The implications of partner selection strategies for HIV prevention differ for persons who have tested HIV positive versus those who have tested HIV negative. For HIV positive persons and their HIV positive partners, who are able to openly and accurately disclose their HIV status, serosorting under these circumstances eliminates the risks for new HIV infections. However, it is essential that disclosure be explicit rather than implicit, and that both HIV positive partners be aware of the risks to their health posed by co-infection with other STI and potentially superinfection. Furthermore, condom use remains the most effective option for protecting one’s health. For individuals who have tested HIV negative, there is a protective value in serosorting when it is practiced under limited conditions. For couples who test HIV negative within the context of a mutually monogamous relationship, engaging in unprotected intercourse poses little or no risk for HIV infection.
However, for HIV negative MSM who have concurrent or multiple sex partners, serosorting possesses limitations that impede its potential for risk reduction. HIV status of sex partners is often assumed rather than openly discussed, HIV testing is typically infrequent, and considerable risk for HIV since last test is commonly reported. It is important to highlight that HIV testing is insufficient for providing protective knowledge of HIV status when risk behavior continues. Given that risk behaviors may actually increase with serosorting coupled with the biological sequelae of acute infections, it is unlikely that HIV negative MSM who serosort could ever test for HIV frequently enough for testing to provide protection against HIV infection.
Although serosorting appears to be flawed for preventing HIV infection among HIV negative MSM, combing this practice with other measures of prevention may offer opportunities for HIV risk reduction. By serosorting MSM are clearly seeking to meet sexual needs while protecting themselves from HIV. Serosorting combined with strategies such as condom use, strategic positioning, early withdrawal, and negotiated safety may assist MSM in taking rational and calibrated risks, a concept referred to as seroadapting (Le Talec and Jablonski, 2008
). Although, with the exception of condom use, these methods alone are probably not highly effective, together they may lead to overall reductions in risk.
Content for interventions that focus on serosorting should emphasize the necessity of explicit HIV status disclosure discussions, including emphasizing errors in assuming own or partner’s HIV status. In particular, stressing that implicit disclosure is not disclosure. For HIV negative MSM who have multiple partners, condom use continues to be the most viable option for preventing HIV transmission and its importance needs to remain a clear message in behavioral interventions. HIV negative individuals who choose serosorting and not condom use as their means for reducing risks for HIV infection must recognize the importance of mutually monogamous relationships for protection against HIV. Additionally, within an intervention context, consideration needs to be given to the fact that some MSM who engage in serosorting will not be familiar with the term or even identify with the term.
From this review, we posit that public health messages pertaining to serosorting include clear statements regarding the difficulty of men who maintain high risk practices to ever test often enough for HIV to know they are not infected. HIV testing must be considered a medical diagnostic rather than an HIV prevention strategy. The ineffectiveness of HIV negative serosorting alone for HIV prevention further illustrates the pressing need for effective risk reduction counseling.
Limitations to this review include the challenges associated with summarizing studies from multiple literature domains. However, this process was necessary to fully appreciate and explore the many characteristics of serosorting that affect its effectiveness as an HIV prevention strategy. These challenges include having to cover a broad spectrum of research in areas relating to public health, psychology, and biology, and identifying information most relevant to serosorting. Moreover, given that serosorting occurs within a broader context of risk reduction strategies and risk behavior, it is difficult to ascertain the absolute effectiveness of serosorting. Finally, to better understand risk taking among ethnic minority MSM, further studying of their partner selection strategies is warranted.
Given the continued high rates of HIV infection among MSM, it is critical that public health service providers and the prevention messages they deliver continue to promote condom use when engaging in anal intercourse or alternatives to UAI. Serosorting among HIV negative men should be discouraged as the sole means of reducing HIV transmission risks. Addressing the limitations of using serosorting for protection against HIV is critical and may prevent further spread of HIV infection among MSM.