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1.  A novel approach to prevention for at-risk HIV negative men who have sex with men: Creating a teachable moment to promote informed sexual decision making 
American journal of public health  2011;101(3):539-545.
Objectives
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.
Methods
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.
Results
Men in the serosorting intervention reported fewer sexual partners (Wald X2=8.79,p=<.01) at study follow-ups.
Discussion
Addressing risks associated with serosorting in a feasible, low -cost intervention has the potential to significantly impact the HIV epidemic.
doi:10.2105/AJPH.2010.191791
PMCID: PMC3036682  PMID: 21233441
2.  Serosorting Sexual Partners and Continued Risk for HIV Transmission among Men who have Sex with Men 
Objective
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1016/j.amepre.2007.08.004
PMCID: PMC3151147  PMID: 18022064
3.  Failure of Serosorting to Protect African American Men Who Have Sex with Men from HIV Infection 
Sexually transmitted diseases  2012;39(9):659-664.
Background
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.
Methods
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.
Results
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).
Conclusions
In at least some AA MSM populations, serosorting does not appear to be protective against HIV infection.
doi:10.1097/OLQ.0b013e31825727cb
PMCID: PMC3424487  PMID: 22902660
4.  HIV Transmission Risk among HIV Seroconcordant and Serodiscordant Couples: Dyadic Processes of Partner Selection 
AIDS and behavior  2008;13(2):185-195.
Selecting sex partners of the same HIV status or serosorting is a sexual risk reduction strategy used by many men who have sex with men. However, the effectiveness of serosorting for protection against HIV is potentially limited. We sought to examine how men perceive the protective benefits of factors related to serosorting including beliefs about engaging in serosorting, sexual communication, and perceptions of risk for HIV. Participants were 94 HIV negative seroconcordant (same HIV status) couples, 20 HIV serodiscordant (discrepant HIV status) couples, and 13 HIV positive seroconcordant (same HIV status) couples recruited from a large gay pride festival in the southeastern US. To account for nonindependence found in the couple-level data, we used multilevel modeling which includes dyad in the analysis. Findings demonstrated that participants in seroconcordant relationships were more likely to believe that serosorting reduces concerns for condom use. HIV negative participants in seroconcordant relationships viewed themselves at relatively low risk for HIV transmission even though monogamy within relationships and HIV testing were infrequent. Dyadic analyses demonstrated that partners have a substantial effect on an individual’s beliefs and number of unprotected sex partners. We conclude that relationship partners are an important source of influence and, thus, intervening with partners is necessary to reduce HIV transmission risks.
doi:10.1007/s10461-008-9480-3
PMCID: PMC2937197  PMID: 18953645
HIV; serosorting; MSM; dyad; multilevel modeling
5.  Serosorting Is Associated with a Decreased Risk of HIV Seroconversion in the EXPLORE Study Cohort 
PLoS ONE  2010;5(9):e12662.
Background
Seroadaptation strategies such as serosorting and seropositioning originated within communities of men who have sex with men (MSM), but there are limited data about their effectiveness in preventing HIV transmission when utilized by HIV-negative men.
Methodology/Principal Findings
Data from the EXPLORE cohort of HIV-negative MSM who reported both seroconcordant and serodiscordant partners were used to evaluate serosorting and seropositioning. The association of serosorting and seropositioning with HIV seroconversion was evaluated in this cohort of high risk MSM from six U.S. cities. Serosorting was independently associated with a small decrease in risk of HIV seroconversion (OR = 0.88; 95%CI, 0.81–0.95), even among participants reporting ≥10 partners. Those who more consistently practiced serosorting were more likely to be white (p = 0.01), have completed college (p = <0.0002) and to have had 10 or more partners in the six months before the baseline visit (p = 0.01) but did not differ in age, reporting HIV-infected partners, or drug use. There was no evidence of a seroconversion effect with seropositioning (OR 1.02, 95%CI, 0.92–1.14).
Significance
In high risk HIV uninfected MSM who report unprotected anal intercourse with both seroconcordant and serodiscordant partners, serosorting was associated with a modest decreased risk of HIV infection. To maximize any potential benefit, it will be important to increase accurate knowledge of HIV status, through increased testing frequency, improved test technology, and continued development of strategies to increase disclosure.
doi:10.1371/journal.pone.0012662
PMCID: PMC2936578  PMID: 20844744
6.  Sexual Serosorting among Women with or at Risk of HIV Infection 
AIDS and behavior  2011;15(1):9-15.
