People who use drugs

Alcohol and other drug use may exacerbate behaviours which can increase the risk of sexually transmitted infections (STIs)
Injecting drugs can also increase the risk of bloodborne infections, including HIV, hepatitis B and C, although transmission of HIV through injecting drug use is rare in Aotearoa New Zealand because of initiatives such as needle exchange programmes
Methamphetamine use is an independent risk factor for HIV acquisition, and has also been linked to the heterosexual syphilis epidemic overseas, although data are lacking in Aotearoa New Zealand
Around 1% of the Aotearoa New Zealand population uses methamphetamine. Comprehensive data are lacking, but rates are thought to be much higher in certain groups
Chemsex refers to the use of a combination of drugs including methamphetamine and gamma-hydroxybutyrate (GHB) by men who have sex with men (MSM) before or during sex. Sexual activity can sometimes last for days, and often involves condomless group sex. International research suggests 5-7% of MSM have chemsex each year. Chemsex is thought to be less prevalent in Aotearoa New Zealand compared with overseas, but is becoming more common
Due to the high risk of HIV and STI acquisition associated with chemsex, STI screening is recommended every 3 months (see MSM guideline), and HIV pre-exposure prophylaxis (PrEP) should be recommended
Harm minimisation strategies for drug users, and other resources for MSM engaging in chemsex are available (see Resources)

Consider hepatitis A vaccination for people who inject drugs (not funded)
Hepatitis B vaccination is recommended (not funded) for people who inject drugs. Serological testing after completing vaccination is recommended
Hepatitis C status should be confirmed in all people who report having injected drugs. Annual testing in those with an ongoing history of injecting drugs is recommended
Hepatitis C is generally not sexually transmitted, however sexual transmission is seen in HIV-positive MSM, and high-risk MSM, e.g. those using PrEP and those engaging in chemsex. Consider annual testing in these groups
Hepatitis C antibody remains positive for life. In those with a past history of treated hepatitis C, test for hepatitis C viral load if new risk

Clinical indicators for testing

See sexual health check guideline for indications for testing
Testing for HIV, hepatitis C, (and hepatitis B if non immune) should be offered to all people who inject drugs, especially those reporting use of shared injecting equipment (needles, syringes, spoons etc)

If test results are positive, refer to relevant STI management guideline

Even if all test results are negative, use the opportunity to:

Educate about condom use and harm minimisation
Consider PrEP for MSM who use methamphetamine
Vaccinate for hepatitis A and B, if susceptible (not funded)
Discuss the availability of drug and alcohol services, and how to access them
Discuss and activate reminders for regular testing according to risk, especially if behaviours indicate the need for more frequent testing