Serosorting is the practice of choosing sex partners or selectively using condoms based on a sex partner’s perceived HIV status. The extent to which serosorting protects African American (AA) and Hispanic men who have sex with men (MSM) is unknown.
We analyzed data collected from MSM STD clinic patients in Seattle, WA, 2001–10. Men were asked about the HIV status of their anal sex partners in the prior year and about their condom use with partners by partner HIV status. We defined serosorters as MSM who had unprotected anal intercourse (UAI) only with partners of the same HIV status, and compared the risk of testing HIV positive among serosorters and men who reported having UAI with partners of opposite or unknown HIV status (i.e. nonconcordant UAI). We used generalized estimating equations to evaluate the association of serosorting with testing HIV positive.
A total of 6694 MSM without a prior HIV diagnosis were tested during 13,657 visits; 274 men tested HIV positive. Serosorting was associated with a lower risk of testing HIV positive than nonconcordant UAI among white MSM (2.1 vs. 4.5%, OR 0.45 95% CI 0.34–0.61), but not AA MSM (6.8 vs. 6.0%, OR 1.1 95% CI 0.57–2.2). Among Hispanics, the risk of testing HIV positive was lower among serosorters than men engaging in nonconcordant UAI, though this was not significant (4.1 vs. 6.0%, OR 0.67 95% CI 0.36–1.2).
In at least some AA MSM populations, serosorting does not appear to be protective against HIV infection.
Among HIV-negative men who have sex with men (MSM), any incident of unprotected anal intercourse (UAI) between casual partners is usually regarded as risky for HIV transmission. However, men are increasingly using knowledge of their casual partner’s HIV-status to reduce HIV risk during UAI (i.e., serosorting). Since familiarity between casual partners may lead to higher levels of UAI and serosorting, we examined how often men have UAI and practice serosorting with three types of casual partnerships that differ in their degree of familiarity.
We included 240 HIV-negative men of the Amsterdam Cohort Study among MSM. We distinguished three types of casual partnerships: one-night stand (‘met by chance and had sex only once’); multiple-time casual partner (‘met and had sex with several times’); and the ‘regular’ casual partner (‘sex buddy’). Serosorting was defined as UAI with an HIV-concordant partner. GEE analyses were used to examine the association between type of casual partnership and sexual risk behaviour.
Analyses revealed that men with a sex buddy were more likely to have UAI than men with a one-night stand (OR[95%CI] 2.39 [1.39–4.09]). However, men with a sex buddy were also more likely to practice serosorting than men with a one-night stand (OR[95%CI] 5.20 [1.20–22.52]).
Men with a sex buddy had more UAI but also reported more serosorting than men with a one-night stand. As a result, the proportion of UAI without serosorting is lower for men with a sex buddy, and therefore men might have less UAI at risk for HIV with this partner type. However, the protective value of serosorting with a sex buddy against HIV transmission needs to be further established. At this time, we suggest that a distinction between the one-night stand and the sex buddy should be incorporated in future studies as men behave significantly different with the two partner types.
men who have sex with men; serosorting; sexual behaviour; risk reduction behaviour; types of casual partnerships; unprotected anal intercourse
Racial/ethnic minorities and men who have sex with men (MSM) represent populations with disparate sexually transmitted infection (STI) rates. While race-specific STI rates have been widely reported, STI rates among MSM is often challenging given the absence of MSM population estimates. We evaluated the race-specific rates of chlamydia and gonorrhea among MSM and non-MSM in San Francisco between 1999-2008.
2000 US Census data for San Francisco was used to estimate the number of African-American, Asian/Pacific Islander, Hispanic, and white males. Data from National HIV Behavioral Surveillance (NHBS) MSM 1, conducted in 2004, was used to estimate the total number of MSM in San Francisco and the size of race/ethnic sub-populations of MSM. Non-MSM estimates were calculated by subtracting the number of estimated MSM from the total number of males residing in San Francisco. Rates of MSM and non-MSM gonorrhea and chlamydia reported between 1999 and 2008 were stratified by race/ethnicity. Ratios of MSM and non-MSM rates of morbidity were calculated by race/ethnicity.