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.
doi:10.1007/s10461-010-9710-3
PMCID: PMC2987377  PMID: 20490909
HIV; Unprotected sex; Serosorting; Risk reduction; Condom use
7.  Serosorting and sexual risk behaviour according to different casual partnership types among MSM: The study of one-night stands and sex buddies 
AIDS care  2011;24(2):167-173.
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.
doi:10.1080/09540121.2011.603285
PMCID: PMC3561689  PMID: 21861633
men who have sex with men; serosorting; sexual behaviour; risk reduction behaviour; types of casual partnerships; unprotected anal intercourse
8.  Sexual Partner Selection and HIV Risk Reduction Among Black and White Men Who Have Sex with Men 
American journal of public health  2010;100(3):503-509.
Objectives
In the US, black men who have sex with men (BMSM) are diagnosed with HIV at a rate far exceeding other men. However, many studies report no substantial increase in risk behavior among BMSM. Here we examine a partner selection strategy as a potential risk factor for HIV among BMSM and white MSM (WMSM).
Methods
Cross-sectional surveys were collected from self-reported HIV negative BMSM and WMSM attending a gay pride festival in Atlanta, GA.
Results
HIV negative WMSM were more likely to report having unprotected anal intercourse with HIV negative men, and HIV negative BMSM were more likely to report unprotected anal intercourse with HIV status unknown partners. Furthermore, WMSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than BMSM.
Conclusions
WMSM appear to be using risk reduction strategies to reduce the likelihood of HIV infection more so than BMSM. Partner selection strategies have serious limitations; however they may explain in part the disproportionate number of HIV infections among BMSM.
doi:10.2105/AJPH.2008.155903
PMCID: PMC2820059  PMID: 20075328
ethnicity; men who have sex with men; risk behavior; perceptions of risk
9.  Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting? 
Sexually Transmitted Infections  2006;82(6):461-466.
Background
Sexually transmitted infections (STI) and unprotected anal intercourse (UAI) have been increasing among men who have sex with men (MSM) in San Francisco. However, HIV incidence has stabilised.
Objectives
To describe recent trends in sexual risk behaviour, STI, and HIV incidence among MSM in San Francisco and to assess whether increases in HIV serosorting (that is, selective unprotected sex with partners of the same HIV status) may contribute to preventing further expansion of the epidemic.
Methods
The study applies an ecological approach and follows the principles of second generation HIV surveillance. Temporal trends in biological and behavioural measures among MSM were assessed using multiple pre‐existing data sources: STI case reporting, prevention outreach programmatic data, and voluntary HIV counselling and testing data.
Results
Reported STI cases among MSM rose from 1998 through 2004, although the rate of increase slowed between 2002 and 2004. Rectal gonorrhoea cases increased from 157 to 389 while early syphilis increased from nine to 492. UAI increased overall from 1998 to 2004 (p<0.001) in community based surveys; however, UAI with partners of unknown HIV serostatus decreased overall (p<0.001) among HIV negative MSM, and among HIV positive MSM it declined from 30.7% in 2001 to a low of 21.0% in 2004 (p<0.001). Any UAI, receptive UAI, and insertive UAI with a known HIV positive partner decreased overall from 1998 to 2004 (p<0.001) among MSM seeking anonymous HIV testing and at the STI clinic testing programme. HIV incidence using the serological testing algorithm for recent HIV seroconversion (STARHS) peaked in 1999 at 4.1% at the anonymous testing sites and 4.8% at the STI clinic voluntary testing programme, with rates levelling off through 2004.
Conclusions
HIV incidence among MSM appears to have stabilised at a plateau following several years of resurgence. Increases in the selection of sexual partners of concordant HIV serostatus may be contributing to the stabilisation of the epidemic. However, current incidence rates of STI and HIV remain high. Moreover, a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one's own and one's partners' serostatus.
doi:10.1136/sti.2006.019950
PMCID: PMC2563862  PMID: 17151031
men who have sex with men; sexual risk behaviour; sexually transmitted infections; HIV
10.  Men having sex with men serosorting with casual partners: who, how much, and what risk factors in Switzerland, 2007-2009 
BMC Public Health  2013;13:839.
