Betty Greene Salwak

To the Barebackers

Filed By Betty Greene Salwak | August 26, 2009 5:00 PM | comments

Filed in: Living
Tags: barebacking, HIV/AIDS, South Florida Blade, unprotected sex

An online conversation about unprotected sex began with the publication of Father Tony's recent column in the South Florida Blade. Other bloggers have responded with essays of their own, The Milkman's being especially eloquent. I offer here a different point of view.

You who continue to have unprotected sex:

You think this is only about your right to choose. You think that you should have carte blanche on how you live and whether you die young or not.

Let me tell you from terrible experience: this isn't only about you.

If you contract HIV, your quality of life will be irrevocably altered. If you have good insurance, you will still have to deal with reactions to harsh and costly medications. If you do not have insurance, you will likely lose your job because of the hours you will spend in clinics and the emergency room.

In the end, though, it comes down to this: do you have anyone who loves you? Anyone at all? When money, health and time run out, when that end of life comes, the people who love you will have to watch you die.

Those who love you will try to help you keep a sense of "normal," taking you to the store for food that you cannot eat, keeping watch on you so that you don't wander away, and hurrying you through the line before you soil yourself in public.

They will have to stand by helplessly while you slowly starve on a diet of up to 4000 calories a day, because the simple yeast infection which ravages your digestive system won't let the food stay in your body long enough for the nutrients to be absorbed.

Those who haven't seen you in a long time will try to hide with forced smiles their shock at your appearance when they first see you, looking for all the world like an aging prisoner of a concentration camp, with joints bigger than your limbs, sunken eyes, bleeding gums.

The people who love you will push you to the TV room in a wheelchair in which you are strapped with a belt across your slender chest because you will be too weak to sit upright. Before you are bedridden and hooked to IVs, they will watch the hospice nurses carry you in their arms to set you down in the living room to talk about things that don't matter at all.

Those who love you will agonize over how to help you when you hallucinate that there are insects crawling all over you, helping you to brush them off so that your panic will subside.

They will try to stop their tears when you have no idea who they are or that they have traveled hundreds of miles to make sure you know they love you.

One who loves you will hold you as you struggle to stay in this life, giving you permission to leave; and, with a final sigh, you will go.

The people who love you will ultimately be grateful for the peace--yours and theirs--that your death will bring, even though they will always be haunted by the images of your slow and excruciating demise.

Those who love you will most likely go through this in silence, for even today no one wants to talk about it.

You who have unprotected sex do in fact have the right to choose. My brother and those many thousands who were decimated by this cruel disease did not have what you do today: a manner of informed consent. You know how to stop HIV from spreading.

The greatest enemy of autonomy is self-destruction. Police yourselves. Claim the brotherhood you share by honoring the deaths of those who came before you. Please, choose love. Choose life.


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Betty,

The following is a cut/paste of my comments today on the article on "post AIDS":

Having lived through the 1980's and early 1990's when 70% of my cloest friends died of AIDS, I find this "post-AIDS" attitude quite unsettling. I remember a time when AIDS was a death sentence. I can remember a time when on a weekly basis LGBT publications had numerous obituaries of individuals who had died of AIDS.

With all the new drugs, infection with the HIV virus can be controlled and is no longer an immediate death sentence. The very smart ads by the drugs companies, many in LGBT publications, give the false impression that one should not be concerned. They seems to say that if one is infected with HIV all one has to do is take some drugs and all with be fine.

I personally know a number of individuals who are HIV positive and can see how being HIV positive has greatly affected their daily lives.

I will have to read the posts that inspired this essay.

It is easy to simply say "use a condom every time" but as I have more discussions with gay men who bareback, I think it's complex situation with no easy answers.

When I told some friends that I have yet to bareback, they said I was able to insist on condoms because I hadn't had "real sex" and that if I had, I would understand why people don't use them.

Then you have a myriad of other issues associated with unprotected sex and I am just about at the point of adopting the attitude that some people just can't be saved.

Some people need the wake up call this provides.

AIDS should have been stopped twenty five years ago when we first knew the transmission method. There are plenty of strategies that would have worked: monogamy with testing and condoms, serial monogamy with testing and condoms, free love with testing and condoms, negative people together, positive people together, basic respect for others, honesty, and a willingness to protect our brothers' lives and health.
Instead we have coldhearted monsters lecturing about their right to throw us all under the bus.
Only selfish and heartless people think barebacking is only about them. It's always been about spreading the virus and contempt for our community. But there's no talking to them. We've tried for years. And they just spew bulls--t rationalizations.

Joseph Kowalski | August 26, 2009 8:37 PM

Thank you Betty Greene Salwak for writing this article which serves as a reminder of how devastating an AIDS diagnosis is even today.

