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SF Forum Reveals Conflicting Views about Serosorting to Reduce HIV Transmission Risk


Bay Area gay and bisexual men hold a wide spectrum of views about condom-free sex and serosorting, according to a well-attended community discussion last week. "Seroadaptive" practices are a popular sexual harm reduction approach, but due to lack of awareness about recent infection, it may actually be safer to have unprotected sex with an HIV positive partner on antiretroviral therapy (ART) with stable viral load suppression.

"Seroadaptive" refers to making decisions about sexual partners and activities taking into account HIV serostatus, which can range from "pure serosorting" (only having sex with same-status partners) to "seropositioning" (negotiating top and bottom roles based on HIV status).

The September 12 forum -- the second in the San Francisco AIDS Foundation (SFAF) and Stop AIDS Project's Real Talk series -- featured a panel of HIV-positive and HIV-negative men moderated by local personality Sister Roma. But the debate was well underway on Facebook in the days leading up to the event.

Introducing the panel, SFAF CEO Neil Giuliano recognized that sex without condoms and sex-related harm reduction can be uncomfortable, bringing up issues around stigma, rejection, ethics, and honesty.

"A condom is still the most effective tool to prevent HIV and other sexually transmitted infections [STIs], but the fact is sometimes condoms go unused and we need to discuss that reality," Giuliano said. "We see this as the beginning of a conversation that, hopefully, will leave guys feeling more empowered to make smart choices about condom use and partnering that are most comfortable to them."

What Happens in the Real World?

A phone text poll conducted during the forum revealed that 97% of audience participants said they had "ever fucked without a condom," while only 3% had not. Another lopsided majority, 85%, answered "no" to the question, "Do you think condom use is the norm in San Francisco?"

In response to a question about how important it is to have sex with someone of the same HIV status, nearly 40% said it was unimportant or of little importance, about 50% said it was important, and 12% opted for very important. About half of respondents said they had consistently had conversations about sex and HIV risk before hooking up, 37% did so sometimes, and 11% said they did not.

Getting down to specifics, panel members talked about their different risk-reduction approaches.

Douglas McLaughlin, a bartender and participants in Stop AIDS' Bridgeman group for men in their 30s and 40s, said he became infected after having sex with a man who claimed he was HIV-negative.

Now, McLaughlin tells prospective partners up-front that he is HIV-positive, and if they don't want to deal with it, he moves on to the next guy. The onus should not always be on positive people to negotiate safer sex, he said. "If you're HIV negative, you have to take personal responsibility to say you want to use a condom."

Ramon Martinez, a clinical psychologist, is HIV positive and in a "magnetic" relationship with a partner who remains negative after eight years. He always uses a condom, both with his partner and in outside relationships -- even with people who are also positive, in order not to bring home other STIs. "I personally hate condoms, but they're necessary in this day and age," he said.

Derek Brocklehurst, a nurse and study coordinator at Quest, is HIV negative and sometimes has sex without condoms with both negative and positive partners. He employs a variety of risk-reduction strategies including frequent HIV testing, in-depth pre-sex conversations about risk, and using Truvada (tenofovir/emtricitabine) for pre-exposure prophylaxis (PrEP) -- an indication that just received Food and Drug Administration approval on July 16, 2012.

"My most important message is not to demonize people who choose to have condom-less sex, but to encourage other safer sex strategies," Brocklehurstsaid. "Meet them where they're at and listen to their needs and desires."

Looking at the big picture, SFAF development and operations director Jen Hecht presented findings from a 2008 survey showing that about 40% of HIV negative men and just over 50 percent of HIV positive men in San Francisco said they practiced some form of seroadaptive strategy.

"[Serosorting] is the most common risk reduction strategy, and it seems to be increasing," she summarized.

What Do the Data Show?

But how effective is serosorting?

A 2008 study by Matthew Golden and colleagues found that serosorting was safer than unprotected receptive anal intercourse -- reducing transmission risk by 26% -- but 73% less effective than condom use. A study reported in 2010 found that serosorting was associated with a 64% reduction in HIV transmission compared with unprotected sex, while another showed a 3-fold increase relative to condom use. Furthermore, a more recent study by Golden found that serosorting was less effective among black gay men, who have a high and rising rate of new infections.

The weakness of serosorting and other seroadaptive strategies is incomplete or incorrect information.