Between 1999-2008, MSM accounted for 72% of gonorrhea cases and 51% of chlamydia cases. Throughout the study period, African-American MSM had the highest chlamydia rate with 606 cases per 100,000 in 1999 increasing to 2067 cases per 100,000 in 2008. Asian/Pacific Islander MSM consistently had the lowest rate among MSM with1003 cases per 100,000 in 2008. The ratio of MSM/non-MSM for chlamydia was highest among whites 11.6 (95% CI: 8.8-14.4) and Asian/Pacific Islanders 8.6 (95% CI: 6.2-11), and lowest among African-Americans 1.53 (95% CI: 1.2-1.9) and Hispanics 4.43 (95% CI: 2.8-6.0). Gonorrhea rates were similar for African-American, white, and Hispanic MSM between 2137-2441 cases per 100,000 in 2008. Asian/Pacific Islander MSM had the lowest gonorrhea rate with 865 cases per 100,000 in 2008. The ratio of MSM/non-MSM for gonorrhea was highest among whites 11.6 (95% CI: 8.8-14.4) and Asian/Pacific Islanders 8.6 (95% CI: 6.2-11), and lowest among African-Americans 1.53 (95% CI: 1.2-1.9) and Hispanics 4.43 (95% CI: 2.8-6.0).
For all racial/ethnic groups in San Francisco, MSM carried a substantially higher burden of STIs compared to non-MSM except among African-American men. These racial and sexual behavior disparities warrant further public health attention and resources.
Objectives: A high incidence of HIV continues among men who have sex with men (MSM) in industrialised nations and research indicates many MSM do not disclose their HIV status to sex partners. Themes as to why MSM attending sexually transmitted infection (STI) clinics in Los Angeles and Seattle do and do not disclose their HIV status are identified.
Methods: 55 HIV positive MSM (24 in Seattle, 31 in Los Angeles) reporting recent STI or unprotected anal intercourse with a serostatus negative or unknown partner from STI clinics underwent in-depth interviews about their disclosure practices that were tape recorded, transcribed verbatim, coded, and content analysed.
Results: HIV disclosure themes fell into a continuum from unlikely to likely. Themes for "unlikely to disclose" were HIV is "nobody's business," being in denial, having a low viral load, fear of rejection, "it's just sex," using drugs, and sex in public places. Themes for "possible disclosure" were type of sex practised and partners asking/disclosing first. Themes for "likely to disclose" were feelings for partner, feeling responsible for partner's health, and fearing arrest. Many reported non-verbal disclosure methods. Some thought partners should ask for HIV status; many assumed if not asked then their partner must be positive.
Conclusions: HIV positive MSM's decision to disclose their HIV status to sex partners is complex, and is influenced by a sense of responsibility to partners, acceptance of being HIV positive, the perceived transmission risk, and the context and meaning of sex. Efforts to promote disclosure will need to address these complex issues.
Serosorting, the practice of selectively engaging in unprotected sex with partners of the same HIV serostatus, has been proposed as a strategy for reducing HIV transmission risk among men who have sex with men (MSM). However, there is a paucity of scientific evidence regarding whether women engage in serosorting. We analyzed longitudinal data on women’s sexual behavior with male partners collected in the Women’s Interagency HIV Study from 2001 to 2005. Serosorting was defined as an increasing trend of unprotected anal or vaginal sex (UAVI) within seroconcordant partnerships over time, more frequent UAVI within seroconcordant partnerships compared to non-concordant partnerships, or having UAVI only with seroconcordant partners. Repeated measures Poisson regression models were used to examine the associations between serostatus partnerships and UAVI among HIV-infected and HIV-uninfected women. The study sample consisted of 1,602 HIV-infected and 664 HIV-uninfected women. Over the follow-up period, the frequency of seroconcordant partnerships increased for HIV-uninfected women but the prevalence of UAVI within seroconcordant partnerships remained stable. UAVI was reported more frequently within HIV seroconcordant partnerships than among serodiscordant or unknown serostatus partnerships, regardless of the participant’s HIV status or types of partners. Among women with both HIV-infected and HIV-uninfected partners, 41% (63 HIV-infected and 9 HIV-uninfected) were having UAVI only with seroconcordant partners. Our analyses suggest that serosorting is occurring among both HIV-infected and HIV-uninfected women in this cohort.
HIV; Unprotected sex; Serosorting; Risk reduction; Condom use
Although efficacy is unknown, many men who have sex with men (MSM) attempt to reduce HIV risk by adapting condom use, partner selection, or sexual position to the partner’s HIV serostatus. We assessed the association of seroadaptive practices with HIV acquisition.