Many people today believe AIDS is a manageable disease much like diabetes. It's far from it. It's a permanent, life changing event which forever negatively alters the way a person lives their life.

To me, it's like murder. If you know you are positive and do not wear a condom, even if the other person goes along with it, you are contributing to the death of another human being.

Anyone who advocates barebacking is totally selfish and irresponsible. Sadly, those who most need to heed the warning in this article will ignore it and go on spreading a fatal disease.

Sister Mary FP | August 26, 2009 9:05 PM

This has been an ongoing topic with my group: on the one hand, we want to encourage freedom from guilt and sexual repression. On the other hand, lack of guilt doesn't mean absence of responsibility. We want to promulgate joy, not foolhardiness. Thanks for opening up this discussion.

Surely there's a way to address the issue in the positive - not censorship but substitution?

PositiveSex | August 26, 2009 9:08 PM

We are doing just fine barebacking thank you very much. Sorry your brother died of AIDS, but he didn't have the advantages that we have with new drugs that take care of opportunistic diseases.

My partner and I are both HIV- and enjoy unprotected sex everyday of our life since the 1980's. You as a straight sunday school teacher have no business mingling in our business.

Every week I see people who are taking the new drugs. They battle serious side effects, like numb feet that prevent them from walking or lack of sleep and appetite. They often have to take a "vacation" from those new drugs to allow their livers and other organs to recuperate from the assault. The drugs slow down the effect of HIV, but they won't stop it.

The facts remain facts regardless of who is stating them. I want you and your partner to live long and healthy lives.

Dear Positive Sex,
I've read your comment several times, looking for an indicator that this is an attempt at humor. Not finding any, and assuming you are serious, I am startled by this sightless and thoughtless remark.
As if HIV-couples in seriously monogamous relationships should be championing unprotected sex in a world of men who have multiple sex partners. I can't even bring myself to say that I am happy for you. I think you owe Betty an apology for your smug and stupid claim that she should not be addressing this issue, but I don't expect we'll see such from you.

PositiveSex | August 27, 2009 9:21 PM

No. I find this Sunday School teacher very arrogant to be supervising LGBT's sex life. My husband and I are monogamous and have been for years. We are married with a license in California and not referred to as "barebackers". I find that description very condescending. I am not giving the "churchlady" advice concerning her sex life, and I am sure many straight people in her church have anal sex. What is it about Indiana Christians? They take the liberty to dictate morals that they think come from God. Not unlike the musical "Music Man", "sin right here in River City". Frankly, I find it discusting. Wearing condoms and having anal sex is not a new concept. The information has been around since Rock Hudson died. Do we need an insignificant church lady to tell us to wear condoms? Not.

Dear Positive Sex,
Now we see your true colors. Taking swipes at people without regard to their actual words. Categorizing indiana Christians, and the like. I knew that given enough rope....Well, if you were thoughtful at all, you'd see that you very much owe her an apology, but now you've gone and attacked a wider group. You are not ahead, but you should quit while your officious nose is still above the quicksand.

On a selfish note, how about we poor activists who have to answer, in a live public forum, questions from the Christian Right and other conservatives about the "reckless, promiscuous behaviour of homosexuals/sodomites and the cost to the taxpayers for keeping them alive, the public paying for their behaviour?"

The best reply that I could ever come up with was "well, Lesbians have a very low rate of HIV, lower than straights so I guess that we come out even"

Back when people actually said that HIV/AIDS was God's divine punishment, I often pointed out that since lesbians have a lower rate of infection than heterosexuals, then the "divine judgement" argument would mean that lesbians are God's favorite people.

It usually confused folks more than opened their minds.

On websites like gay.com, and adam4adam I see just about half the kids under 25 outright state in their profiles that they do not practice safe sex. It is alarming to me. Almost all of these 18-25 year olds were born after the big scare in the mid 80's. Many hit puberty after the protease cocktails hit the market.

I myself in my early 30's have not known anybody my age who has died from AIDS, despite having hundreds (thousands maybe) gay friends and associates.

Yet I have known one man (I didn't know him well) who had been HIV positive for a few years and one day came down with the flu and was dead a week later.

Now I have an old coworker who I suspect is positive and has come down with the swine flu. He is in the ICU and most likely is going to pass. It isn't AIDS that kills you, it's the once every 10 year "big illness" that everybody gets every now and then. Even HIV negative people face death from the flu, and H1N1, or pneumonia. If you are positive the chances of death from that sort of illness skyrockets.

HIV destroys you over time and very likely will kill you once you get it.