Background
Serosorting is practiced by men who have sex with men (MSM) to reduce human immunodeficiency virus (HIV) transmission. This study evaluates the prevalence of serosorting with casual partners, and analyses the characteristics and estimated numbers of serosorters in Switzerland 2007-2009.
Methods
Data were extracted from cross-sectional surveys conducted in 2007 and 2009 among self-selected MSM recruited online, through gay newspapers, and through gay organizations. Nested models were fitted to ascertain the appropriateness of pooling the datasets. Multiple logistic regression analysis was performed on pooled data to determine the association between serosorting and demographic, lifestyle-related, and health-related factors. Extrapolations were performed by applying proportions of various types of serosorters to Swiss population data collected in 2007.
Results
A significant and stable number of MSM (approximately 39% in 2007 and 2009) intentionally engage in serosorting with casual partners in Switzerland. Variables significantly associated with serosorting were: gay organization membership (aOR = 1.67), frequent internet use for sexual encounters (aOR = 1.71), having had a sexually transmitted infection (STI) at any time in the past 12 months (aOR = 1.70), HIV-positive status (aOR = 0.52), regularly frequenting sex-on-premises venues (aOR = 0.42), and unprotected anal intercourse (UAI) with partners of different or unknown HIV status in the past 12 months (aOR = 0.22). Approximately one-fifth of serosorters declared HIV negativity without being tested in the past 12 months; 15.8% reported not knowing their own HIV status.
Conclusion
The particular risk profile of serosorters having UAI with casual partners (multiple partners, STI history, and inadequate testing frequency) requires specific preventive interventions tailored to HIV status.
doi:10.1186/1471-2458-13-839
PMCID: PMC3848594  PMID: 24025364
Sexual risk behaviour; Men who have sex with men; Serosorting; HIV; Switzerland
11.  Sexual Risk Behavior and Drug Use in Two Chicago Samples of Men Who Have Sex with Men: 1997 vs. 2002 
Employing data from two Chicago-based household probability samples of men who have sex with men (MSM) implemented 5 years apart (the “UMHS 1997” and the “2002 MSM supplement” studies), we evaluated changes in risk behavior as well as the potential viability of two alternative perspectives for explaining these changes—risk management and safe-sex norm abandonment. We found significantly increased rates of unprotected insertive and receptive anal intercourse in the 2002 study. Sixty-eight percent of UMHS men reported having sex with partners having HIV positive or unknown status, compared with 38% of the MSM supplement men (p < .0001). Serosorting mediated and moderated the most extreme forms of risk behavior. Positive statistical associations between drug use and unprotected sex were stronger in the UMHS sample than in the MSM supplement. Findings suggesting that “risk management” strategies have shaped MSM behavior as it emerged in the early part of this decade have considerable implications for HIV prevention strategies.
doi:10.1007/s11524-009-9432-x
PMCID: PMC2871084  PMID: 20217485
Epidemiology; HIV/AIDS; Men who have sex with men; Sexual behavior; Substance use
12.  Seroadaptive Practices: Association with HIV Acquisition among HIV-Negative Men Who Have Sex with Men 
PLoS ONE  2012;7(10):e45718.
Background
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.
Methodology/Principal Findings
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).
Conclusions/Significance
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.
doi:10.1371/journal.pone.0045718
PMCID: PMC3463589  PMID: 23056215
13.  POSITIVE, NEGATIVE, UNKNOWN 
Serosorting (i.e., engaging in unprotected sex with partners known to be of the same serostatus) can be a difficult process for men who have sex with men (MSM) who frequently make assumptions about their partners’ serostatus. This process can be further complicated by a partner’s dishonesty as well as other individual and contextual factors. The present study specifically examined how assumptions of serostatus made about unknown serostatus partners impact on the sexual behavior of 110 alcohol-abusing HIV-positive MSM. Although previous research has shown that HIV-positive MSM are more likely to serosort with other known HIV-positive men than with known HIV-negative men, our data suggest that unprotected sex behavior may not be specifically driven by whether or not they made assumptions of seroconcordance or serodiscordance. The types of assumptions these HIV-positive MSM made about their unknown status sexual partners and the basis for such assumptions were also examined. Owing to the ambiguities involved in assumptions of a partner’s serostatus in sexual encounters, the “unknown status” partner category is analytically distinct from “known status” categories, and needs to be more fully explored because of its impact on perceived serosorting, rather than actual serosorting, among HIV-positive men.
