Queer Health: South Africa Unveils First Chemsex Guidelines to Reduce Harm and Save Lives

South Africa has taken a major step towards safer queer sexuality and drug harm reduction with the release of the South African Harm Reduction Guidelines for Chemsex. This is the country’s first comprehensive framework designed to support people who engage in chemsex, as well as the health workers and community organisations that work with them.

Chemsex – the use of specific drugs such as crystal meth, GHB/GBL, mephedrone and others to enhance sex – is increasingly visible within queer communities, primarily among gay, bisexual and other men who have sex with men (MSM), and transgender women.

While often linked to pleasure, connection and confidence, it also carries risks, including overdose, addiction, sexual assault, HIV/STI transmission, mental-health challenges and stigma. Until now, South Africa has had no standardised national approach to care.

The new guidelines were recently published in the Southern African Journal of HIV Medicine. They were authored by experts from organisations including the SA HIV Clinicians Society, the University of Pretoria, TB HIV Care, Anova Health and OUT LGBT Well-being, among others. The work was funded by the World Health Organization and supported in part by the Elton John AIDS Foundation. A needs analysis among MSM in Johannesburg and Cape Town helped inform the document.

Breaking Stigma

OUT LGBT Well-being Executive Director Dawie Nel believes the guidelines were urgently needed. OUT has provided health services to MSM who engage in chemsex since 2023, mainly in Soweto.

“MSM tend to remain quiet about their chemsex practises and clinicians pathologise drug use. All of this happens in a society where drug use is criminalised. There are thus multiple levels of stigma which we need to break,” says Nel.

He adds that a non-judgmental approach aimed at reducing harm is more effective than only prioritising absence. “Beyond an abstinence approach, clinicians should respect the clients’ needs and have knowledge of what drugs are used, what combinations, what quantities, what the related health issues are, how one can reduce harms and so on. Gay men enjoy chemsex; otherwise, they would not be doing it. One needs to respect choice and see how it can be done more safely.”

It is unclear how widespread chemsex is in South Africa, although international research suggests that about 16% of MSM in Europe engage in chemsex. Nel notes that, in Soweto alone, OUT tested more than 1,000 MSM who engage in chemsex for HIV over a 12-month period.

OUT has identified two distinct groups in South Africa. A more middle-class group tends to connect online through platforms like Grindr and meet in private venues. The second group – often working-class, unemployed or informally employed – does not have access to private spaces and instead meets in chemsex houses. For some, drug use also becomes a means to cope with poverty.

A Harm-Reduction Approach, Not Moral Policing

Significantly, the guidelines centre on harm-reduction rather than judgment. They recognise that people engage in chemsex for many reasons – from pleasure and intimacy to trauma and coping – and focus on supporting people to stay safer, rather than demanding abstinence.

Nel says a non-judgemental approach aimed at reducing harm has been shown to be more effective than prioritising abstinence alone.

“As with alcohol use, not all drug use is problematic, and it is estimated that [only] about 10% of drug users are problematic. The vast majority can manage their use and derive pleasure from it, but need to understand the risks and how they can be minimised,” he explains.

“These men have information and health questions which are best met by competent clinicians who can assist them to be safe. The alternative is that gay men avoid services altogether because of stigmatisation and take potentially life-threatening risks like overdosing, HIV and STI infections, untreated wounds and tooth decay.”

Key goals of the guidelines include:

• Reducing deaths, overdoses and drug-related harm
• Improving access to non-judgemental healthcare, including emergency care
• Supporting community-based services to engage compassionately with chemsex users
• Integrating chemsex care into HIV testing, PrEP/PEP provision and STI services
• Providing guidance on safer injection, dosing and mixing of substances
• Offering mental-health support and pathways to treatment for those seeking help

Tools for Clinics, NGOs & Community Workers

The document also outlines clinical protocols and includes community-friendly tools such as:

• Screening and risk-assessment guides
• Overdose response steps, including GHB rescue guidance
• Best practices for safer sex, condoms, lube access and PrEP
• Support for people experiencing dependency or compulsive use
• Guidance on respectful, stigma-free conversations with clients
• Safety planning for partnered sex, group settings and party environments

Crucially, the guidelines emphasise consent, safety planning, autonomy and trauma-informed care.

Nel acknowledges that for the guidelines to make an impact, they must be adopted throughout the healthcare sector. “We do need training, and OUT will incorporate the guidelines in its planned training to staff from the Gauteng Department of Health and to work with other partners, including sex work programmes, to provide competent services and support.”

Why This Matters

With international HIV funding cuts and the closure of queer-friendly clinics in 2025, many LGBTQ+ people have been pushed back into general healthcare spaces where stigma can thrive. The guidelines encourage healthcare facilities, community workers and peers to meet people where they are, ensuring those who engage in chemsex are not left behind.

“It is important that when MSM are open about their use of chemsex, they receive non-judgemental services that are competent and guide them to safe use, rather than isolating them from better health,” says Nel.

Chemsex exists. These guidelines aim to make it safer, healthier and less shame-filled – replacing fear and judgement with supportive health care, information and dignity.