We pooled data on North American MSM from four longitudinal HIV-prevention studies. Sexual behaviors reported during each six-month interval were assigned sequentially to one of six mutually exclusive risk categories: (1) no unprotected anal intercourse (UAI), (2) having a single negative partner, (3) being an exclusive top (only insertive anal sex), (4) serosorting (multiple partners, all HIV negative), (5) seropositioning (only insertive anal sex with potentially discordant partners), and (6) UAI with no seroadaptive practices. HIV antibody testing was conducted at the end of each interval. We used Cox models to evaluate the independent association of each category with HIV acquisition, controlling for number of partners, age, race, drug use, and intervention assignment. 12,277 participants contributed to 60,162 six-month intervals with 663 HIV seroconversions. No UAI was reported in 47.4% of intervals, UAI with some seroadaptive practices in 31.8%, and UAI with no seroadaptive practices in 20.4%. All seroadaptive practices were associated with a lower risk, compared to UAI with no seroadaptive practices. However, compared to no UAI, serosorting carried twice the risk (HR = 2.03, 95%CI:1.51–2.73), whereas seropositioning was similar in risk (HR = 0.85, 95%CI:0.50–1.44), and UAI with a single negative partner and as an exclusive top were both associated with a lower risk (HR = 0.56, 95%CI:0.32–0.96 and HR = 0.55, 95%CI:0.36–0.84, respectively).
Seroadaptive practices appear protective when compared with UAI with no seroadaptive practices, but serosorting appears to be twice as risky as no UAI. Condom use and limiting number of partners should be advocated as first-line prevention strategies, but seroadaptive practices may be considered harm-reduction for men at greatest risk.
Surveillance data on sexually transmitted infections (STIs) and behavioral characteristics identified in studies of the risk of seroconversion are often used as to track sexual behaviors that spread HIV. However, such analyses can be confounded by “seroadaptation”—the restriction of unprotected anal intercourse (UAI), especially unprotected insertive UAI, to seroconcordant partnerships.
We utilized sexual network methodology and repeated-measures statistics to test the hypothesis that seroadaptive strategies reduce the risk of HIV transmission despite numerous partnerships and frequent UAI.
In a prospective cohort study of HIV superinfection including 168 HIV-positive men who have sex with men (MSM), we found extensive seroadaptation. UAI was 15.5 times more likely to occur with a positive partner than a negative one (95% confidence interval [CI], 9.1–26.4). Receptive UAI was 4.3 times more likely in seroconcordant partnerships than with negative partners (95% CI, 2.8–6.6), but insertive UAI was 13.6 times more likely with positives (95% CI, 7.2–25.6). Our estimates suggest that seroadaptation reduced HIV transmissions by 98%.
Potentially effective HIV prevention strategies, such as seroadaptation, have evolved in communities of MSM before they have been recognized in research or discussed in the public health forum. Thus, to be informative, studies of HIV risk must be designed to assess seroadaptive behaviors rather than be limited to individual characteristics, unprotected intercourse, and numbers of partners. STI surveillance is not an effective indicator of trends in HIV incidence where there are strong patterns of seroadaptation.
The incidences of reportable sexually transmitted infections (STI) among men who have sex with men (MSM) have increased since the late 1990 s in Norway. The objectives of our study were to assess factors, associated with recent selected STI among MSM, living in Norway in order to guide prevention measures.
We conducted a cross-sectional Internet-based survey during 1-19 October 2007 among members of a MSM-oriented Norwegian website using an anonymous questionnaire on demographics, sexual behaviour, drug and alcohol use, and STI. The studied outcomes were gonorrhoea, syphilis, HIV or Chlamydia infection in the previous 12 months. Associations between self-reported selected STI and their correlates were analysed by multivariable Poisson regression. P value for trend (p-trend), adjusted prevalence ratios (PR) with 95% confidence intervals  were calculated.