I had sex with plenty of guys I met online who were over 40, and, trust me, only one used a condom without me reminding him like 8 times (or doing the, yeah, I'm using one, and then you feel down there and surprise! no condom). He was poz, so I guess he knew better. The older crowd, at least in IN, isn't doing all that well on these counts either.

That was a punch to the gut: easily the most powerful description of the ravages of AIDS I have ever read. I thought understanding prognoses for AIDS on an academic level would be enough; I've never seen anyone pass, or been in this situation. After reading this I know better.

I'm bookmarking this page and sending it to everyone I know. It's just that important.

I agree wholeheartedly with the substance of this message.

However, I believe its tactic and form are ineffective and possibly counter-productive.

Those who share your experiences and views will write supportive comments, sharing your righteous indignation. They are the choir and you need not convert them.

The presumed target audience will not read past the first gruesome paragraph. Scare tactics do not work. If fear was enough to stop HIV- people from having unsafe sex, then this column would not be necessary. Our culture has grown immune to fire and brimstone preached by the purportedly righteous from high pulpits.

Your piece is titled "To the Barebackers." I suspect you (and the other commenters) don't know a single person who belongs to the group to whom you are preaching. There are a few bizarre exceptions like the commenter "PositiveSex," who I would suspect is a fundamentalist Christian plant trying to kill queers by spreading disinformation, rather than a real person, or perhaps he's just amazingly stupid and contrary. But for the most part, I assert that "the barebackers" are a group of average, intelligent people who will never admit or talk about what they do and why they do it, especially because they will be met with the kind of fury and vitriol you express here. You fail entirely to engage the group for whom you purport to have great care--to the contrary, you send them further into hiding and make them less likely to join the conversation.

I believe I have some insight into this, because despite hearing safer sex messages all my life, I was one of "the barebackers." I am poz now.

I am afraid to post this comment. I am afraid to be judged by you and the many who read this blog. I am ashamed of myself. I hurt. My every instinct tells me to run from this conversation, because I can, and there is no point in enduring the emotional battering.

I will post it, despite my fear, because I never hear from someone like me in these discussions, though I know my peers are legion. The statistics show it.

I implore you: stop these hateful, judgmental, and fear-based methods of prevention. Quit driving away the audience you wish to persuade. Quit calling us stupid. I know you are emotional over those who have been lost, and you are entitled to that, but try to understand that while it may feel good for you to vent, in the long run this course is unproductive. The statistics show this, as well.

I have a story, just like you and your brother. If you're in NYC, meet me for coffee and attempt to understand the whole human being I am. If not, find someone near you who qualifies as one of "the barebackers" and have a real conversation with him. Listen more than you speak. Watch carefully for the deeper motivation behind his behavior--is it depression? Low self-esteem? Drugs? Mental illness? Lack of family support structure?

If you truly love the people you are trying to save, then speak like it and act like it. Please.

Another One | August 27, 2009 12:36 PM

Christian,

I just wanted to say Thank You for your comment. Of course, my story is a lot like yours - and I'm using a pseudonym for fear of the same repercussions that you mention. It was painful just to skim this article, an essay narrating as an exercise in prevention the likely horror of my own eventual death.

I also agree with you that the approach is wrong-headed. I remember how I got the disease... I can't recognize the person who was doing all those things, honestly. I was depressed and wanted to die. I relied on drugs to get myself through almost any social situation, sexual or otherwise. I tried getting help a few times, but nothing stuck. When I finally woke up and realized how much I had to live for, I grieved.

It's been a few years now, but I'm still grieving, perhaps more quietly now, but grieving.

So this message, I think, does little good. The intended audience, something of a straw man itself, is deliberately deaf. And it does some harm, making it clear that our welcome in this community is suspect at best.

A more welcome approach, I think, would be to call to those of us who have come out of the darkness, scathed but still alive, to reach out to those others still finding their way. I don't know if counseling with someone who understood me would have helped. I don't know how I would have found it. But it sounds like something that might have been good for me, before I became infected.

You are welcome.

I did not shed a tear for the essay, but your comment has me bawling. We are not alone. You and I deserve love. Do not let the tone of these writings convince you otherwise.

Furthermore, I firmly believe that we will not die in this manner. I believe better treatments and perhaps a cure will be found. I must believe this, because without hope, I would fall back into the destructive behavior that brought me to this place. I choose to use my virus as a force of positive change in my life. Far from doomed to ignominy and pain, we are blessed with the opportunity to live long and happy lives, if we learn from our mistakes and continue to improve ourselves.

Ms. Salwak, I was startled to find that one of your other Bilerico essays is entitled "What Would You Do If You Weren't Afraid?" I am inspired by that essay and, indeed, have been applying those ideas to my own life for some years. I do not understand how a proponent of that admirable philosophy can turn around and attempt to persuade with the very fear she struggles to overcome in her own life.

