Negotiated safety

‘Negotiated safety' might be described as ‘serosorting plus’: it is a specialised kind of serosorting between regular partners involving an agreement about which sexual practices are allowed within and outside the main relationship, taking into account the HIV status of both partners. It is most often given this name when both partners are negative.

Negotiated safety does not even have to happen within the context of a couple; anecdotally, at least, from the early days of the epidemic some HIV-negative gay men attempted to organise themselves into ‘sex buddy’ groups where unprotected sex was allowed within a tightly controlled group, but not with HIV-positive men or people outside the network.

Negotiated safety has rarely been promoted by HIV-prevention campaigns. This is partly due to fears of stigma against people with HIV and, indeed, most HIV-prevention campaigns around the world have consistently promoted the message, “Positive or negative, it's all the same”, as a means of encouraging solidarity between infected and uninfected people. At least as importantly, however, negotiated safety is a highly fallible method of ensuring safety, especially if ‘extramarital’ sex is allowed.

The term ‘negotiated safety’ was first coined in 1993 by Australian researcher Susan Kippax.¹ In 1997² she looked at whether, if gay male couples made explicit agreements about unprotected sex, it had any effect on the likelihood that they would have unprotected sex outside their primary relationship.

In this sample of 165 men in seroconcordant HIV-negative relationships, 61% had engaged in unprotected anal intercourse at some point. She found that amongst this group the following factors were associated with a lower likelihood of having unprotected sex with casual partners and with a primary partner:

• Having an agreement about unprotected sex outside the relationship.
• The agreement including no anal sex with casual partners.

No other demographic or behavioural factors were found to be significant.

In 2005, a US survey³ conducted further examination of HIV-negative gay couples' strategies for staying negative. It looked at agreements partners had worked out to allow unprotected sex between them, but outlaw it with others, and to tell each other when the rules had been broken. It found couples often had difficulty keeping to their own rules.

The survey initially looked at 340 HIV-negative gay men in San Francisco. It found that 60% had no current steady relationship and that 10% had an HIV-positive partner. The other 30% had an HIV-negative partner, of which 76 men (22.4% of the whole group) were with ‘long-term’ lovers, meaning for six months or more.

It found that 13 of these 76 men did not have anal sex, and 17 (22%) practised the supposed ‘gold standard’ of 100% condom use with their partner. Interestingly, six men had unprotected sex with casual partners, but maintained 100% condom use with their boyfriend - a stance protecting their partner, but not themselves.

Another eight of them (11%) had unprotected anal sex within and outside the relationship and had not negotiated rules prohibiting it.

But the remaining 50% of the men in a long-term seroconcordant HIV-negative relationship had arrived at some form of negotiated safety agreement with their partner. A quarter of them (19 men) had negotiated total monogamy, i.e. no sex of any kind with men outside the relationship. Three disallowed anal sex of any kind with other men, but allowed other sex. And 16 men (21%) allowed anal sex outside the relationship as long as it was with a condom.

Of the 38 men with an agreement, eleven (29%: 14% of all men in a long-term seroconcordant HIV-negative relationship) had broken their own rules in the previous three months: a quarter of the ‘monogamous’ group and a third each of the ‘no anal sex’ and ‘no unprotected sex’ groups.

Three-quarters of the men who had negotiated safety also had a rule that they must tell their partner if they had broken their agreement. This did seem to help: only 18% of those with an ‘always tell’ rule had strayed outside their agreement, while the majority (60%) of those who had no ‘always tell’ rule had in fact broken it. Two out of every five men broke the rules they had negotiated in as short a time as three months.

"Nevertheless," say the study authors, "it is important to recognize that gay men attempt negotiated safety and may not be willing to use condoms consistently with their primary partners."

They recommended that health advisors could help HIV-negative couples by making sure both partners had the same understanding of the ‘rules’ they had agreed to, and also recommended couples have an STI test before deciding to abandon condom use.

Several other factors are likely to distort the strategy of negotiated safety:

• Ability to negotiate and assert - some individuals may find it less easy to assert their doubts about the chosen strategy.
• Pressures on the gay scene to have sex outside the primary relationship, increasing the potential for slip-ups.
• Unwillingness to wait long enough to go through a demanding testing procedure (linked to the length of the test’s window period). Unprotected sex may become the norm very quickly in a relationship as a signal that the relationship is intensifying.
• Lapses in condom use before the HIV test-window period is over.