HIV Infogram: Serosorting among Gay and Bisexual Men

As a prevention or healthcare professional, you may have the chance to talk with gay/bisexual clients and patients who have multiple sex partners about serosorting. By outlining essential facts and messages, this fact sheet can help guide those conversations. The goal is to help HIV-positive and HIV-negative men assess the pros and cons of serosorting as one of their sexual risk reduction options.

Serosorting is deciding whether to have sex, how to have sex (oral, anal, kissing, etc.), and whether to use condoms with someone – based on that person’s known or perceived HIV status. While the term “serosorting” is used more by HIV and STD prevention professionals than gay and bisexual men themselves, the practice may be becoming more common. Both local and national studies suggest that many HIV-positive and HIV-negative men often limit sex to partners of the same known or perceived HIV status.

Most men view serosorting as a way to have sex and decrease the risk of getting infected or infecting someone else. Many men who serosort also choose not to use condoms for anal sex, believing that serosorting is enough protection.

Not enough. There is no way to guarantee the HIV status of a partner. As many as one-third of men who have sex with men (MSM) newly diagnosed with HIV report having unprotected anal sex with only men they thought were HIV negative [1]. Many men who say they are negative may, in fact, have been infected since their last HIV test. Serosorting provides no protection against STDs other than HIV. HIV-positive men may also risk getting re-infected with other HIV strains.

Does serosorting reduce new infections?

It may, but it depends on whether serosorting replaces higher risk behaviors or safer behaviors. Increasing serosorting among HIV-positive men should help decrease the overall incidence of new HIV infections.

What do we know about HIV re-infection?

HIV re-infection or “superinfection” is when someone who already has HIV gets a second strain of HIV. It can be hard to prove whether this has taken place unless the strains are really different. Studies suggest that re-infection can occur anytime (even years) after the initial infection.

A new strain of HIV that is already resistant to some HIV drugs or entire classes of HIV drugs can be very hard to treat. People may develop AIDS more quickly. Public Health recommends that HIV-infected partners still use condoms or other ways to not share HIV during sex.

What about other STDs?

In King County, rates of syphilis and gonorrhea are still increasing among gay and bisexual men, and are particularly high among men with HIV. Any partner, regardless of HIV status, can have one or more STDs. Many STDs do not have symptoms or the symptoms may be hard to notice (in the rectum or throat). Serosorting for HIV does not protect against the other STDs.

What can reduce the risks of serosorting?

1.	Knowing HIV status. Men can be newly infected and wrongly assume they are still negative if they: do not notice or don’t even have symptoms of acute infection. While most newly-infected people will have symptoms, these can be mild and wrongly seen as the flu. test too early for antibodies to be detected. Standard HIV antibody testing has a “window period” after infection when there may not be enough antibodies for the test to detect. RNA or viral load testing looks for the actual HIV virus. It can provide an accurate HIV diagnosis sooner than antibody tests. RNA testing is routinely available for MSM at the STD clinic at Harborview. haven’t tested recently and rely on old test results.
	Transmission is up to 10 times more likely to occur in the early stages of HIV infection when viral loads are highest and men are least likely to know they are infected. Find current HIV/ STD screening guidelines for MSM.
2.	Disclosing HIV status. Serosorting depends on timely, honest and accurate disclosure. Unfortunately, many men don’t discuss their status with partners. Sometimes partners may misunderstand or misrepresent their true infection status.
3.	Using condoms. Men still need to use condoms to protect against STDs and exposure to other strains of HIV.

[1] Data from the STD Clinic at Harborview.

KEY MESSAGES

FOR ALL GAY AND BISEXUAL MEN

1.	Know your HIV status. All MSM outside of long-term, mutually monogamous relationships should test at least once a year. Men with any of the following risks should test every 3-6 months: Methamphetamine or poppers use Recent STD Unprotected anal sex with an HIV-positive man or man of unknown HIV status.
2.	Serosorting alone is not a perfect strategy. It’s better than no strategy at all, but there are pitfalls. Use as many strategies as possible (condoms, fewer sex partners, being a top if you’re negative and a bottom if you’re positive, choosing oral over anal sex, etc).
3.	*Serosorting depends on timely, honest* and accurate disclosure of HIV status.** Partners may tell you the wrong thing.
4.	Serosorting with condoms is much safer than serosorting without them.
5.	Condoms can protect against STDs and other strains of HIV.

FOR MEN WHO ARE HIV-NEGATIVE OR DON’T KNOW THEIR STATUS
1.	Serosorting alone does not completely protect you. Consistent condom use is much safer.
2.	If you’ve had unprotected anal sex or shared injection equipment since your last HIV test, you may have HIV and not know it. Get tested again.
3.	Your partner may not know his real status either, even if he seems certain.

FOR MEN WHO ARE HIV-POSITIVE
1.	Having sex only with other positives is preferable. This will protect your partners and your community. If you have *any* doubt about your partner’s status, use a condom.
2.	Serosorting does not protect you against other STDs. STDs may be more serious and difficult to treat with HIV present. Condoms protect against other STDs. Getting other strains of HIV may make HIV progress faster or result in drug resistance.