"Masc athletic guy seeks raw bb sex. I'm HIV neg and bug free, UB2." "Poz guy seeks same for hot sex." Ads like these are increasingly common online. The guys posting these ads, whether they know it or not, are engaging in what is now being called "serosorting" or "status sorting." Through community forums, health promotion campaigns, and the news media, serosorting has taken center stage as the newest innovation in HIV prevention. But what is serosorting and does it work?
Serosorting is deciding who you have sex with (and what kind of sex you will have) based on HIV status. Recently, these decisions have played a role in a dramatic 20 percent drop in new infections reported in San Francisco. But HIV status has played a significant factor in what gay, bi, and trans men have done sexually since the beginning of the epidemic. So why the recent increased impact on transmission rates?
For starters, more of us know our status than ever before. The growing popularity of Internet hookups allows us to self-identify HIV status even before beginning a conversation. This enables men who choose to forgo condom use the ability to use serosorting as a means of reducing, rather than eliminating, the risk of HIV transmission.
But should serosorting be considered both an effective and practical prevention strategy? The San Francisco Department of Public Health has weighed in on the issue with its recent Disclosure Initiative, stating, "We as a health department are acknowledging what many men in the community have embraced as a harm reduction strategy."
In order for serosorting to work effectively, however, the following three things need to happen: 1) you must truly know your current status, not just the results of your last test; 2) clear communication of your HIV status (negative, positive, or unknown); and 3) realistic evaluation of your ability to know your partner's status.
Serosorting between poz guys works, if the goal is to prevent transmitting HIV to a negative person. Poz men may serosort to avoid the possibility of rejection after disclosure and eliminate fear or anxiety about transmitting HIV to their partners. Trends over the last few years show that more poz guys are serosorting and that when they don't use condoms they are doing so with other poz guys. But condoms are still an important health choice: STDs can increase viral load, impair the immune system, and infection with another strain of HIV may be possible (though it has not been determined how common or harmful this can be).
Serosorting for negative guys can be effective too, but it is more complicated. In San Francisco, an estimated 20 percent of poz guys are unaware of their HIV status and 50 percent of all new HIV infections happen from those who are unaware of their HIV status. So a guy might self-identify as HIV-negative and truly believe it, when in fact he is positive. To truly know your status, or that of your partner, HIV testing is necessary every three months, being mindful that it may not detect HIV for up to 6-12 weeks after infection. This means that someone who was infected just before their HIV test would have received an HIV-negative result.
In addition, the viral load of the poz guy can make a difference between an exposure to HIV (where HIV enters the body but infection does not take hold) and an actual HIV infection. A high viral load can make someone more infectious. A guy's viral load is extremely high just after becoming infected with HIV, at a time before an HIV test may be able to detect it.
This means that an HIV-positive guy who knows his status, manages his health, and whose viral load is low or undetectable could pose less of a risk for transmitting HIV than a guy who says and thinks he is HIV-negative, but was recently infected and has a high viral load. Effective serosorting between negative guys requires informed decision making and a strong sense of the level of risk with which one is comfortable.
Clearly, serosorting without condoms is neither a one-size fits all approach nor a magic bullet solution for sexual health. It does not prevent possible re-infection or co-infection, is ineffective with respect to other STDs, and only works when everyone involved is forthcoming and diligent. While imperfect, serosorting has nevertheless helped reduce new HIV infections and added one more option to our menu of safer sex. But perhaps most promising is that even 25 years into the epidemic, the resourcefulness and resilience of gay, bi, and trans men continue to foster new ways of keeping each other healthy.
Jen Hecht is the education manager and Jason Riggs is the communications director of the Stop AIDS Project.