Today’s chemsex pandemic requires novel approaches

Luís* is a 29-year-old bilingual Latino gay man who works two service jobs, lost consistent primary care during the pandemic and now gets most sexual connections through hookup apps late at night after long shifts. Occasionally using meth in sexual settings to push through exhaustion and feel more connected, his PrEP refills lapse intermittently, condom use varies with fatigue, alcohol and stimulant effects, and testing happens only when a scare occurs—not because of a lack of knowledge, but because healthcare access never quite fits his life.

Luís represents a modern version of the chemsex phenomenon common in the men who have sex with men (MSM) community for many years. This typically involves methamphetamine use and other mood-altering substances such as GHB. It has long been associated with both the chance of HIV seroconversion as well as complications and progression once seroconversion has occurred. From the earliest days of the meth epidemic, researchers have been aware that the heightened release of dopamine and other neurochemicals could override both rational thoughts and impulse control, resulting in less condom use, poorer decisions and higher rates of insertive anal intercourse.

The contours of the chemsex epidemic have shifted but its significance has not waned. Thirty years later, the use of meth and other drugs along with sexual behavior (now broadly termed as sexualized drug use), continues to complicate the HIV landscape. As with any epidemic, syndemic elements collude to heighten the impact of sexualized drug use on both the potential for acquisition and trajectory of HIV. 

Surviving one epidemic only to face another

Meth and HIV have long been intertwined in a complicated relationship. Once protease inhibitors became available in 1995, HIV mortality rates began to drop. Men who expected to die and had given up careers, racked up credit card debt and went on disability, now found themselves surviving. At the same time, methamphetamine and Viagra entered the scene. In that setting meth was the perfect drug to dissociate or check out from life’s problems, replacing them with a surge of dopamine that frequently merged with distracting sexual fantasies and behaviors. More than one observer has noted the irony of surviving HIV only to succumb to chemsex.

In those days, nearly all methamphetamine was created by so-called mom-and-pop cookers who blended thousands of pseudoephedrine tablets with a variety of toxic chemicals to create homemade batches that were often distributed locally. In 2005, the Combat Methamphetamine Act restricted the sale of pseudoephedrine; nearly overnight local meth cookers were out of business. Demand remained high, however, and Mexican drug cartels, quickly realizing the opportunity, stepped in to meet demand. Production shifted from pseudoephedrine-based precursors to phenylacetone (phenyl-2-propanone, or P2P), effectively modernizing an older manufacturing process to one known as the P2P method.¹

Many researchers believe this formula change resulted in a significantly more dangerous drug. Meth produced with the P2P method has higher potency, purity and availability.² By 2010, nearly 90% of the meth sold in the United States was manufactured using this new method. Because it was cheaper and more potent there was increased market penetration, which compounded the impact of its toxicity. P2P meth isn’t just more potent, it’s often thought to be “dirtier” and associated with more intense psychoactive effects, including extreme persistent paranoia and hallucinations, longer lasting intoxication and higher risk of psychosis, aggression, cognitive damage and unpredictable behavior. In my own clinical experience, psychosis caused by meth in the 1990s typically would resolve within several days of stopping use. With P2P meth, it is not unusual for psychosis to persist. In about one-third of cases it may never resolve and can in fact lead to other serious mental disorders such as schizophrenia,³ especially in those with preexisting vulnerability to acquisition. 

Because production now occurs at an industrial scale in factories just across the U.S.–Mexico border, supply is harder to disrupt, driving lower prices and greater availability. This saturation has accelerated dependence, destabilized housing and employment and placed increasing strain on healthcare, shelter and public safety systems.

These changes demand that we adapt our response to the syndemic of HIV and substance use. Those of us working at the intersection of these epidemics have a responsibility to address increasingly potent substances, shifting behavioral patterns and their expanding impacts on healthcare systems, housing stability, community safety and relational health.

Chemsex continues to drive potential acquisition through complex systems

The use of meth and other drugs in sexualized settings remains a significant factor in HIV transmission potential. Rather than limiting the focus to individualized risk, however, research indicates that network density, prolonged sexual activity, partner turnover and app-based partner finding all contribute to heightened probability of vulnerability.⁴ Much of the research has focused on specific groups and potential for seroconversion. Using demographic categories as a stand-in for complex behavioral phenomena, however, can obscure actual drivers and reinforce stereotypes. These complex relational system dynamics, not demographic descriptors, are significant. They include how isolation shapes the hunger for attachment, how minority stress and other pressures can increase compulsive reliance on soothing behaviors, how disruptions in health care systems have altered prevention continuity and how online environments have accelerated intensity and risk.

