HIV NEG UB2: Does Serosorting Protect You?
When the concept of safer sex was introduced, no one knew whether it would prove effective. When AIDS first appeared, its cause was a mystery. People blamed everything from poppers to hot tubs to leather. Truly safe sex in those days meant only one thing -- no sex at all. Many voices were raised, both within and outside the gay community, to demand that gay men stop having sex. The response of certain gay men back in 1983 was to say, "No, we will not stop having sex -- we just created a vibrant, open, public sexual culture for the first time in history! What is killing us is not some divine punishment or evil fate, but a virus or bacterium that we don't understand yet. So we'll try to protect ourselves, and our partners, by using condoms for anal sex."
Scientists did not prove condoms could prevent the spread of AIDS until 1985. Prior to this, AIDS prevention campaigns warned gay men that the use of condoms for anal sex was "possibly unsafe". The use of condoms was a gamble by gay men that involved a willingness to accept a reasonable but unknown risk, in order both to defend their lives from a lethal epidemic and to preserve their erotic pleasures.
The use of condoms for anal intercourse, the practice of oral sex without ejaculation, and other kinds of risk-reduction techniques have proven practical and effective in slowing or reducing the spread of HIV, despite having once been considered risky. This is important because it is unreasonable and impractical to expect people to take no risks at all. A policy of total risk elimination can be difficult to sustain over a person's entire lifetime. Too strict an insistence on eliminating all risk can backfire, leading to periodic and highly risky lapses, which can be quite dangerous. The safety of any specific prevention technique should be measured not just by how well it protects people from infection in any particular act of sex, but how well it protects them over the course of a lifetime.
Once an infectious disease has taken hold in a population, it is very difficult to get rid of it by purely behavioral means. It's all very well to ask people to alter their behavior, but no one expects behavioral interventions to be completely effective. During a flu outbreak, we may try to wash our hands and cough into our sleeves, but we don't think it's up to us as individuals to stop the epidemic by altering our behavior. We place our hopes in a vaccine. Until there is a vaccine or a cure for AIDS, behavioral interventions remain our best weapon (though we are gradually finding biomedical options, too -- see Can a Pill a Day... Keep HIV Away?). Meanwhile, some of us are simply going to get sick. That is not necessarily our fault; there's an epidemic out there!
It is clear why the safer sex techniques that gay men invented could not have been embraced at the outset by public health authorities; they were not absolutely safe. They involved risks, sometimes quite significant risks, depending on how skillfully they were practiced, how intelligently and consistently they were put into operation, and how the larger social context of their use evolved. Risk-reduction practices have to be monitored so that they do not lead to risk increase.
What these historical examples imply is that "safety" and "risk" are not black-andwhite categories. A lot of what passes today for safer sex is the result of earlier spontaneous improvisation by gay men with varying degrees of risk. This collective effort continues, as gay men experiment with their own bodies to find compromises and practical solutions that may prevent the spread of HIV while not destroying their unique cultures of pleasure.
Serosorting is the latest of these attempts. But when HIV-negative men use it instead of condoms, especially with casual partners or with those whose HIV status is unknown (which is often what "HIV-negative" really means), they are taking significant risks -- both for themselves and for the gay community as a whole.
"Negotiated safety" is a concept that might be called "serosorting plus". It involves an agreement between two HIV-negative partners in a stable relationship, who after being together for a while, repeatedly testing negative, and talking through the issue, decide to give up using condoms with each other. They also agree either to be monogamous or always to have safer sex with other partners. Some agreements include a decision not to have anal sex with casual partners.
"Negotiated safety" was coined in 1993 by the Australian researcher Susan Kippax, who discovered this prevention technique by studying how some HIV-negative gay male couples actually behaved. She argued that not all condomless sex should be considered unsafe -- it depended on the context. The same thing is true of serosorting in general. In the case of negotiated safety, Kippax found that couples who had an agreement not to have anal sex with casual partners turned out to have less chance of being infected.
The effectiveness of negotiated safety as a prevention technique can vary widely. To make it work, it should involve:
- Repeated testing of both partners
- A waiting period before taking off the condoms
- An agreement to be monogamous, or to avoid risky sex with others and always to use condoms when having anal sex with others
- An agreement to inform each other immediately if either partner slips up, has risky sex with someone else, or breaks the agreement in some other way, and to start using condoms again until repeated HIV tests are negative
- A promise (this is crucial) that if the agreement is broken, a frank admission of that fact will not lead to an immediate breakup, but rather to some other way of handling the issue (including discussion, or counseling if necessary)
Without the final element, an agreement could be very risky, since few of us would likely admit to our primary partners that we had had unsafe sex with someone else if we thought that such an admission would mean the end of our primary relationship.
The same thing applies to monogamy as a prevention technique. After all, being in a monogamous relationship with a partner who is unfaithful but afraid to admit it does not afford any protection. That is one of the reasons why love itself can be a risk factor for HIV infection.
Does negotiated safety really work? In 2005, a U.S. survey of 340 HIV-negative gay men in San Francisco found that 38 of them were in long-term seroconcordant HIV-negative relationships and had some form of negotiated safety. Of those men, 11 had broken their own rules in the preceding three months.
Three-quarters of the men also had a rule that they must tell their primary partners if they had broken their agreement. This did seem to help -- only 18% of those with an "always tell" rule had strayed outside their agreement, while the 60% of those who had no such rule had in fact broken their agreement.
Finding ways to push safer sex beyond condom use and exploring ways to have safer sex without condoms could prevent the "condom fatigue" that is now so common in the gay community. And it should also remind us that the condom is our friend, insofar as using it gives us more sexual freedom than we can safely have without it. It also sends the message that even though HIV prevalence is higher in the gay community than among heterosexuals, it is still possible for both HIV-positive and HIV-negative gay male couples to enjoy the intimacy of condom-free sex, as their straight counterparts routinely do.
Gay men have a bad rap about sexual risktaking. But we shouldn't lose sight of the fact that the majority of gay men in the U.S. are not HIV positive, that they consistently practice safer sex, and that most will likely remain uninfected. Until there is a vaccine or a cure for AIDS, behavioral interventions remain our best weapon. As we wait for better information on the effectiveness of serosorting and other grass-roots HIV prevention techniques, efforts should be made to remind gay men that we were the first to adopt the condom as a weapon against HIV -- and as our ticket to an expansive and nondiscriminatory sexual culture.
David Halperin is the W. H. Auden Distinguished University Professor of the History and Theory of Sexuality at the University of Michigan. Robert Valadéz is a policy analyst at GMHC.
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