丁盈盈 何 納，2△

（1復(fù)旦大學(xué)公共衛(wèi)生學(xué)院流行病學(xué)教研室－公共衛(wèi)生安全教育部重點(diǎn)實(shí)驗(yàn)室 上海 200032；2美國(guó)埃默里大學(xué)公共衛(wèi)生學(xué)院行為科學(xué)與健康教育學(xué)系 亞特蘭大 30306）

Introduction

The incidence of the use of so－called club drugs has increased dramatically over the last 20years in many parts of the world［1－3］and is highly prevalent in several populations，such as female sex workers and men who have sex with men （MSM）［4－5］．In China，sexual transmission of HIV has recently replaced blood transmission and injection drug use，becoming the single largest cause of new infections．In 2011alone，there were approximately 48，000new infections，sexual transmission accounted for 81．6%of cases compared to 44．7%in 2007［6－7］．Club drugs have been identified in a number of studies as a predictor of risky sexual behaviors that may transmit HIV［8－9］．This relationship，coupled with emerging evidence that club drug use is on the rise in China［2］，suggests that club drug use may be contributing to the rapid increase in sexual transmission of HIV in China．The present article provides a general review of definitions and characteristics of club drugs and their linkage to HIV／STIs （sexually transmitted infections）risks with specific reference to china．

What are club drugs？

Club drugs are so named due to their initial popularity in “raves，”all－night dance parties featuring loud and repetitive electronic music，attracting primarily adolescents and young adults［10］．Young people may use these drugs for increased stamina and intoxicating highs that are said to deepen the rave or dance experiences［11］．Although these drugs became popular in the club scene，they are now widely used in other settings［12－13］．A review of literature reveals a lack of consistency in the types of drugs categorized as“club”drugs．The U．S．National Institute of Drug Abuse（NIDA）describes club drugs as a category of recreational drugs that are associated with social venues such as “raves”，clubs and dance parties，including gamma－h(huán)ydroxybutyrate （GHB），Rohypnol，ketamine，dimethy l－3，4 methylenedioxyphenethyamine（MDMA），methamphetamine and lysergic acid diethylamide（LSD）［14］，while others included only GHB，Rohypnol，ketamine，MDMA as club drugs［15－16］．According to Sanders［17］，club drugs were divided into three categories：those first becoming popular within club and rave settings（ecstasy，GHB，ketamine）；those regaining popularity within such settings （LSD，psilocybin mushrooms）；and those with a long history of abuse but also becoming common in raves and clubs （cocaine，crystal methamphetamine）．

Many club drugs，such as ecstasy，ketamine and methamphetamine，are also called designer drugs because they are synthetic rather than found in or derived from nature （marijuana or opium derivatives）［18－19］．These drugs are popular because of their low cost and easy distribution as small pills，powders，or liquids［15］．They are often adulterated or substituted，making their effects unpredictable［15］．They are usually taken together，with alcohol，or with other drugs to enhance their effect［20－21］．There has been a growing body of literature indicating that club drug abuse is associated with a series of health and psychiatric disorders［11，22－25］，and criminality［26－27］as well as risky sexual behaviors and HIV infection［8，28］，which contribute to problems for individuals，families and society．

The most popular club drugs and the risk for HIV／STIs acquisition

Club drugs put the users at increased risk of acquiring and transmitting HIV and other STIs mainly by encouraging sexual risk－taking behaviors［8，28－29］．Moreover，the use of methamphetamine，ketamine，ecstasy by injection has been reported in literature［12，30－32］，which may also increase the risk of HIV／STIs transmission［33－34］． We here focus on methamphetamine，ecstasy，and ketamine because they are the most common club drugs abused in China．

Methamphetamineis a synthetic stimulant that affects many areas of the central nervous system．The effect lasts up to 10to 12hours．The use of methamphetamine causes the release of large quantities of neurotransmitters in the brain （large amounts of dopamine and smaller amounts of norephinephrine）that，in turn，increase sexual desire and reduce sexual inhibitions［35－36］．There is strong evidence that the use of methamphetamines stimulates sexual activity［37－38］．A growing body of research in diverse populations has repeatedly observed a link between methamphetamine use and“marathon sex”（prolonged sexual activity）［39－40］，unprotected receptive and insertive anal sex［41－44］，an increased number of sexual partners［41－42，45－46］，having anonymous sex partners［45］，and unprotected sex with HIV－serodiscordant partners or partners of unknown HIV serostatus［47］，as well as increased risk of HIV and syphilis infection［48－49］．Cessation of methamphetamine use could result in a reduction in risky sexual behaviors［50－51］．There is also HIV risk associated with sharing injection equipment when methamphetamine is used intravenously［33－34］．

Ecstasy／MDMAis a psychoactive drug with both stimulant （amphetamine－like） and hallucinogenic（LSD－like） properties． It was derived from methamphetamine，and has similar properties and effects［52］．Its effects last approximately 3to 6hours．MDMA may alter one’s mental state and enhance sexual function［53］and sexual desires［54］though it leads to increased release of serotonin as well as inhibition of its reuptake［23］．Some persons use MDMA specifically for sexual enhancement［54］．The use of MDMA has been associated with unprotected anal and vaginal sex［55－58］and an increased number of sexual partners［59－61］in both heterosexual and homosexual populations．A meta－analysis of the association between ecstasy use and risky sexual behavior revealed a small to moderate sized effect［62］．