doi:10.1521/aeap.2006.18.2.139
PMCID: PMC1994777  PMID: 16649959
14.  RESILIENCE, SYNDEMIC FACTORS, AND SEROSORTING BEHAVIORS AMONG HIV-POSITIVE AND HIV-NEGATIVE SUBSTANCE-USING MSM 
Serosorting is commonly employed by MSM to reduce HIV risk. We hypothesize that MSM perceive serosorting to be effective, and that serosorting is predicted by resilience and inversely related to syndemic characteristics. Surveys included 504 substance-using MSM. Logistic regression models examined syndemic and resilience predictors of serosorting, separately by serostatus. For HIV-positive men, positive coping behaviors (P = .015) and coping self-efficacy (P = .014) predicted higher odds, and cognitive escape behaviors (P = .003) lower odds, of serosorting. For HIV-negative men, social engagement (P = .03) and coping self-efficacy (P = .01) predicted higher odds, and severe mental distress (P = .001), victimization history (P = .007) and cognitive escape behaviors (P = .006) lower odds, of serosorting. HIV-negative serosorters reported lower perceptions of risk for infection than non-serosorters (P < .000). Although high risk HIV-negative men may perceive serosorting to be effective, their high rates of UAI and partner change render this an ineffective risk reduction approach. Relevant public health messages are urgently needed.
doi:10.1521/aeap.2012.24.3.193
PMCID: PMC3480663  PMID: 22676460
15.  Behavior, Intention or Chance? A Longitudinal Study of HIV Seroadaptive Behaviors, Abstinence and Condom Use 
AIDS and behavior  2012;16(1):121-131.
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.
doi:10.1007/s10461-011-9936-8
PMCID: PMC3686637  PMID: 21644001
Men who have sex with men; Serosorting; HIV
16.  A Behavioral Intervention Reduces HIV Transmission Risk by Promoting Sustained Serosorting Practices Among HIV-Infected Men Who Have Sex with Men 
Objective
To examine factors that explain the effect of a cognitive-behavioral intervention on reductions in HIV transmission risk among HIV-infected men who have sex with men (MSM).
Method
Of the 1,910 HIV-infected MSM screened, 616 participants considered to be at risk of transmitting HIV were randomized to a 15-session, individually delivered cognitive-behavioral intervention (n = 301) or a wait-list control (n = 315).
Results
Consistent with previous intent-to-treat findings, there was an overall reduction in transmission risk acts among MSM in both intervention and control arms, with significant intervention effects observed at the 5, 10, 15, and 20 month assessments (Risk Ratios = .78, .62, .48, and .38, respectively). These intervention-related decreases in HIV transmission risk acts appeared to be partially due to sustained serosorting practices. MSM in the intervention condition reported a significantly greater proportion of sexual partners who were HIV-infected at the 5 and 10 month assessments (Risk Ratio = 1.14 and 1.18).
Conclusions
The Healthy Living Project, a cognitive-behavioral intervention, is efficacious in reducing transmission risk acts among MSM. This appears to have been due in large part to the fact that MSM in the intervention condition reported sustained serosorting practices.
doi:10.1097/QAI.0b013e31818d5def
PMCID: PMC2659703  PMID: 18989221
Men Who Have Sex with Men; Prevention with Positives; Randomized Controlled Trial; Prevention Case Management
17.  HIV serosorting as a harm reduction strategy: Evidence from Seattle, Washington 
AIDS (London, England)  2009;23(18):2497-2506.
Objective
We sought to estimate how serosorting may affect HIV prevalence and individual risk among MSM in Seattle, Washington, and how the results vary under different assumptions of HIV testing frequency, heterogeneity in sexual behavior, and condom use.
Methods
We developed a deterministic mathematical model of HIV transmission dynamics. Data from the 2003 random digit dial study of MSM conducted in Seattle, Washington (n = 400) are used to parameterize the model.