Again, I implore all who read this to consider more loving and humane tactics for prevention. Not only is fear statistically ineffective, it is hurtful to a great many of us.

Christian and Another One, thank you for being so gracious in your honesty. You have given me a great deal to think about. Whenever I make it to NYC (or wherever you are), I would be glad for the chance to sit down with you and talk.

Another One | August 28, 2009 1:23 PM

Christian,

I don't know about you, but I'm in a committed relationship - I do worry about my boyfriend, who is negative, about the risk I pose to his health, about the possibility of a painful decline sometime in the future. For the time being, my medication seems to be working fine, but I'm not optimistic about a cure. I do think that I have a number of decades left in me yet, regardless.

Betty,

I appreciate that you were willing to listen - I may have overreacted a bit myself. Your words were hard words to read, is all. I don't know anyone who has been through that death. I'm sorry about your brother.

I've always wondered about the fact there isn't a similar name for STRAIGHT unprotected sex. Or the same combination of stigma, disdain, and paranoia. I think this piece fulfils a particular function and is obviously founded upon the writer's own experience with her brother - but it hardly serves as the standard discourse on the topic.

There's a lot that gets left out here, including our complicated thoughts about pleasure, sex, and what gets classified as "danger."

I agree with the spirit of Christian's response above. And, frankly, I also have to agree with an earlier poster about the Sunday School rhetoric here.

Most of all, I'd want people to acknowledge that barebacking occurs among straights as well. And that HIV rates are pretty high in that population as well. The current discourse on barebacking only replicates the same "patient zero" logic - find the queers who bareback, and we will get rid of the epidemic. The reality is far more complex and this kind of chastisement and moralising gets us nowhere.

Re: Yasmin's comment I'd just like to throw a few CDC statistics in here:

MSM (men who have sex with men) made up more than two thirds (68%) of all men living with HIV in 2005, even though only about 5% to 7% of men in the United States reported having sex with other men.

http://www.cdc.gov/hiv/topics/surveillance/basic.htm#hivaidsexposure

MSM transmission made up 53% of new infections in 2006; high-risk heterosexual contact made up 31%.

http://www.cdc.gov/hiv/topics/surveillance/incidence.htm

I'm not saying heterosexual transmission is not happening or alarming, especially for women, who are far more likely to be diagnosed with HIV/AIDS after sexual transmission of HIV than heterosexual men are. I'm just pointing out that in total sexual transmission is not an even playing field between MSM and straights, with MSM getting too much of the hot lights. Far from it.

Re: Dustin's figures:

I just attended the national LGBTI Health Summit in Chicago, and there are some interesting discussions around the issue of MSM and HIV transmissions. The most salient of them have to do with how MSMs get classified as such - as I understand it, the category of MSM is considered a problematic one by some researchers because it doesn't take the myriad and complicated forms of sexual behaviour into account. Instead, MSM as a category too easily conflates sexual IDENTITY with sexual BEHAVIOUR. The contradiction inherent in the numbers above indicate that.

In other words, someone who is an MSM could also be a "heterosexual." The numbers may still tell a similar story, if we considered more complicated ways to categorise people, but they might tell us a story we don't want to hear - which is that HIV transmission cuts across sexual and identity categories in ways that challenge our concepts of who's straight or gay. And that's all I'll say in response to any more issues around numbers - because, as anyone who read my comment will understand, the numbers are only a part of my point.

My comment, as I'm sure most people will have understood, is about the ferocity of the stigma and the needlessly chastising and punitive tone taken on by those who have decided that barebackers are

a)queers
b)largely responsible for this epidemic
c) need to be treated as sinners or infantilised, or both.

If we thought about desire, sexuality, pleasure, danger, and sex in more complicated ways, perhaps we'd be closer to understanding the phenomenon.

Yasmin, I think you are correct that the category of MSM includes those who identify as straight. Wasn't the purpose of creating the term "Men who have Sex with Men" to focus on risk behavior, rather than sexual identity? As I recall, the concern was that health messages directed at gay or bisexual men wouldn't necessarily reach those who identify as heterosexual, but were still having sex with other men.

I think the "straights do it too" argument is a bit misleading. As Dustin pointed out, the risk is not proportionate. Men engaging in unprotected sex with other men statistically are at much, much higher risk than heterosexual couples engaged in similar activity. Because of that, I think the issue of unprotected sex in our community needs a higher level of attention than given to unprotected straight sex.

But yes, I agree we need to avoid unnecessary chastising. As Christian and AO mentioned in their important (and very welcome) comments, such shame messages are counter-productive. And yes, scapegoating or judging is even worse. But I don't think this topic is something our community can just say: "Free choice, buyer beware" and then walk away from the issue.