Among 2430 eligible 16-74 years old respondents, 184 (8%) reported having had one of the following: syphilis (n = 17), gonorrhoea (n = 35), HIV (n = 42) or Chlamydia (n = 126) diagnosed in the past 12 months. Reporting Chlamydia was associated with non-western background (PR 2.8 [1.4-5.7]), number of lifetime male partners (p-trend < 0.001), unsafe sex under the influence of alcohol (PR 1.8 [1.1-2.9]) and with younger age (p-trend = 0.002). Reporting gonorrhoea was associated with unrevealed background (PR 5.9 [1.3-26.3]), having more than 50 lifetime male partners (PR 4.5 [1.3-15.6]) and more than 5 partners in the past 6 months (PR 3.1 [1.1-8.8]), while mid-range income was protective (PR 0.1 [0.0-0.6]). Reporting HIV was associated with residing in Oslo or Akershus county (PR 2.3 [1.2-4.6]), non-western background (PR 5.4 [1.9-15.3]), unrevealed income (PR 10.4 [1.5-71.4]), number of lifetime male partners (p-trend < 0.001) and being under the influence of selected drugs during sex in the past 12 months (PR 5.2 [2.7-11.4]). In addition, the frequency of feeling drunk was reversibly associated with HIV.
Our study demonstrates different associations of demographic and behavioural factors with different STI outcomes in the study population. Number of lifetime male partners was the most important potential predictor for Chlamydia and HIV. The STI prevention efforts among MSM should focus on Oslo and Akershus, promote safe sex practices and tackle sex-related drug and alcohol use.
HIV seroadaptive behaviours such as serosorting and strategic positioning are being increasingly practised by homosexual men, however, their impact on sexually transmissible infections (STIs) is unclear.
Participants were 1,427 initially HIV-negative men enrolled from 2001 to 2004 and followed to June 2007. Participants were tested annually for anal and urethral gonorrhoea and chlamydia, herpes simplex virus, and syphilis. In addition, they reported diagnoses of these conditions, and of genital and anal warts between annual visits, and sexual risk behaviours.
Compared with men who reported no unprotected anal intercourse (UAI), serosorting was associated with an increased risk of urethral (HR=1.97, 95% CI 1.43–2.72) and anal (HR=1.62, 95% CI 1.11–2.36) chlamydia. Compared with men who reported UAI with HIV non-concordant partners, men who practised serosorting had significantly lower risk of incident syphilis (HR=0.21, 95% CI 0.05–0.81) and urethral gonorrhoea (HR=0.61, 95% CI 0.39–0.96). Compared with men who reported no UAI, strategic positioning was associated with an increased risk of urethral gonorrhoea (HR=1.72, 95% CI 1.05–2.83) and chlamydia (HR=2.22, 95% CI 1.55–3.18). Compared with men who reported receptive UAI, the incidence of anal gonorrhoea (HR=0.38, 0.20–0.74) and chlamydia (HR= 0.44, 95% CI 0.27–0.69) was significantly lower in those who practised strategic positioning.
For men who reported seopadaptive behaviours, rates of some bacterial STIs were higher than in men who reported no UAI. However, rates were lower than for men who reported higher HIV risk behaviours.
Cohort study; STI; Homosexuality; male; HIV seroadaptive behaviour; Australia
Seroadaptive behaviors have been widely described as preventive strategies among men who have sex with men (MSM) and other populations worldwide. However, causal links between intentions to adopt seroadaptive behaviors and subsequent behavior have not been established. We conducted a longitudinal study of 732 MSM in San Francisco to assess consistency and adherence to multiple seroadaptive behaviors, abstinence and condom use, whether prior intentions predict future seroadaptive behaviors and the likelihood that observed behavioral patterns are the result of chance. Pure serosorting (i.e., having only HIV-negative partners) among HIV-negative MSM and seropositioning (i.e., assuming the receptive position during unprotected anal sex) among HIV-positive MSM were more common, more successfully adhered to and more strongly associated with prior intentions than consistent condom use. Seroconcordant partnerships occurred significantly more often than expected by chance, reducing the prevalence of serodiscordant partnerships. Having no sex was intended by the fewest MSM, yet half of HIV-positive MSM who abstained from sex at baseline also did so at 12 month follow-up. Nonetheless, no preventive strategy was consistently used by more than one-third of MSM overall and none was adhered to by more than half from baseline to follow-up. The effectiveness of seroadaptive strategies should be improved and used as efficacy endpoints in trials of behavioral prevention interventions.
Men who have sex with men; Serosorting; HIV
There is evidence that methamphetamine and sildenafil (Viagra) use are associated with sexual risk behaviour among men who have sex with men (MSM). We investigated the association of methamphetamine, sildenafil, and other substance use with unprotected receptive and insertive anal sex among MSM by conducting an encounter specific analysis.
Data were from a cross sectional, community based survey of MSM in San Francisco regarding behaviour during their most recent anal sex encounter. Mulitvariate regression analysed independent associations of specific substance use and demographic variables with unprotected anal sex behaviours.
