Patrick Cash from QX writes that the correlation between drug use and gay men becoming HIV positive throughout much of London’s scene is an example of a “syndemic” – defined as two or more societal problems that work together to create a bigger negative impact on a community’s health.

It’s been realised for a while that there’s a problem in certain sections of the gay scene related to drug use. People were beginning to remark that you could go to some clubs on the weekends and see people who’d been up for days; that over a course of months you could witness a visible physical change for the worse in some guys who’d too totally adopted this lifestyle. Yet the problem of this syndemic is no longer confined to clubs. It’s spilled out of their limits in the forms of chill-outs and sex parties, all over London, at least in part driven by the recent rise in smartphone hook-up apps.

Let’s be honest, I’m writing about this world as a world I know. I could now speak about the incidences I’ve witnessed of people misjudging their use of drugs, or the guys who actively go out of their way to try and stop you using condoms. But these symptoms, whilst physically problematic to the gay community’s health, don’t explain the real psychology behind this syndemic. It’s not enough to just say “drugs and unsafe sex are bad.” We know there’s a tripwire between hedonism and self-destruction, but to try and repair it we’ve got to first understand why so many are tripping.

“People use drugs for the problems they’ve got, all drugs serve a problem of some sort,” says David Stuart from LGBT drug/addiction charity Antidote, who run walk-in club drug clinic Code on Tuesdays at 56 Dean Street. “If you offer the average gay guy heroin, it’s a dissociative, and that doesn’t work. The gay community needs a drug for a different purpose, tied up with their relationship to sex. Historically it was illegal, it was a mental health disorder, it’s been a crime.

“It’s the sex that your Mum and Dad are imagining your sister in a marriage, when they imagine you with your partner they’re picturing s**t on dicks basically, so I mean sex is really complicated for a lot of people. To find a tool or drug that taps into that is like ‘ah yes, I’m horny and I’m allowed to be, I like getting fucked, I like being a bottom’.” Later in our conversation, Stuart delves even deeper into the modern gay male psyche to give his own theories upon this rationale: “Human beings learn about anything as infants that they incorporate into their lives later on, from feeling love to feeling worthwhile, and in an ideal family you’re accepted, that is intimacy. A lot of gay men, they were pretending to their Mum and Dad they were straight, they were pretending at school, performing all the time, a hyper-vigilance about being discovered and rejected. That’s a very unhealthy way for a child to spend every minute of their life, and it’s the exact opposite of intimacy.

“Sex is about a hell of a lot of things, but it’s also about intimacy. We’re trying to negotiate a world where sex is normalised with no frame for intimacy, and that might be directly responsible for the harm that we’re seeing with people using drugs as a tool because they disinhibit us, they take away that hypervigilance, they take away that fear of being rejected’.”

Finally in my talk with Stuart, I ask him what he thinks is the best way of dealing with this situation in health terms, and he is adamant with his response. “Everyone should be able to travel,” he states. “Drugs have been divided by boroughs. You go to your local borough drugs service and say ‘oh my god, I’ve stayed awake for three days, I’m getting fisted by three men, and I still have a good time but I don’t understand why I’m doing it’, you want to say that to someone who’s straight and who has no idea about it? You’re not going to do it. Every minority group, every most ‘at-risk’ group, should be able to travel outside of their borough to find expert care. That will reduce HIV, it will reduce Hepatitis C, it will reduce drug use, it will reduce harm. It’s the only way to go.”

Drug use and high-risk sexual behaviour are essentially two sides of the same coin for many gay men in London, and a number of influential figures in gay men’s health are arguing that they be treated in conjunction with one another rather than the separation local boroughs traditionally operate. This need is made more pertinent by the recent dissolution of the pan-London HIV prevention programme in April 2013. Yusef Azad, Director of Policy and Campaigns at the National AIDS Trust, says: “In terms of the syndemic, I think there have been small-scale activities but the bottom line is there haven’t been as yet any upscale pan-London systematic attempts to address the interrelation between problematic drug use and alcohol use and high-risk sex. However, this has really come up the agenda as an issue in the last nine months. One reason why there’s been increased attention is the fact that for the first time we’re getting strong evidence that gay men are injecting. Traditional drug policies are driven by an injecting risk.

“We have sent the London Councils an open letter saying ‘you need to commission drug services tailored for gay men.’ And they need to be pan-London, which means that whichever borough you’re in in London you need to be able to access a specialised service, because you won’t be able to afford a good quality specialised service in every borough for this high-specific need. You need three or four, however many, centres of excellence in London to which anyone can go wherever they are in the city and if that’s to work all London Councils need to chip in basically.”

I contacted Public Health England (PHE) to ask them some questions about the issues raised within this article. When asked if they were aware of the current problem with the health of men who have sex with men (MSM) in London, they said yes, and supplied some of their statistics: “MSM accounted for 54% of new HIV diagnoses in 2011. It is estimated that one fifth of HIV positive MSM do not know their status. MSM also accounted for 57% of gonorrhoea cases in London and 81% of syphilis… PHE would recommend a holistic approach to the current health issues facing MSM as they are caused by a variety of complex social and personal factors, including an emerging issue regarding recreational drug use.

“It is recognised that traditional drug harm reduction services have traditionally been designed to meet the needs of opiate users. There is evidence that MSM are using different recreational drugs and therefore commissioners will have to consider how best to design services to meet their needs. When accessing services, choice is an important factor for men who have sex with men and the most effective or accessible services may not be those provided locally. The currently on-going London HIV needs assessment will be the foundation for future commissioning of HIV prevention in the capital.”

Encouraging words from PHE, and in fact, in terms of services and people working for the gay community in London, it all feels quite encouraging despite recent funding cuts. People like David Stuart and Yusef Azad are committed and passionate about their jobs and helping the health of gay men, to staunch the tide of London’s syndemic. Yet, as with the Terrence Higgins Trust’s recent HIV campaign ‘It Starts With Me’, a degree of personal responsibility must be admitted for any of these services to work and any of this funding and programme-making to be worthwhile. It starts with understanding yourself, starts with knowing how to appreciate and love yourself. It starts with acknowledging there is a problem if there is one, and then doing something about it.

This article was first published in QX.