The SF public health department, and some AIDS orgs have strated using a couple of strategies that I thought were effective.

1) Giving men permission to serosort (ie, if you are negative, sleep with neg men, if you are poz sleep with poz men.) Asking HIV+ men to do their best to serosort.

2) Demanding that HIV+ men take responsibility for not spreading the disease they have.

In many cases HIV+ men played the victim and decried having to be responsible for not infecting people with a terminal disease. Selfish. Despite that though I think those two strategies have worked with the general population. It is more than just an education campaign, it's a life saving campaign.

Anonymouse, please cite the link for your information because I do not believe for a nanosecond that "the SF public health department, and some aids orgs" have advocated the first strategy you cite. Perhaps, your personal strategy is to serosort, but I've got news for you, it will not work. Do a little research and don't write such misinformation in the future. Here in simple language is Wikipedia's take on serosorting: http://en.wikipedia.org/wiki/Serosorting

Anonymouse Me | August 27, 2009 8:05 PM

Since you asked here is one study on the results of the serosorting strategy many gay men in SF have started using:

http://www.aidsmap.com/cms1270367.aspx

The data shows that is does work as a strategy. No where does anybody say that serosorting should be the ONLY strategy used to avoid HIV infection.

You're right, the SF DPH did not outright endorse serosorting as an effective means of HIV prevention. They did however unofficially promote the practice to Stop AIDS (an SF based Aids org):

http://mpetrelis.blogspot.com/2006/11/sf-dph-releases-hiv-serosorting-slides.html

The SF Aids Foundation however has endorsed it:

http://www.ebar.com/news/article.php?sec=news&article=800

No, they did not! Here is what they said:

"I think that the leveling off or slight reduction of HIV infections in San Francisco is due primarily to serosorting and what we call negotiated safety," said Steven Tierney, deputy director for programs and services at SFAF. "We didn't think it up. Guys are using it in order to improve their health while still having fun. It is a good thing guys are making that decision."
But when asked if the ads will be an endorsement of serosorting, Tierney described the campaign being more informational than promotional.

"... the social marketing campaign is designed to increase community dialogue on what does serosorting mean and what does negotiated safety mean. How can you have the sex life you want to and deserve but ultimately be concerned about your sexual health and the health of your partners?"

This is by no means an endorsement. You cannot selectively decide that the San Francisco Aids Foundation or anyone else endorses something just because you want it to be true.

Anonymouse Me | August 27, 2009 8:13 PM

BTW Kim,

I use serosorting AND condoms. You act like serosorting exists in a strategy vacuum. Not sleeping with men you know, or suspect are HIV positive, or who you believe engage in behaviors likely to lead to infection, is what serosorting is. If I stack religious usage of condoms on top of that strategy, I'm going pretty far at reducing risk factors.

Considering at this point I've had several thousand partners and I'm still HIV negative, my dual strategy seems to be working.

People use selection in almost everything they do so the fact that some serosort is not new. If you have had thousands of sex partners and you are HIV negative, you are very lucky, but I don't much think you have an ounce of common sense, the ability to analyze facts, nor are you much of a poster person for any particular cause I can think of. I do hope you do not contract HIV/AIDS or any other infectious disease and I do hope you don't infect anyone with HIV/AIDS or any other infectious disease. While this practice has been happening since the beginning of the epidemic, it's been just recently that HIV infection rates among gay men have been impacted by the practice. Data suggests that sero-sorting may decrease the rate of new HIV infection because there is less unprotected sex between positive and negative partners. However, the data also suggests that the rate of other sexually transmitted diseases actually may increase in frequency. The reason is simple.

Sero-sorting increases the rate of unprotected sex versus safer sex. Countless studies have proven that STDs are more common in people who have unprotected sex. While an HIV positive and negative couple (sero-discordant couple) likely would use safer sex to prevent infecting the negative partner, couples which have two positive members use safer sex much less often, thereby increasing the incidence of sexually transmitted diseases. In addition, couples where both partners are thought to be negative may not have considered the window of time between exposure and a positive HIV test. The body takes some time to produce enough antibodies for an HIV test to detect. Therefore, if a test is done before there is enough antibodies to be detected, the result will be negative even though there is an HIV infection. Negative couples who do not take this fact into consideration may not use safer sex methods which in some cases may result in new STD or HIV infections.

Keep in mind that while there is evidence that sero-sorting can decrease the rate of new HIV infections, it does nothing to prevent the re-infection of HIV positive partners with new strains of HIV. Because of that, experts remind everyone that safer sex methods are still a must even between two HIV positive people. And, you never, ever truly know if your sex partner(s) are positive or negative.