The sample (n = 388) was diverse in race/ethnicity, age, income, education, HIV status, and homosexual/bisexual identification. More than half (53%) reported unprotected anal sex, including insertive (29%) and receptive (37%) during their most recent anal sex encounter; 12% reported unprotected insertive and 17% reported unprotected receptive anal sex with an HIV discordant or unknown partner. Methamphetamine was used by 15% and sildenafil was used by 6% of the men before or during the encounter; 2% used both drugs. In multivariate analysis controlling for demographic factors and other substance use, methamphetamine use was associated with unprotected receptive (odds ratio (OR), 2.03; 95% confidence interval (CI), 1.09 to 3.76) and sildenafil use was associated with unprotected insertive (OR, 6.51; CI, 2.46 to 17.24) anal sex. Effects were stronger with HIV discordant or unknown sex partners specifically.
Encounter specific associations of methamphetamine and sildenafil use with unprotected receptive and insertive anal sex, respectively, indicate the importance of assessment specificity and tailoring risk reduction efforts to address certain drugs and sexual behavioural roles among MSM.
MSM; sexual risk; sildenafil; Viagra; methamphetamine
Men who have sex with men (MSM) are the largest HIV risk-group in the United States. Sexual concurrency may contribute to high HIV incidence, or to racial/ethnic HIV disparities among MSM. Limited information is available on concurrency and racial/ethnic differences among MSM, or on the extent to which MSM engage in concurrent unprotected anal intercourse (UAI).
Data are from baseline responses in a prospective online study of MSM aged ≥ 18 years, having ≥ 1 male sex partner in the past 12 months, and recruited from social networking websites. Pair-wise sexual concurrency and UAI in the previous 6 months among up to 5 recent partners was measured, using an interactive questionnaire. Period prevalences of concurrency and concurrent UAI were computed and compared across racial/ethnic groups at the individual and triad (a respondent and 2 sex partners) levels.
2,940 MSM reported on 8,911 partnerships; 45% indicated concurrent partnerships and 16% indicated concurrent UAI in the previous 6 months. Respondents were more likely to have UAI with two partners when they were concurrent, compared to serially monogamous (OR [95% CI] = 1.93 [1.75, 2.14]). No significant differences in levels of individual concurrency or concurrency among triads were found between non-Hispanic white, non-Hispanic black, and Hispanic men.
Concurrency and concurrent UAI in the previous 6 months was common. Although there were no differences by race/ethnicity, the high levels of concurrency and concurrent UAI may be catalyzing the transmission of HIV among MSM in general.
Concurrency; MSM; sexual networks; UAI; racial disparities
Black men who have sex with men (MSM) are disproportionately affected with HIV in the US. Limited event-specific data have been reported in Black MSM to help understand factors associated with increased risk of infection. Cross-sectional National HIV Behavioral Surveillance Study data from 503 MSM who reported ≥1 male sexual partner in the past year in New York City (NYC) were analyzed. Case-crossover analysis compared last protected and last unprotected anal intercourse (UAI). A total of 503 MSM were enrolled. Among 349 tested for HIV, 18% were positive. Black MSM (N = 117) were more likely to test HIV positive and not know their HIV-positive status than other racial/ethnic groups. Case-crossover analysis of 208 MSM found that men were more likely to engage in protected anal intercourse with a first time partner and with a partner of unknown HIV status. Although Black MSM were more likely to have Black male partners, they were not more likely to have UAI with those partners or to have a partner aged >40 years. In conclusion, HIV prevalence was high among Black MSM in NYC, as was lack of awareness of HIV-positive status. Having a sexual partner of same race/ethnicity or older age was not associated with having UAI among Black MSM.
HIV infection; Sexual partnering; Black men who have sex with men; African American; Unprotected anal intercourse
We assessed changes in sexual behavior among men who have sex with men (MSM), before and for several years after HIV diagnosis, accounting for adoption of a variety of seroadaptive practices.
We collected self-reported sexual behavior data every 3 months from HIV-positive MSM at various stages of HIV infection. To establish population level trends in sexual behavior, we used negative binomial regression to model the relationship between time since diagnosis and several sexual behavior variables: numbers of (a) total partners, (b) potentially discordant partners (PDP; i.e., HIV-negative or unknown-status partners), (c) PDPs with whom unprotected anal intercourse (UAI) occurred, and (d) PDPs with whom unprotected insertive anal intercourse (uIAI) occurred.