Ketamineis a dissociative anesthetic that can cause sedation and loss of muscle control［63－64］．It exerts strong hallucinogenic and euphoric effects．Ketamine is produced in liquid form or as white powder that is often snorted or smoked with marijuana or tobacco products．The effects have a rapid onset in 1to 30minutes，depending on the route of administration used and last 30to 180 minutes［8］．The risk of loss of physical control may result in unwanted or unplanned sexual contact［23］．Ketamine could also result in increased tolerance to pain［65］，which may lead to more sexual partners and longer duration of sexual contact．These factors could result in a higher risk of HIV or STI acquisition．Ketamine use has been associated with sexual risk behaviors，including unprotected sex and increase in sex partners［47，57，66］．However，the evidence regarding the association between ketamine use and risky sexual behaviors was not strong as the association between methamphetamine and risky sexual behaviors［8］．

In addition，given that some of club drugs were often used in combination with other drugs（such as ecstasy＋ ketamine）or alcohol，and many club drug users tend to be polydrug users［67］，it is unclear whether the increase in risky sexual behaviors was partly or wholly due to the effects of other drugs or alcohol，which were not considered in many previous studies．Another issue is that the context surrounding drug users may influence their engagement in risky sexual behaviors［17］．Future research should take these issues into consideration．

Club drug use and HIV／STIs risks in China

The definition of club drugs varies by country and region．In China，club drugs are often called“new－type” drugs，referred to a category of recreational drugs emerging in China in recent years，as distinguished from opium and heroin，including a wide variety of drugs such as methamphetamine，ketamine，ecstasy，magu （a mixture of methamphetamine and cocaine），happy water （a mixture of methamphetamine and ketamine）， psilocybin mushrooms， and so on［68－70］．

The new－type drugs including amphetaminetype stimulants （ATS） and ketamine have penetrated to China through various channels since 1997［71－72］．Since 2008，methamphetamine in pill and crystalline form has overtaken opium as the second most commonly used drug in China and ecstasy has ranked the third．Ketamine use has also become increasingly prevalent since it was first reported in 2004and has ranked as the fifth．Heroin remains the most commonly used drug in China，although its use is reportedly declining［3］．There was a dramatic increase in the use of synthetic drugs．At the end of 2010，0．43million people were using synthetic drugs （ATS，ketamine，etc．），accounting for 28%of the 1．54 million registered drug users，while 0．06million people used ATS in 2005，accounting for 6．7%of registered drug users at the end of 2005．Of newly identified drug users in 2010，about 0．12million（55%）used synthetic drugs and of them most were below the age of 25［3，73］．In addition，seizures of ATS increased dramatically during the past few years，with a total of approximately 58．4million methamphetamine pills in 2010，40．5million pills in 2009and 6million pills in 2008［2－3］．

However，there is a lack of nationally representative drug use prevalence estimates．High prevalence of club drugs use has been reported among female and male sex workers in China．A pilot study in Shanghai indicated that about 12%of the “money boys”（i．e．，male sex workers）participants reported ever using illicit drugs with ecstasy and methamphetamine being the most popular，but only 3%of the general male migrants reported any drug use［74］．A later study of male sex workers in Shenzhen found that the prevalence of drug use in the past 6 months was 14．8%for ketamine，9．1%for methamphetamine，5．5%for ecstasy，3．8%for“magu”tablets，and 2．4%for marijuana［75］．A study of female sex workers in Qingdao revealed that 30．2%reported using methamphetamine in the last 6months with 1．6%of them ever injecting［76］．A survey of motor vehicle drivers involved in a traffic accident or violation found that 0．15%used methamphetamine，0．03%used ketamine and 0．01%used MDMA［77］．

The literature examining the association between club drugs and risky sexual behaviors and HIV／STIs acquisition in China is limited．In a study of club drug users who were administratively detained，a high rate of risky sexual behaviors was reported and polydrug users were found to be more likely to report unprotected sex with both stable and nonstable sex partners，casual sex，and group sex after drug use［70］．A study of club drug users recruited through RDS in Shanghai found that recent methamphetamine use was associated with having multiple sex partners but not associated with unprotected sex with non－regular partners in multivariate analysis［78］．Methamphetamine use has been associated with unprotected sex and syphilis［76］and ATS presented a strongly association with the sexual transmission of HIV［69］．A recent study of money boys found that consistent condom use by drug users was lower than that by nonusers，whereas HIV，syphilis，and herpes simplex virus 2infections were higher among drug users［75］．

Conclusions

There is an urgent research need to examine use and abuse of club drugs or new type drugs and in particular their associations with risky sexual behaviors and HIV／STIs infections．Effective interventions to decrease both drug use and sexual risk behaviors among club drug users need to be developed and incorporated into current HIV／AIDS prevention and intervention programs in China．Users who inject club drugs should be referred to the existing needle－exchange programs．

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