Anonymouse Me | August 27, 2009 5:43 PM

So, I did a little data mining of the search abilities on Adam4Adam and pulled the following data out. I am counting omissions of safe sex answer into the anything goes category since the question must be skipped intentionally to create a profile. This data is for Central California which includes both the central valley, and the central coastal region of the state.

Age::Omit/Anything Goes::SafeOnly
18-21 123 483 = 20% unsafe
22-25 165 569 = 22% unsafe
26-29 186 491 = 27% unsafe
30-33 184 316 = 36% unsafe
34-37 164 288 = 37% unsafe
38-41 163 253 = 39% unsafe
42-45 120 173 = 40% unsafe
46-49 56 123 = 31% unsafe

Thank you Christian and Another One.

One thing we should have learned by now is that what one person feels inside is not what other people feel. What is easy for one person to give up can be very hard for someone else. I found it relatively easy to give up all anal sex (with or without a condom) because I was already tiring of it by the late 70s and was doing it because it was expected rather than because I really wanted it.

Oral sex, however is another matter. Even if the risk were the same, I'm not sure I could or would give it up or even use a condom. The only times I have used a condom for oral sex is when I was with a "professional" who insisted on it. And even with anal sex, there have been a few times since the early 80s when I just had to have it. And most of those times, I'm not sure if a condom was used or not. Once I get in that submissive mindset, I find it hard to say "yes, but". That's why most of the time its no, period.

I am still HIV negative (mostly luck considering the thousands if not tens of thousands of sexual encounters I had in the 70s). However, I have Diabetes, that other "manageable" chronic disease that HIV/AIDS is now compared to. Trust me, it's no picnic.

Although I have changed my eating habits and get more exercise, every day I eat or drink something I shouldn't. The small Cherry Coke I had last night at the movies was better than sex! When you deny yourself something, it makes it so much more desirable and at some point you just have to have it, consequences be damned.

Here is the latest information from the Centers for Disease Control (CDC):

Meeting Summary: “Consultation on Serosorting Practices among Men who Have Sex with Men”

March 31, 2009

Background:

On December 2-3, 2008, the US Centers for Disease Control and Prevention (CDC) sponsored a Consultation on Serosorting Practices among Men who Have Sex with Men (MSM). Serosorting is most often defined as a person choosing a sexual partner known to be of the same HIV serostatus, often to engage in unprotected sex, in order to reduce the risk of acquiring or transmitting HIV. The consultation sought to explore the extent of serosorting among MSM and the level of HIV risk associated with serosorting under different conditions. Approximately 25 external consultants attended this consultation, including social and behavioral scientists, public health personnel, clinicians, laboratory scientists, and community members from a variety of organizations. Participants reviewed available data and discussed implications for prevention messages as well as defined gaps requiring future research.

Presenters at the consultation presented on:

Patterns of serosorting among persons infected with HIV, including a review of the biology of sexual HIV transmission, with an emphasis on the likelihood of infection with an additional strain of HIV (superinfection) and other potential harms such as sexually transmitted infections (STIs).
Serosorting among persons who are not infected with HIV as well as “negotiated safety,” a strategy studied in Australia for committed partners not infected with HIV.
Perspectives on serosorting from three MSM community members who discussed their real-world experiences and challenges to help contextualize the scientific data.
Summary

Broad issues discussed during the consultation included the definition of serosorting and related terms; the extent to which serosorting is intentional; the effectiveness of serosorting given that decisions may be made based on assumptions, rather than knowledge, about serostatus; and the complex contextual environment (relational, psychosocial and structural) for MSM in the United States. Consultants discussed the meaning of various terms, such as serosorting, strategic positioning, seroguessing, and seroadaption; when and how those terms are being (or should be) used; and the risks associated with some of these behaviors. The consultants perceived seroadaptation to be a broader and more inclusive term than serosorting and, more consistent with the broader goal of improving the sexual health of gay and bisexual men in the United States. Discussions also focused on possible ways to frame prevention messages, including breadth and content of the messages as well as specific messages for partnerships in which both members are infected with HIV, partnerships in which both partners are not infected with HIV, and partnerships in which the members are serodiscordant or serostatus is unknown. General concern was expressed that using serosorting in some particular contexts would not reduce HIV risk and might actually increase it.

The concern with regard to unprotected sex between men who are infected with HIV focused on the potential for increased STIs and superinfection. While STIs are much more common among MSM who are infected with HIV than among those not infected with HIV, there is not yet a demonstrated difference in STIs between those who practice serosorting and those who do not. Untreated STIs were discussed as factors that could increase risk both to the overall health of men who are HIV infected and for superinfection. The consultants discussed the benefits of STI screening and treatment to reduce transmission from men infected with HIV.