Results
Predicted population-level HIV prevalence as well as an individual’s risk of HIV acquisition decreases when the odds of serosorting are increased in the mathematical model. In our model based on observed levels of serosorting, we predict an HIV prevalence of 16%. In contrast, if serosorting were eliminated in the population, we predict that HIV prevalence would increase to 24.5%. However, our findings depend on rates of condom use, mean anal sex contact rates, and HIV testing in the population.
Conclusions
Under realistic scenarios of sexual behavior and testing frequency for MSM in the US, serosorting can be an effective harm reduction strategy.
doi:10.1097/QAD.0b013e328330ed8a
PMCID: PMC2886722  PMID: 19834319
HIV/AIDS; mathematical modeling; homosexual men; HIV testing
18.  The impact of HIV seroadaptive behaviours on sexually transmissible infections in HIV-negative homosexual men in Sydney, Australia 
Sexually Transmitted Diseases  2012;39(3):191-194.
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1097/OLQ.0b013e3182401a2f
PMCID: PMC3282017  PMID: 22337105
Cohort study; STI; Homosexuality; male; HIV seroadaptive behaviour; Australia
19.  SEXUAL RISK BEHAVIOR AND RISK REDUCTION BELIEFS AMONG HIV-POSITIVE YOUNG MEN WHO HAVE SEX WITH MEN 
AIDS and behavior  2013;17(4):1515-1523.
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.
doi:10.1007/s10461-012-0155-8
PMCID: PMC3361604  PMID: 22350830
Young men who have sex with men (YMSM); HIV-positive; risk reduction; secondary prevention; serosorting
20.  Perceived serosorting of injection paraphernalia sharing networks among injection drug users in Baltimore, MD 
AIDS and behavior  2011;15(1):16-21.
We examined perceived serosorting of injection paraphernalia sharing networks among a sample of 572 injection drug users (IDUs). There was evidence for serosorting of high-risk injection behaviors among HIV-negative IDUs, as 94% of HIV-negative IDUs shared injection paraphernalia exclusively with perceived HIV-negative networks. However, 82% of HIV-positive IDUs shared injection paraphernalia with perceived HIV-negative networks. The findings indicate a potential risk of rapid HIV transmission. Future prevention efforts targeting IDUs should address the limitation of serosorting, and focus on preventing injection paraphernalia regardless of potential sharing networks’ perceived HIV status.
doi:10.1007/s10461-010-9713-0
PMCID: PMC3037514  PMID: 20490907
Serosorting; Injection drug use; Injection paraphernalia sharing; HIV risk; Social network
21.  HIV risk reduction behaviours in gay men 
AIDS (London, England)  2009;23(2):243-252.
Objective
A range of risk reduction behaviours in which homosexual men practise unprotected anal intercourse (UAI) has been described. We aimed to assess the extent of any reduction in HIV risk associated with these behaviours.
Design
A prospective cohort study of HIV-negative homosexual men in Sydney, Australia.
Methods
Men were followed up with 6-monthly detailed behavioural interviews and annual testing for HIV. The four risk reduction behaviours (behaviourally defined) examined were serosorting, negotiated safety, strategic positioning, and withdrawal during receptive UAI (UAI-R).
Results
In 88% of follow-up periods in which UAI was reported, it occurred in the context of consistent risk reduction behaviours. Compared with those who reported no UAI, the risk of HIV infection was not raised in negotiated safety [hazard ratio = 1.67, 95% confidence interval (CI) 0.59–4.76] and strategic positioning (hazard ratio = 1.54, 95% CI 0.45–5.26). Serosorting outside negotiated safety was associated with an intermediate rate of HIV infection (hazard ratio = 3.11, 95% CI 1.09–8.88). Withdrawal was associated with a higher risk than no UAI (hazard ratio = 5.00, 95% CI 1.94–12.92). Patterns of UAI differed greatly according to partner’s serostatus. Men who reported serosorting were less likely to report either strategic positioning or withdrawal.
Conclusion
Each behaviour examined was associated with an intermediate HIV incidence between the lowest and highest risk sexual behaviours. The inverse association between individual behaviours suggests that men who practise serosorting rely on this protection. The high prevalence of these behaviours demands that researchers address the contexts and risks associated with specific types of UAI.
doi:10.1097/QAD.0b013e32831fb51a
PMCID: PMC2768371  PMID: 19098494
Australia; cohort study; HIV; homosexuality; male; risk factor; risk reduction
22.  Behavior Change Following Diagnosis with Acute/Early HIV Infection—A Move to Serosorting with Other HIV-Infected Individuals. The NIMH Multisite Acute HIV Infection Study: III 
AIDS and behavior  2009;13(6):1054-1060.
