Serosorting, sexual harm reduction and disclosure: some conclusions

Serosorting and attempting to use sexual harm-reduction techniques other than condom use have caused controversy in the last few years. Initially this was because, to a generation brought up on the message “Choose safer sex: wear a condom” serosorting at first appeared to be nothing other than reckless ‘barebacking’. However, as researchers started to look in more detail at the epidemiological data about who was really doing it with whom, the difference between serosorting and reckless behaviour was understood better.

If it is acknowledged that condoms cannot always be eroticised and that for many different reasons people may not be able or willing to use them, then serosorting and other sexual harm-reduction strategies may be a valuable second-best. The data presented in this chapter show that, on the balance of probability, they may help to reduce HIV incidence, or at least keep pace with the reductions in condom use seen in some populations since the advent of antiretrovirals (see ‘Condoms’for data on this).

Nonetheless, serosorting as a strategy is clearly less effective than condom use, and this has led public health educators to be wary of promoting it as a harm-reduction method in itself. Some may also have a moral position and see any relaxation from 100% condom use as irresponsible. Conversely, some HIV activists may be wary of strategies that impose a duty of disclosure on people with HIV, which 100% condom use does not.

However, as gay men and other people voted with their feet and started to have more unprotected sex, it has come to be recognised that gay men and others, particularly those with HIV and their partners, will use a variety of information to inform their HIV-prevention strategies and base the degree of risk they are happy with on this information. These are very individual choices and recommending a single course of action to a whole community may be pointless.

Drives to get more high-risk people to test for HIV have been based on the assumption that, once they test positive, people will moderate their behaviour, and most do. However, the change in behaviour seen may look, to people unaware of serosorting, like increased risk behaviour, and certainly is more risky when it comes to other STIs.

If, however, HIV-positive people and those at risk of it are at least attempting to inform and protect their sexual partners, should more HIV-prevention activities be directed towards enabling them to do so? Serosorting in itself may be a risky strategy to promote. However, the behaviours that make it possible – frequent HIV testing, disclosure of status and negotiation of sex that is safe enough for both partners – are ones that any HIV-prevention strategy should aim to support.