Regarding superinfection, the consultant noted that few cases have been reported in the literature and that the risk appears highest soon after seroconversion and may decline over the course of infection. Some data discussed by the consultants also indicate limited clinical consequences of superinfection. However, the consultants noted the lack of research among African American and Latino men and on superinfection in general. The consultants discussed how superinfection risks should be framed in communications to patients and the larger community. The consultants felt that there is a great deal of public confusion on the risks, and expressed the belief that the medical and prevention communities may have overemphasized the likely risk of superinfections, as well as the severity of its consequences.

Regarding serosorting among men who are not infected with HIV, presenters and consultants highlighted conflicting data and opinions. On the one hand, HIV transmission cannot occur between two seronegative persons, and serosorting is a community-developed strategy that is already operating in some MSM networks and might be enhanced through public health research and messaging. However, ascertainment of serostatus can be difficult, especially because MSM in the United States, particularly African American and Hispanic/Latino MSM, have high rates of HIV prevalence and incidence, and large percentages of unrecognized infection. The consultant expressed support for research into home-based HIV-detection technologies that might help in some cases of ascertainment serostatus (but could be problematic with very recent infection). The consultants again noted the lack of research data about serosorting practices among African American and Latino MSM.

The consultants also discussed Australian data on a negotiated safety strategy. Important elements of negotiated safety are captured by a marketing campaign titled “Talk, Test, Test, Trust” and include at least a 6-month relationship, shared knowledge of HIV-negative serostatus supported by two tests separated in time, clear agreement about sex inside and outside the relationship, and sex with casual partners being “safe.” Data presented showed a protective effect among MSM who were not infected with HIV and who strictly followed its tenets. The limitations of negotiated safety were discussed with casual or one-time partners as well as early in relationships, when changes occurred in long-term relationships, and when negotiated safety agreements were not revisited. Additionally, the transferability of these findings to the United States was discussed in light of the racial/ethnic and HIV epidemic differences between the United States and Australia. Some of the prevention topics that consultants discussed regarding serosorting between men who are not infected with HIV, or perceive themselves not to be infected, included:

The recommended frequency of HIV tests;
The technological limits for detecting acute HIV infection;
An understanding of what prevention options are being replaced by serosorting;
Whether serosorting practices vary by partner type (main/casual);
The heightened risk of seroconversion over time among MSM who are not infected with HIV but who practice serosorting;
The potentially detrimental consequences of higher-risk MSM networks overlapping with lower-risk MSM networks;
The role of condoms in serosorting.
Conclusion:

The consultation highlighted the need to clearly define seroadaptation practices, and particularly serosorting, among MSM, and to understand the differing risks based on a variety of contextual factors. Several areas for future research were recommended. The information obtained in this consultation will inform potential future CDC activities, the development of prevention messages or guidance documents, and the creation of future funding announcements. As follow-up to this consultation, CDC will develop a fact sheet on serosorting among MSM that will include definitions of various seroadaptation practices, the state of the science with regard to behavioral patterns and their potential HIV risk under different situations and with different types of partners, and recommendations for future research. The fact sheet will be released later this year.

Last Modified: April 2, 2009
Last Reviewed: April 2, 2009
Content Source:
Divisions of HIV/AIDS Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Anonymouse Me | August 28, 2009 12:05 PM

And here is the common sense key for why people should use serosorting:

"Regarding serosorting among men who are not infected with HIV, presenters and consultants highlighted conflicting data and opinions. On the one hand, HIV transmission cannot occur between two seronegative persons, and serosorting is a community-developed strategy that is already operating in some MSM networks and might be enhanced through public health research and messaging."

I don't really understand your "sky is falling" viewpoint on serosorting.

Whatever the case, the basic reality is that serosorting is effective (when combined with condom usage) in reducing HIV infection because it reduces the number of potential accidental exposures when condoms fail. People who are in serodiscordant relationships have to have PERFECT with condom usage, EVERY time. PERFECT TO THE LETTER. And if the condom fails due to a manufacturing flaw, well, hopefully that wasn't the one time it takes to become infected.

The reality is safer sex practices are not 100% safe. Let's say condoms are 90% effective and I've reduced the number of HIV+ partners I have down from 30% of total partners to only 10% using serosorting, I've reduced my chances of being accidently infected from 3% to 1%. I'll those improved chances anyday. The reality is that the effectiveness of condoms is more around the 98% level and serosorting further reduces my risk should a sexual experience fall into the 2% failure rate. I go from something like a .6% chance to a .2% chance if I've used serosorting to reduce my HIV+ partners from 30% to 10%.

