D is for disclosure, serosorting and sexual harm reduction

The Abstain-Be faithful-Condoms ‘ABC’ approach to HIV prevention does not work for a lot of people. Sexual abstention is a personal choice that may not be possible or desired and which few people maintain for life. Being faithful may be irrelevant if you are someone like a sex worker, or ineffective if your partner is not faithful. Using condoms may be impossible, due to unavailability or partners’ unwillingness to use them. Even if they can be used, for a variety of reasons mentioned above, many people find maintaining 100% use difficult. Circumcision is likely to provide most benefit to heterosexual men. Post-exposure prophylaxis (PEP) is an occasional emergency measure that is unlikely to make a difference to HIV prevalence in the population, though it may mean a lot to the individual.

For all these reasons, we need to develop other prevention methods against HIV. But with the exception of circumcision, significantly positive results, let alone widespread application, are still likely to be years away.

In their absence, people vulnerable to HIV or already infected are adopting a set of other strategies to reduce the risk of acquiring or transmitting the virus. These include:

• attempting to restrict sex or unprotected sex to people of the same HIV status (‘serosorting’ or ‘negotiated safety’),
• restricting unprotected sex to types of sex less likely to transmit the virus (‘strategic positioning’ and withdrawal),
• restricting unprotected sex to times when the positive partner has an undetectable viral load.

Taken together, these measures are sometimes called sexual harm reduction. One feature of them is that, unlike ABC, they also usually require two pre-existing conditions to be met for them to be effective:

a) people need to test for HIV and know their status, and

b) people need to disclose status and discuss it.