basic building blocks of HIV prevention - abstinence, monogamy and condoms - do
not work for many people who are vulnerable to acquiring or transmitting HIV.
continued absence of other effective methods of reducing their risk, some people
in the vulnerable communities have adopted a set of personal strategies to
reduce risk which between them may be called ‘sexual harm reduction’ (SHR) by
analogy with harm-reduction-based policies in injecting drug users.
building blocks of SHR include:
- attempting to restrict sex or unprotected sex
to people of the same HIV status (‘serosorting’ or ‘negotiated safety’)
unprotected sex to types of sex less likely to transmit the virus (‘strategic
positioning’ and withdrawal)
unprotected sex with HIV-positive partners to people who have an undetectable
strategy is considered separately in HIV treatment as prevention.
harm-reduction methods that take one’s own and one’s partners’ HIV status into
account have also been called ‘seroadaptation’.
feature of sexual harm reduction is that, unlike ‘ABC’ (abstain, be faithful,
use a condom), these strategies also usually require two pre-existing
conditions to be met for them to be effective:
need to test frequently enough for HIV to know their status accurately
need to disclose their HIV status and discuss it.
extent to which people adopt these methods and whether they contribute to
reducing HIV transmission, have no effect or even exacerbate it are very
unclear, and evidence is often indirect or inferred. Even the degree of use of
these strategies by gay men, the community in which serosorting was first
investigated, is hard to establish. Different studies come up with very
different answers as to whether, for instance, gay men take viral load into
question when making decisions about condom use.
instance, in a qualitative study from Australia in the year 2000,1 the researchers found that considerations of viral load, strategic positioning
and withdrawal were already well integrated into gay men’s attempt to reduce
the risk of HIV.
contrast, in a qualitative survey of HIV-positive gay men conducted by Sigma Research in the UK, Relative Safety II, which was published in 2009,2
the researchers comment that: “Not one respondent described attending to the
duration of anal intercourse, or to their own or their partner’s viral load, as
a means of reducing the risk of HIV transmission”.
number of men who serosorted was rather different: in this survey, about
one-fifth of respondents reported always disclosing their status before sex and
using serosorting as a method of sexual harm reduction:
“I would rather go
with somebody and say ‘Right I am HIV positive, you are HIV positive, let’s do
bareback sex…You know it’s done and dusted in like two minutes and there is
none of all that which goes with it all and that ‘Oh I don’t want to do this
and I can’t do that’. Have it out in the open and move on from that and just
have good sex and then if you decide to meet again it’s a bonus. It’s as simple
however, other gay men relied on unreliable strategies such as inferring partners’
status from their behaviour:
You said that a lot
of the guys you have sex with are positive. How do you know they are positive? “Because they wouldn’t fuck without a condom otherwise
would they? If I say ‘Can you use a condom?’, and I have told them, you know,
that I am positive... I have had guys saying ‘Do you bareback?’, and I think,
‘well bareback, you know, he must be positive. If he wants to bareback me then
fine. It’s no skin off my nose’.”
Part of the difficulty, then, in researching
strategies like serosorting is that some strategies intended to reduce risk may
be ineffective or even harmful. Another part of the difficulty is that
respondents in surveys may not view such behaviours as socially approved, and
may assume that researchers regard such attempts to minimise harm as a failure
to maintain safer sex. As a result, respondents’ use of such strategies may not
be volunteered unless specifically asked about.