HIV NEG UB2: Does Serosorting Protect You?
Safer sex is a gay, grass-roots invention. In fact, just about every behavioral technique used in the U.S. to stop or slow the spread of HIV was invented and first practiced by gay men. These techniques were considered risky by the public health establishment when they were first promoted. It was only later, as their effectiveness was gradually revealed, that public health authorities accepted them and turned them into public health policy. Now, a recent trend in HIV prevention among gay men, called serosorting, is getting a lot of attention.
But how effective is serosorting? Serosorting is the practice of selecting partners according to whether they are HIV positive or HIV negative, having sex only with someone of the same HIV status, or always using condoms only with people of a different HIV status. It implies having unprotected anal intercourse when both partners are already HIV positive, or when both are HIV negative.
Other behavioral strategies that aim to prevent HIV infection without using condoms fall within the larger category of "seroadaptation". These include "strategic positioning", in which the insertive (top) and receptive (bottom) sexual roles are chosen according to HIV status, relative risk, or viral load, with the uninfected partner typically taking the insertive role. Another seroadaptive behavior is the use of viral load as a basis for decision-making. When a person with HIV has an undetectable viral load, some gay men feel it is safe to have sex with an uninfected partner without using condoms, especially if the man with HIV is the bottom. But while an undetectable viral load lowers the risk of HIV transmission, it does not eliminate it.
When Negative Isn't Negative
There are real issues with risk-reduction practices that try to do away with condoms. To be effective, they need to be used carefully, intelligently, consistently, and with awareness of the larger context. Serosorting is certainly safer for HIV-positive men than it is for HIV-negative men. First, while people with HIV can be superinfected with a different strain of HIV, experts are divided on how common this is and its consequences. Second, men who have tested positive know their HIV status -- someone who says he has HIV is probably not lying. Finally, sex between HIV-positive men cannot transmit HIV to uninfected men -- a lesser impact on public health.
For HIV-negative men, however, strategic positioning, partner serosorting, and unprotected receptive anal sex with an HIV-positive partner who has an undetectable viral load are all subject to misuse. In 2008, 63% of sexually active HIV-positive men in U.S. urban areas between the ages of 18 and 29 were unaware they had HIV, according to the latest figures from the CDC's National HIV Behavioral Surveillance report. This is quite worrying, because a person who has been recently infected is extremely infectious. In fact, approximately half of new sexually acquired HIV infections in the U.S. are transmitted by the 21% of HIV-positive people who are unaware of their HIV status. This means that having unprotected sex with a guy who says, even believes, that he is uninfected may be very risky for someone who is HIV negative.
One study that ran from 2001 to 2007 observed serosorting trends among HIV-positive and negative gay men who received services from a clinic in Seattle, Washington. The study showed that the practice of serosorting increased over the six years, especially among HIV-positive gay men. Of those men who became HIV positive over the course of the study, 32% were gay men who practiced serosorting. Perhaps those men had taken other, greater risks in their sexual practices. Still, those findings suggest that serosorting does not eliminate the risk of contracting HIV. The level of protection that comes from serosorting is uncertain. But what is certain is that there are many ways serosorting by HIV-negative men can fail to provide protection from HIV.
Recent studies have shown that HIV treatment can substantially lower the rate of transmission from a positive but treated partner to a negative partner, especially when the positive partner has an undetectable viral load. But this belief may have particularly dangerous results for gay men. First, new research suggests that only 19% of HIV-positive people in the U.S. actually have an undetectable viral load. The CDC has a more optimistic estimate of 28%, based on more recent data and a different method of calculation, but it still seems reasonable to assume that only about a quarter of all Americans currently living with HIV have their viral load down to an undetectable level. Second, viral load fluctuates significantly, even in people who succeed in getting it down to undetectable levels. Third, even if the virus cannot be detected in your blood, it may be present in your semen (which is not tested).
A recent study of 101 HIV-positive men who have sex with men found this to be true. The Fenway Institute in Boston discovered that roughly a quarter of the men with undetectable HIV in their blood had detectable HIV in their semen. The study also showed, however, that men with undetectable viral loads in their blood had significantly lower viral loads in their semen compared to men with detectable HIV in their blood. How exactly that translates to infectiousness remains to be seen. The study did not look at whether those with low-but-detectable levels of HIV in their semen were more likely to transmit the virus than those whose semen had undetectable viral loads. Researchers are also concerned that the HIV present in semen when a person's viral load is undetectable in the blood could be resistant to a particular HIV medication, in which case exposure to that semen could lead to the spread of a treatment-resistant virus.
The most striking evidence for an undetectable viral load reducing HIV infection comes from a recent study of serodiscordant heterosexual couples (one partner HIV positive and the other HIV negative). It showed a 96% reduction in HIV transmission when the HIV-positive partner started HIV treatment early. It may be assumed, however, that much if not all of the sex that occurred among the heterosexual couples was vaginal sex. Unfortunately, the risk of HIV transmission through anal sex is much higher than through vaginal sex. So gay men should not throw out their condoms because of the results of this study. More research is needed to understand if an undetectable viral load in the blood reduces HIV transmission in people who practice anal sex.
There are also other unwelcome consequences of trying to move beyond condom use while still trying to avoid HIV. The technique of partner sorting rather than condom use leads some gay men to practice racial sorting, because the prevalence of HIV is known to be higher among black men and Latinos than among white men. Sorting partners by age is another misguided attempt to stay HIV negative without using condoms. These techniques only serve to continue misinformation about contracting HIV, while promoting racist and ageist behavior.
Although there is much to be concerned about regarding serosorting, we should also remember that the riskreduction practices that are currently approved as safe were not considered safe when they were first invented. What is now called safer sex (using condoms) is a case in point. Nowadays, safer sex is routinely contrasted with risk-taking, barebacking, and other supposedly irresponsible forms of unprotected sex. The terms "safe" and "unsafe" sex are pitted against each other as polar opposites. But the use of condoms for anal sex is not now, nor has it ever been, absolutely safe. Condoms can break, especially if misused. People have to know how to put them on properly, use a water-based lubricant, store them properly, and not use them past their expiration date.
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