"Serosorting by HIV positive men to protect others is totally different from serosorting by HIV negative men thinking it will keep them safe," said forum attendee Carl Barnes. "HIV positive serosorting works because if someone identifies as HIV positive, it means they know they're HIV positive, and if 2 HIV positive men bareback, they can't spread HIV. But HIV negative men who are sexually active cannot know they're HIV-negative."

The Centers for Disease Control and Prevention (CDC) estimates that 1 in 5 people with HIV are not aware they are infected. Some have never been tested and others have not had a test recently, but even people who test regularly may have been infected recently, before they produce enough antibodies to show up on a standard screening test.

"The people who are reasonably mistaken got tested within the last six months or yesterday, were HIV negative, and are in some stage of acute infection, which makes them more infectious," said long-time community advocate Stephen LeBlanc. "The people who are unreasonably mistaken got tested two years ago, have had an active sex life since then, and insist they are negative because they have been in perfect health since their last test."

HIV viral load can be very high during the acute stage of infection, raising the risk of transmission. Experts think a substantial proportion of new infections are transmitted by people with acute HIV, but again the numbers vary widely in different studies, from less than 10% to nearly 90%.

An HIV RNA test can detect viral genetic material within days, long before an antibody test is accurate (which takes several weeks to a few months). Some people with acute HIV experience symptoms such as fever, fatigue, and headache, but this is often attributed to a routine illness like the flu.

More information needs be shared with HIV negative men about the acute phase or first few months of infection when a HIV antibody test can show up negative but the person can have a high viral load and is in fact, very infectious," said forum participant Rajat Dutta.

Clinicians could offer HIV RNA tests when people at risk for HIV infection present with symptoms suggesting acute infection. But for this to make a difference, "we would need to get every person in the community to see a doctor and get RNA testing every time they get a sniffle," said Henry Raymond from the San Francisco Department of Public Health. "How would we fund this? It would be unsustainable."

In other cases, people may not reveal that they are HIV positive due to fear of the consequences.

"For a practice like serosorting to be effective, we need to strive for a world in which disclosure of HIV-positive status does not come at a risk of violence and rejection," said Cyd Nova, harm reduction services coordinator at the St. James Infirmary."We need to get to a place where those conversations are safe for people to have."

What about ART?

In 2008 the Swiss Federal Commission for HIV/AIDS stated that an HIV positive person on ART with completely suppressed viral load for at least 6 months and no other STIs "is not sexually infectious." More recently, the HPTN 052 trial showed that early antiretroviral treatment reduces the likelihood of HIV transmission within serodiscordant couples by 96%.

But these findings are based on data from heterosexual couples, and in HPTN 052 participants received a comprehensive prevention package in the setting of a clinical trial. Whether the same will hold true for gay men in the real world remains to be seen.

There is ample evidence that the lower a person's plasma viral load, the less likely he is to transmit HIV. However, several studies have found that men with fully suppressed blood viral load can still have HIV in their semen. Data presented last week at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2012), for example, showed that nearly 8% of gay/bisexual men on antiretroviral therapy with undetectable blood viral load intermittently shed HIV in their semen -- more than twice as often as heterosexual men.

When making estimates about infection risk, "community viral load" can also be important. A 2010 study by Moupali Das from the SF DPH and colleagues found that 44% of HIV-positive people in San Francisco have suppressed virus. Nationwide, the CDC put the proportion at 28%.

The effectiveness of ART leads to the counterintuitive conclusion that an HIV positive person on treatment may actually be less likely to transmit the virus than a random person who thinks he is HIV-negative.

"If you have multiple partners (or your partner has multiple partners) and you (or he) only has sex with people who believe they are negative, you are more likely to have sex with someone highly infectious than if you only have sex with people who you know are taking HIV medications regularly and have had undetectable viral load for at least six months," according to LeBlanc.

Nevertheless, the overall sentiment at the forum suggested that serosorting is likely to remain a popular prevention strategy.

"[Gay men] who are serosorting know they're doing harm reduction and that it's not completely safe," said forum participant Jackson Bowman. "People in the community are saying we're not going to use condoms every time. The current message endangers those men by not providing them with tools and information that they can use to reduce their risk."

New prevention approaches are needed for people who have a different experience of HIV/AIDS than those who lived through the worst years of the epidemic in the 1980s and 1990s, another young audience member emphasized. "We need to focus on education...just being scared is not enough."

[An earlier version of this report appeared in the September 19, 2012, Bay Area Reporter.]



San Francisco AIDS Foundation/Stop AIDS. Real Talk: Serosorting -- Fuck without Condoms? Ever? Community forum, September 12, 2012.