weekly use 0.7%
EDM use in previous six months
Never used 78%
Less than monthly use 12%
Monthly use 6%
Weekly use 5%
How usually obtain erectile dysfunction medications
0% 13% 25% 38% 50%
Doctor
Regular partner
Casual partner
Dealer
Acquaintance
Gay friend
Straight friend
Stranger
Online
Other
Excludes non-users
The Flux Study: Following men for 1 year
www.flux.org.au
Age of initiation
46
Birth Cohort
Mean Age
<1960s 1960s 1970s 1980s 1990s
0
8
16
24
32
40
Marijuana Party Drugs
The Flux Study: Following men for 1 year
Prevalence by cohort
www.flux.org.au
Birth Cohort
<1960s 1960s 1970s 1980s 1990s
100%
75%
50%
25%
0%
Speed Crystal GHB
The Flux Study: Baseline data
www.flux.org.au
Most recent occasions of casual sex with & without crystal use
48
HIV-negative men only (n=140) Did not use Used other
drug
Used crystal
%
Condomless sex (cas. partners) 38 43 68
TasP/PrEP-protected 10 7 17
Seroconcordant 21 24 29
Insertive only 2 3 3
Receptive – no protection 6 10 19
Highs and Lows of Methamphetamine Use
www.flux.org.au
Reasons for methamphetamine use
Preliminary findings
49
100%75%50%25%0%
For fun
To get a buzz
PnP Session
It was available
To see what it was like
To party for a long time
To become less inhibited
To help me have sex for longer
Someone else wanted me to use it
Something different
Make it easier for me to get fucked
I feel like I need to use it
To counter the effects of other drugs
I did not know what it was at the time
Highs and Lows of Methamphetamine Use
www.flux.org.au
Lows of methamphetamine use
Preliminary findings
50
100%75%50%25%0%
Had unsafe sex
Became sick
Accidental self injury
Couldn't pay bills
Problems with family
Friendship break up
Verbally abused
Received warning at work
I became abusive to others
Relationship break up
Hospital emergency department
Needed medical attention
Forced to move
Lost job
Sexually assulted
Physically assulted
Was made homeless
Drug use – ever & 6 months
Ever 6 months
0%
23%
45%
68%
90%
Any drugs Any party drugs
Total sample
Crystal use
Total sample
Ever used Past 6 months Ever used at least
monthly
Ever overdosed
100%
75%
50%
25%
0%
Usual methods of using crystal
Excludes non-users
0% 23% 45% 68% 90% 113%
Swallowed
Snorted
Shafted
Smoked
Injected
Reasons for using crystal
Excludes non-users
0% 20% 40% 60% 80%
For longer sex
PnP session
Party for long time
To counter other drugs
I needed it
To be less inhibited
Fun
Someone wanted me to
Didn't know it was crystal
Something different
Curious
For a buzz
Easier to be fucked
It was available
How much crystal users feel addicted
Excludes non-users
0.58
0.22
0.11
0.09
Not at all
A little
Somewhat
Very much
Types of drugs injected – ever & 6 months
Ecstasy Cocaine Speed Crystal GHB Ketamine LSD Heroin
0%
2%
4%
6%
8%
10%
Ever 6 months
Total sample
Frequency of injecting crystal in previous 6 months
Excludes non-users
1-2 times 42%
Monthly 32%
Weekly 19%
Daily 7%
Safe injecting
• Of the 67 men who reported injecting in the
previous 6 months:
• Just 4 reported using a needle after someone else
• All 4 indicated they sterilised the needle
before using it
• Just 16 reported sharing other equipment
Harms from drug & alcohol use in previous 6 months
0% 8% 15% 23% 30%
Warning at work
Became sick
Relationship break-up
Had to move
Lost job
Made homeless
Broken friendship
Family problems
Couldn't pay bills
Verbally abused
Sexually assaulted
Physically assaulted
Needed doctor
Hurt self
Hospital emergency
Unsafe sex
Became abusive
Chart Title
Total sample
Positives from drug & alcohol use in previous 6 months
0% 10% 20% 30% 40% 50%
New friends
Great parties
Felt happy
More confidence
Closer to people
Better sex
Total sample
Interviews Completed
(n)
Retention
(%)
Baseline 1710 ---
6-month 1325 77.5
12-month 1220 71.3
Cohort retention
61
Drug Incidence in FLUX
Drug Cessation in FLUX
62
Summary
• High proportion of regular tobacco users & risky drinkers
– Strongly associated with poor mental health
• About a third recent viagra/cialis users
• (the majority not prescribed)
• Over three quarters have ever used drugs
• Over a quarter ever used crystal, including one in eight ‘regularly’
• About one in ten ever injected
• Nearly two thirds used drugs in previous six months
• About in seven used crystal
• About in twenty injected (mainly crystal)
Reasons for & consequences of drug use
• A lot of men reporting use in relation to sex
• A lot of positive reasons for use & good feelings
• But balanced by a fair bit of mental health reasons & negative consequences
• About 10% report drug binges
• About 15% ever concerned about their drug use
• Many report ‘unsafe sex’ as a consequence
• The majority report good experiences on drugs