A total of 237 HIV-positive MSM contributed 502 interviews. UAI with PDPs occurred with a mean of 4.2 partners in the 3 months before diagnosis. This declined to 0.9 partners/3 months at 12 months after diagnosis, and subsequently rose to 1.7 partners/3 months at 48 months, before falling again to 1.0 partners/3 months at 60 months. The number of PDPs with whom uIAI occurred dropped from 2.4 in the pre-diagnosis period to 0.3 partners/3 months (an 87.5% reduction) by 12 months after enrollment, and continued to decline over time.
Within months after being diagnosed with HIV, MSM adopted seroadaptive practices, especially seropositioning, where the HIV-positive partner was not in the insertive position during UAI, resulting in a sustained decline in the sexual activity associated with the highest risk of HIV transmission.
HIV continues to disproportionately affect men who have sex with men (MSM). As a result of the impact of HIV among MSM, multiple strategies for reducing HIV risks have emerged from within the gay community. One common HIV risk reduction strategy is to limit unprotected sex partners to those who are of the same HIV status, or to serosort. Although serosorting is commonly practiced for risk reduction, it is closely linked to HIV transmission because of infrequent HIV testing, lack of HIV status disclosure, sexually transmitted infections, and acute HIV infection.
The current study tested a novel, brief, one-on-one, peer counselor-delivered intervention based on informed decision making, to address the limitations of serosorting. One hundred forty nine at-risk men were recruited and randomly assigned to an intervention condition addressing serosorting or a standard-of-care control.
Men in the serosorting intervention reported fewer sexual partners (Wald X2=8.79,p=<.01) at study follow-ups.
Addressing risks associated with serosorting in a feasible, low -cost intervention has the potential to significantly impact the HIV epidemic.
We investigated the influence of partner-provided HIV-specific and general social support on the sexual risk behavior of gay male couples with concordant, discordant, or serostatus unknown outside partners. Participants were 566 gay male couples from the San Francisco Bay Area. HIV-specific social support was a consistent predictor for reduced unprotected anal intercourse (UAI) with both concordant outside partners (all couple types) and outside partners of discordant or unknown serostatus (concordant negative and discordant couples). General social support was associated with increased UAI with concordant outside partners for concordant negative and concordant positive couples (i.e., serosorting). Our findings suggest that prevention efforts should target couples and identify the level of HIV-specific support that partners provide. Partner-provided support for HIV-related behaviors could be an additional construct to consider in gay male relationships, akin to relationship satisfaction and commitment, as well as an important component of future HIV prevention interventions.
HIV-specific social support; social support; gay male couples; sexual risk behavior
We investigated the influence of partner-provided HIV-specific and general social support on the sexual risk behavior of gay male couples with concordant, discordant, or serostatus-unknown outside partners. Participants were 566 gay male couples from the San Francisco Bay Area. HIV-specific social support was a consistent predictor for reduced unprotected anal intercourse (UAI) with both concordant outside partners (all couple types) and outside partners of discordant or unknown serostatus (concordant negative and discordant couples). General social support was associated with increased UAI with concordant outside partners for concordant negative and concordant positive couples (i.e., serosorting). Our findings suggest that prevention efforts should target couples and identify the level of HIV-specific support that partners provide. Partner-provided support for HIV-related behaviors could be an additional construct to consider in gay male relationships, akin to relationship satisfaction and commitment, as well as an important component of future HIV prevention interventions.
Electronic supplementary material
The online version of this article (doi:10.1007/s10461-010-9868-8) contains supplementary material, which is available to authorized users.
HIV-specific social support; Social support; Gay male couples; Sexual risk behavior
The purpose of the current study was to assess whether or not men who have sex with men who limit their unprotected anal sexual partners to those who are of the same HIV status (serosort) differ in their risk for HIV transmission than MSM who do not serosort.
Cross-sectional surveys administered at a large gay pride festival (80% response rate) were collected from MSM. Univariate and multivariate logistic regressions were used to identify predictors of serosorting.
Participants were self-identified as HIV negative MSM (N=628), about one third of whom engaged in serosorting (n=229). Men who serosort were more likely to believe that serosorting offered protection against HIV transmission, perceived themselves as being at no relatively higher risk for HIV transmission, and had more unprotected anal intercourse partners. Over half the sample reported their frequency of HIV testing as yearly or less frequently; this finding did not differ between serosorters and non-serosorters.
