Unknown, Negative or Positive? Using Knowledge of HIV Status as an HIV Prevention Strategy
Assessing the Risks
Aside from incorrect knowledge of HIV status, there are several other risks associated with the use of serosorting and it is important these are communicated to clients.
Recent HIV Infection
HIV-negative serosorting increases the risk of HIV transmission if a sexual partner is presumed to be HIV negative when they are actually HIV positive. This risk is amplified if the incorrectly presumed HIV-negative partner has recently become HIV positive. Research shows the amount of virus (viral load) in the bodily fluids is very high in the first few months after infection and this increases the chance of HIV transmission.23 Even if someone who is recently infected gets tested for HIV, they may receive an HIV-negative result because they are in the window period. The person may then disclose this false-negative result to partners. HIV could spread quickly through sexual networks in this manner because recent infection is hard to identify.
Sexually Transmitted Infections
While negative and positive serosorting may help reduce the risk of HIV transmission, they do not reduce the risk of acquiring other sexually transmitted infections (STIs), such as gonorrhea, syphilis, chlamydia and herpes. Furthermore, STIs can increase the risk an HIV-negative person becomes infected with HIV and the risk that an HIV-positive person transmits HIV.24
HIV-positive serosorting poses a risk for superinfection, which refers to the transmission of a new strain of HIV between two HIV-positive partners (also known as re-infection). If a drug-resistant strain is transmitted, the treatment being used by the re-infected partner may stop working. However, it is unclear how frequently superinfection occurs. While some studies suggest it is rare, other studies suggest superinfection rates among HIV-positive people are comparable to rates of HIV transmission between positive and negative people in the same population. (However, most of these studies have involved heterosexual transmission.)25
Making Serosorting Work
How well serosorting works largely depends on how accurately each partner knows their HIV status and whether they are able to communicate their status to each other. Therefore, effective serosorting requires sexual partners to commit to a process that involves open and honest disclosure of HIV status and -- for HIV-negative serosorting -- a discussion of testing and sexual history.
For couples in a stable relationship, the effective use of serosorting requires several steps and this process is sometimes referred to as negotiated safety or a "talk, test, test, trust" strategy.
First, both partners should discuss this strategy and its potential risks and benefits. Next, both partners need to get tested for HIV. They may get tested separately, although some places that provide HIV testing allow couples to be tested and counselled together. If the test results are negative, and there is no chance either partner was in the window period for the test, then the results are definitive. However, if either partner has had a recent potential exposure to HIV, then they should be tested again at the end of the relevant window period while avoiding any additional potential exposures to HIV during this time.
Once a couple has confirmed they are both HIV negative, the priority is to avoid HIV transmission from sexual activity outside of the relationship. If one partner becomes HIV positive, there is a high risk of HIV transmission to the HIV-negative partner.26-29 Couples may need to develop a strategy for avoiding HIV transmission from outside partners. This may include an agreement about what is and isn't allowed outside of their relationship. Trust and open communication is key, so that both partners are comfortable disclosing when they may have been exposed to HIV. If a potential exposure happens, the couple can take precautions to avoid onward HIV transmission until the exposed partner is tested.
Serosorting in the context of casual sex can be very risky since the accurate knowledge of one's own or one's partner's HIV status is difficult (and potentially impossible) to know for certain. Additionally, some people may have a false belief about their HIV status.
While it can be difficult to be certain of an HIV-negative status in the context of non-monogamous relationships, regular HIV testing is still important as it allows someone to know their HIV status to the best of their ability and (if infection occurs) learn about an HIV-positive diagnosis as early as possible.
The effectiveness of serosorting in preventing HIV transmission depends on context and how well it is used. There are several things that front-line service providers can do to help improve the effectiveness of serosorting for HIV-negative and HIV-positive clients.
Guiding Principles on the Use of HIV Treatment as Prevention: An International Community Consensus Statement
This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
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