In a separate article, published in AIDS & Behavior in December, Jason Mitchell has also reported
on the risk-reduction strategies employed by this group of men, both inside and
outside of their primary relationships.
He was interested in strategies such as serosorting,
strategic positioning, 100% condom use and taking undetectable viral load into
This analysis is especially interesting because Mitchell
actually asked respondents whether they had used strategies to reduce their
risk of HIV or sexually transmitted infections. In contrast, most other studies
on this topic have examined the pattern of men’s sexual practices with partners
of different HIV statuses, and attempted to infer whether there was a strategy
in place or not.
It therefore hasn’t been clear from previous research whether the
conscious and deliberate use of strategies such as strategic positioning is
something widely practiced by gay men, or just a minority pursuit.
For this couple-based analysis, those couples in which both
partners had diagnosed HIV were excluded. Participants were asked about
strategies used in the last previous three months – they could name more than
one strategy, either because strategies were combined, or because different
strategies were used in different situations.
Always using condoms for anal sex, or always doing so with
an HIV-positive partner, was reported by a minority of men. Within the main
relationship, 15% of HIV-negative couples (i.e. in which both partners thought
they were negative) always used condoms, rising to 38% of serodifferent couples
(i.e. in which one partner had HIV and the other did not).
When having sex outside the relationship, 38% of men always
used a condom for anal sex.
Only having oral sex and never anal sex was reported, for
the main relationship, by 23% of HIV-negative couples and 31% of serodifferent
couples. This strategy was more commonly reported for sex with casual partners
– by 51% of men.
'Serosorting' (having unprotected anal intercourse [UAI] with a partner
because he was thought to have the same HIV status) was reported by 66% of
HIV-negative couples. Moreover, this was also reported for sex with casual
partners, by 27% of men.
‘Strategic positioning’ (only having UAI with the
HIV-positive partner in the receptive role) was reported, for the main
relationship, by 32% of serodifferent couples. During casual sex, it was also
reported by 23% of men.
Having unprotected sex because the HIV-positive partner was
either taking HIV treatment or had an undetectable viral load was reported by
24% of serodifferent couples.
It was much less commonly employed as a strategy with casual
partners – by 1% of men in an HIV-negative couple and 14% of men in a
Finally, it’s important to note that a significant
proportion of men did not have a risk-reduction strategy at all, especially
with their main partner. One of the answers men could choose was ‘‘regardless
of HIV-status, we never use condoms and ejaculate inside’’.
For their primary relationship, 24% of HIV-negative couples
and 22% of serodifferent couples chose this answer. It was also chosen by 9% of
men having sex outside the relationship.
Overall, having unprotected sex within the main relationship (in the last three months) was
reported by 87% of HIV-negative couples and 69% of serodifferent couples.
Moreover, for 16% of couples, there had been unprotected sex both with the main
partner and at least one casual partner during the same time frame.