Men who identify as HIV negative and serosort are no more likely to know their HIV status than men who do not serosort and are at higher risk for exposure to HIV. Interventions targeting MSM must address the limitations of serosorting.
A common HIV/AIDS risk reduction strategy among men who have sex with men (MSM) is to limit their unprotected sex partners to those who are of the same HIV status, a practice referred to as serosorting. Decisions to serosort for HIV risk reduction are based on personal impressions and beliefs, and there is limited guidance offered on this community derived strategy from public health services. This paper reviews research on serosorting for HIV risk reduction and offers an evidence-based approach to serosorting guidance. Following a comprehensive electronic and manual literature search, we reviewed 51 studies relating to the implications of serosorting. Studies showed that HIV negative MSM who select partners based on HIV status are inadvertently placing themselves at risk for HIV. Infrequent HIV testing, lack of HIV status disclosure, co-occurring STIs, and acute HIV infection impede the potential protective benefits of serosorting. Public health messages should continue to encourage reductions in numbers of sexual partners and increases in condom use. Risk reduction messages should also highlight the limitations of relying on one’s own and partner’s HIV status in making sexual risk decisions.
serosorting; acute infection; HIV testing; prevention messages
Sexually transmitted infections (STIs) have increased among men who have sex with men (MSM) and are associated with unsafe sex practices, intrinsic morbidity, and enhanced genital shedding and transmission of HIV. Screening for asymptomatic STIs is recommended as part of the HIV prevention efforts, however, optimal screening strategies among HIV-infected MSM have not been well defined. In this study, conducted from April 2004 to September 2006, 212 HIV-infected MSM from two urban HIV clinics were screened for asymptomatic STIs. Testing for Neisseria gonorrhea and Chlamydia trachomatis from pharynx, rectum, and urine, as well as serologic testing for syphilis were performed initially, and then after 6 and 12 months. A self-administered questionnaire was used to assess possible predictors of incident asymptomatic STIs. A cost analysis was performed to assess different screening strategies for detecting incident STIs. The baseline prevalence of STIs was 14% (n = 29; 95% confidence interval [CI] 9%–19%) and the incidence of new infections was 20.8 cases per 100 person years (95% CI 14.8–28.4 cases per 100 person years). Younger age, higher CD4 cell count, and marijuana use were associated with increased risk of acquiring an asymptomatic STI. The laboratory cost to detect one positive STI did not significantly differ between once- and twice-yearly screening. However, almost half of all incident STIs were detected at the 6-month screening visit, potentially resulting in an increased duration of infectivity if these cases remained undiagnosed. In conclusion, prevalent and incident asymptomatic STIs are common among HIV-infected MSM. Our data support current Center for Disease Control and Prevention STI guidelines that recommend routine screening at increased frequency for HIV-infected MSM.
Condom use problems are common amongst Scotland’s men who have sex with men (MSM). To date condom errors have been associated with the likelihood of sexually transmitted infections in heterosexual sexually transmitted infection (STI) clinic attendees but not in MSM and direct evidence of a link between condom problems and STI acquisition in MSM have been lacking. This study investigated the possibility of an independent association between condom proficiency, condom problems and STI acquisition in MSM in Scotland.
An exploratory observational design employed cross-sectional surveys in both STI clinic and community settings. Respondents completed self-report measures of socio-demographic variables, scales of condom proficiency and condom problems and numbers of different partners with whom men have had unprotected anal intercourse (UAI partners) in the preceding year. Self-report data was corroborated with clinical STI diagnosis where possible. Analysis included chi-squared and Mann–Whitney tests and multiple logistic regression.
792 respondents provided data with an overall response rate of 70% (n = 459 clinic sample, n = 333 community sample). Number of UAI partners was the strongest predictor of self-reported STI acquisition over the previous 12 months (p < 0.001 in both clinic and community samples). Demographic characteristics were not associated with self-reported STI diagnosis. However, condom proficiency score was associated with self-reported STI acquisition (p < 0.05 in both samples). Condom problem score was also associated with self-reported STI diagnosis in the clinic (p = 0.001) but not the community sample. Condom problem score remained associated with self-reported STI diagnosis in the clinic sample after adjusting for number of UAI partners with logistic regression.