Effectively responding to chemsex is not just about messaging but rather adjusting system design and service integration. In the U.S., as has long been the case in Europe, clinics and community programs are increasingly offering chemsex-friendly services that blend sexual health, harm reduction, mental health and substance use care⁵ with peer navigators, low-threshold PrEP and initiation of same-day services. This significantly shifts the conversation from strictly risk avoidance counseling to engagement without stigma.

HIV prevention tools shift the narrative

In the last decade we have seen powerful new HIV prevention methods, notably oral PrEP and long-acting injectable PrEP (cabotegravir and lenacapavir) which have shifted the conversation beyond condom use and toward integrating biomedical prevention into community norms and practices. For people engaged in meth-associated sexual networks, PrEP offers a pragmatic strategy where real-world adherence is often complicated. 

U=U—Undetectable = Untransmittable—has also shifted our understanding of preventing sexual transmission with sustained viral suppression. Meth use, however, can be associated with disruptions in care, including missed doses of HIV medication, appointment nonadherence and long and frequent gaps in retention which can undermine the protective benefits of U=U. 

As HIV prevention has rapidly advanced, non-HIV sexually transmitted infections, along with hepatitis C, have become more prominent in sexualized drug use networks. Importantly, doxycycline post-exposure prophylaxis (doxy PEP) is now often included in clinical guidance for individuals with a greater chance of exposure.

Sexualized drug use conceptualization and treatments have progressed

Unlike other categories of substances, stimulants had no effective pharmacotherapy despite widespread trials of many different drugs. Since 2020, evidence has strengthened around certain medication strategies such as combining extended-release naltrexone with bupropion (brand name Contrave).⁶ This, when combined with behavioral interventions, can support people managing substance use that may affect HIV care.

The terminology used to describe sexualized drug use, especially the term “chemsex,” has evolved to more accurately describe specific patterns and context of behavior, not just any use of drugs and sex. Chemsex has long been utilized to describe sexualized drug use involving stimulants and other substances among MSM. More nuanced discussions importantly now look at the type of drug (such as meth vs. GHB/GBL vs. mephedrone), the route of ingesting (e.g., smoking, as opposed to injecting), who is using the drugs and the duration of context (length of sessions, negotiated boundaries, etc.). Such precision improves both research quality and clinical screening.

It is also noteworthy that sexualized drug use has spread beyond the MSM community and is increasingly seen among heterosexual males and females. The potential acquisition of HIV and other STIs, consequently, is increasing among those populations who have traditionally had fewer HIV-related conversations about acquisition.

A call to action

The seemingly unending epidemic has evolved, and our response must evolve as well, incorporating status-neutral HIV care; integrated sexual health, substance use and mental health services; and non-stigmatizing harm reduction and evidence-based interventions grounded in real-world lived experience. 

DAVID FAWCETT, PHD, CST, CSAT, LCSW, is a psychotherapist and sex therapist specializing in sexualized drug use, LGBTQ+ issues, trauma and mental health concerns related to physical illness, especially HIV/AIDS. He co-created the residential treatment program for compulsive sex, porn and chemsex behavior at Seeking Integrity in Los Angeles. He presents workshops globally about addiction and co-occurring mental health issues, particularly those related to long-term survivors of HIV. He is the author of two books, Lust, Men and Meth: A Gay Man's Guide to Sex and Recovery and Sex Under the Influence: Understanding and Healing from Sexualized Drug Use. Learn more at david-fawcett.com or follow him on TikTok, @davidfawcettchemsex.

* “Luís” is a composite example based on multiple patients and case studies; the name does not refer to a specific individual.

REFERENCES

1. Maxwell, J.C. (2011). Methamphetamine
2. Here we go again. Frontiers in Psychiatry.
3. Drug Enforcement Administration. (2024). Mexican cartels produce synthetic drugs including methamphetamine. National drug threat assessment.
4. Glasner-Edwards, S., Mooney, L.J. (2014). Methamphetamine psychosis: Epidemiology and management. Journal of Dual Diagnosis.
5. Centers for Disease Control and Prevention. (2021). HIV and gay and bisexual men. U.S. Department of Health and Human Services.
6. Rodriguez-Esposito, B., et al. (2024). Psychological characteristics associated with chemsex behavior. European Psychiatry.
7. Trivedi, M. H., Walker, R., Ling, W., et al. (2021). Bupropion and naltrexone in methamphetamine use disorder. New England Journal of Medicine, 384(2), 140–153.