Goddamnit Anonymouse, can't you read? Facts are facts and you can reduce your risks and those of others if you use only use the common sense that was given you. Don't advocate for serosorting as a preventive measure because you cannot serosort those who you do not know. Now, there are those among us who will never, ever contract HIV. I can't explain that, but those people exist and they are the lucky ones. Maybe a vaccine can be developed from their good fortune, who knows? Serosorting as inaccurate as it may be may, in you mind, reduce your risk, but I am sorry, it will not protect you for you can never know for sure.

I wish you the best of luck in your sexual exploits, but I do not think you are being a realist and I absolutely know my thoughts are not a sky is falling viewpoint. We all sort to some degree and sometimes we are right, but sometimes we are wrong. Why take that chance?

Jay Vithalani | August 29, 2009 10:29 AM

Ah, such anguish combined with such a pedestrian mind! Columns like these appear with metronomic frequency: in local gay newspapers, on blogs, occasionally in the national media. Reading her column made me want to scream at her and all the people who use Moral Urgency as a putative social tool. Yuck. Well-intentioned imbecility. Yuck.

The term "barebacking" is starting to become common with straight people as well (no condom, vaginal or anal sex). Not to make anyone sick LOL, but it seems it's now cute for women to go on birth control and allow guys to go ahead and try to impregnate her anyway, just so he can look at the results afterwards.

But that's what you get with a young generation who all thinks it's cute to pretend to be pornstars - even wearing the word "pornstar" on their t-shirts.

Those people need to be harassed over the HIV issue as well, and kill 2 birds with 1 stone, prevent them from bringing unwanted children into the world as well.

Hi Betty,

I appreciated your post. While I thought parts were outdated and that I can't relate to the pain you've gone through, it still touched me very deeply.

I'm 23 years old. I'm HIV negative (tested on Thursday!). As an undergraduate, I dated the same person for two years and had unprotected sex. I organized a commemoration of World AIDS Day while still having unprotected sex with my boyfriend with whom I was non-monogamous. After my relationship, I had many sexual partners, often unprotected. I knew the facts, but I had never known anyone HIV positive.

A good friend, with whom I'd also had a sexual relationship, disclosed that he had become HIV positive. I was floored, but still I had some unprotected sex. My ex-boyfriend called to tell me that he had become HIV positive. Still, I had unprotected sex.

I am young, smart, and educated; yet I still have had unprotected sex recently. I've been trending towards being more protected every time I have sex, but after reading this and after my test on Thursday, I will be try my best to be protected every time I have sex.

I should know better, but I haven't. Keep pounding the message, and hopefully, as it finally has for me, it will stick.

Regan DuCasse | August 30, 2009 3:28 PM

The original article could stand as a cautionary essay for EVERYONE. Certainly blacks stand as another marginalized community, one that has less access to education on prevention and protection.
There is a great deal of denial among straight blacks on their culpability and endangerment of each other and future generations with HIV/AIDS.

The rates of infection are on a par with that of gay men in general. And less access to testing and medical care means higher death rates too.

The high rate of pregnancies out of wedlock would indicate just how much unprotected sex is going on among people of color. And with that comes babies born HIV+.

Unprotected sex, is unprotected sex. Period.
And those who belong to communities of greater risk, are mislead and always have been by information that made it seem as if ONLY gay men got HIV, or that gay men having sex with black women introduced the infection into straight black lives.

Yeah. Right.

I spent years working on the AIDS Project LA hotlines and it was very difficult to persuade straight black men to use condoms. Very. Nearly impossible, in fact. Despite how many black men and women had multiple partners, and concurrently conceived children.
Indeed, so many times the onus of birth control was put on the woman, it made me want to holler!


I see that the new infection rates among straight black men and women hasn't changed for the better since I volunteered for APLA. 15 years ago!

No surprise why.

Stigma certainly keeps individuals from being informed or to inform about infection status, and that the advent of drugs keeps PWA's a still invisible population.

In some quarters, once one knows their status, they might slowly fade from the view of their families and friends and colleagues. The 'voodoo' of HIV among Latinos and blacks requires they not talk about it, nor involve anyone being fully informed, even as it impacts those immediately around the person with HIV.

These days, the funerals are less frequent, so is the ceremony of The Quilt, so are the profiles of the long dead from AIDS.
There is a disappearance at work here, not only of the dead...but of those whose lives have been ravaged by the disease.

When blacks see someone 'living with AIDS' who is well known, they see the vigorous and healthy life of Magic Johnson.
They are told of the 'hope of life' through drugs and so on. And in a way, there IS no sense that HIV still lurks and seriously threatens.

I don't know people. Even when the savage results of crack and meth are highly visible in a neighborhood, it still doesn't seem to deter enough from taking risks with it anyway.
Tragically, the same goes for HIV infection.

You can lead a horse to water...