This exploratory study highlights the potential importance of targeted condom use skills interventions amongst MSM. It demands further research examining the utility of condom problem measures in wider populations, across prospective and experimental research designs, and a programme of research exploring their feasibility as a tool determining candidacy for brief interventions.
Condom skills; Men who have sex with men; Sexually transmitted infections; Condom problems; Condom proficiency; Condom measures
This study sought to identify predictors of HIV disclosure and serodiscordant unprotected anal intercourse (SDUAI) among HIV-positive men who have sex with men (MSM). Between January 2005 and April 2006, 675 HIV-positive MSM were recruited into the Positive Connections intervention trial held in six US cities with intentional over-sampling of HIV-positive MSM of Color (74%) and men engaging in unprotected anal intercourse (UAI) in the previous year. Baseline survey data showed 30 and 31%, respectively, of participants disclosed to none or some of their secondary sex partners in the last 90 days. Greater disclosure to secondary partners was associated with having fewer sexual partners, being extremely out as MSM, longer HIV diagnosis, knowledge of CD4 count, detectable viral load and being white. Disclosure to all secondary partners was associated with lower SDUAI. Recommendations for prevention for HIV-positive MSM include the promotion of serodisclosure to all secondary partners and increasing comfort with, and outness about, one’s sexuality.
HIV positive; serodisclosure; men who have sex with men; men of Color; sexual risk
Background: South Africa has one of the fastest growing HIV epidemics in the world and new infections may often result from people who have tested HIV positive. This study examined the sexual practices and risk behaviours of men and women living with HIV/AIDS being treated for a co-occurring sexually transmitted infection (STI). Methods: A sample of men and women receiving services at three South African STI clinics completed a computer administered behavioural assessment. Results: Among the 218 HIV positive STI clinic patients, 34 (16%) had engaged in unprotected vaginal or anal intercourse with uninfected or unknown HIV status sex partners in the previous month. A multivariate logistic regression indicated that unprotected sex with uninfected or unknown HIV status partners was independently associated with older age, female gender, alcohol use, and other drug use, and drug use in sexual contexts. Conclusions: People living with HIV/AIDS who contract co-occurring STI are at significant risk for transmitting HIV to uninfected partners. Positive prevention interventions are urgently needed for South Africa.
HIV/AIDS; HIV infectiousness; positive prevention; sexually transmitted infections.
With young men who have sex with men (YMSM) continuing to be disproportionately affected by the HIV/AIDS epidemic in the U.S., secondary prevention efforts with this population take on increasing significance. We surveyed 200 HIV-positive YMSM (ages 16–24, 66% Black, 18% Latino, 7% White, 7% Multiracial/Other) recruited from 14 HIV primary care sites to examine associations of unprotected anal intercourse (UAI) and partner HIV status with endorsement of serosorting, sexual positioning, and viral load beliefs. Proportions of participants engaging in UAI one or more times during the past three months were consistent across type of UAI (insertive or receptive) and partner status. Belief that an undetectable viral load reduces infectiousness was significantly associated with insertive UAI (p<.05) and receptive UAI (p<.05) with HIV-negative or unknown-status partners and receptive UAI with HIV-positive partners (p<.01). Endorsement of belief in serosorting was significantly associated with receptive UAI (p<.01) and insertive UAI (p<.05) with HIV-positive male partners. Implications for sexual behavior and risk reduction beliefs in this population are discussed.
Young men who have sex with men (YMSM); HIV-positive; risk reduction; secondary prevention; serosorting
This study was designed to examine the impact of HIV treatment optimism on sexual risk among a racially diverse sample of HIV-positive MSM. Survey data were collected from 346 racially diverse HIV-positive MSM. Inclusion criteria: 18 years of age, male, at least one incident of unprotected anal intercourse (UAI) in the last year, currently on treatment. Other variables included demographics, sexual risk, depression, internalized homonegativity, HIV treatment history, alcohol/drug use and beliefs about HIV treatments (Susceptibility to transmit HIV, Severity of HIV infection and Condom Motivation). Those with lower income were more likely to report that HIV was less transmissible. A self-reported decrease in condom motivation was associated with being White, well-educated and increased alcoho/drug use. A decrease in Severity of HIV was associated with better mental health, being non-White and undetectable viral load. Sexual risk appears related to beliefs about how treatment affects the transmissibility of HIV. Race, socioeconomic status, alcoho/drug use, mental health and viral load were also associated with treatment beliefs.