Risk reductions behaviors are especially important during acute/early HIV infection, a period of high transmission risk. We examined how sexual behaviors changed following diagnosis of acute/early HIV infection. Twenty-eight individuals completed structured surveys and in-depth interviews shortly after learning of their infection and two months later. Quantitative analyses revealed significant changes after diagnosis, including reductions in total partners and decreases in the proportion of unprotected sex acts occurring with uninfected partners (serosorting). Qualitative findings indicated that these changes were motivated by concerns about infecting others. However, participants were less successful at increasing the frequency with which they used condoms. These results suggest that the initial diagnosis with HIV may constitute an important component of interventions to promote risk reduction during the acute/early stages of the disease.
doi:10.1007/s10461-009-9582-6
PMCID: PMC2785897  PMID: 19504178
acute HIV; serosorting; behavior change; HIV prevention
23.  Behavior Change Following Diagnosis with Acute/Early HIV Infection—A Move to Serosorting with Other HIV-Infected Individuals. The NIMH Multisite Acute HIV Infection Study: III 
AIDS and Behavior  2009;13(6):1054-1060.
Risk reductions behaviors are especially important during acute/early HIV infection, a period of high transmission risk. We examined how sexual behaviors changed following diagnosis of acute/early HIV infection. Twenty-eight individuals completed structured surveys and in-depth interviews shortly after learning of their infection and 2 months later. Quantitative analyses revealed significant changes after diagnosis, including reductions in total partners and decreases in the proportion of unprotected sex acts occurring with uninfected partners (serosorting). Qualitative findings indicated that these changes were motivated by concerns about infecting others. However, participants were less successful at increasing the frequency with which they used condoms. These results suggest that the initial diagnosis with HIV may constitute an important component of interventions to promote risk reduction during the acute/early stages of the disease.
doi:10.1007/s10461-009-9582-6
PMCID: PMC2785897  PMID: 19504178
Acute HIV; Serosorting; Behavior change; HIV prevention
24.  Don't ask, don't tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle 
Sexually Transmitted Infections  2004;80(6):512-517.
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.
doi:10.1136/sti.2004.010918
PMCID: PMC1744943  PMID: 15572626
25.  HIV Disclosure and Sexual Transmission Behaviors among an Internet Sample of HIV-positive Men Who Have Sex with Men in Asia: Implications for Prevention with Positives 
AIDS and behavior  2012;16(7):1970-1978.
The relationship between HIV disclosure and sexual transmission behaviors, and factors that influence disclosure are unknown among HIV-positive men who have sex with men (MSM) in Asia. We describe disclosure practices and sexual transmission behaviors, and correlates of disclosure among this group of MSM in Asia. A cross-sectional multi-country online survey was conducted among 416 HIV-positive MSM. Data on disclosure status, HIV-related risk behaviors, disease status, and other characteristics were collected. Multivariable logistic regression was used to identify significant correlates of disclosure. Only 7.0% reported having disclosed their HIV status to all partners while 67.3% did not disclose to any. The majority (86.5%) of non-disclosing participants had multiple partners and unprotected insertive or receptive anal intercourse with their partners (67.5%). Non-disclosure was significantly associated with non-disclosure from partners (AOR = 37.13, 95% CI: 17.22, 80.07), having casual partners only (AOR = 1.91, 95% CI: 1.03, 3.53), drug use before sex on a weekly basis (AOR: 6.48, 95% CI: 0.99, 42.50), being diagnosed with HIV between 1–5 years ago (AOR = 2.23, 95% CI: 1.05, 4.74), and not knowing one’s viral load (AOR = 2.80, 95% CI: 1.00, 7.83). Given the high HIV prevalence and incidence among MSM in Asia, it is imperative to include Prevention with Positives for MSM. Interventions on disclosure should not solely focus on HIV-positive men but also need to include their sexual partners and HIV-negative men.
doi:10.1007/s10461-011-0105-x
PMCID: PMC3340458  PMID: 22198313
Disclosure; men who have sex with men; HIV/AIDS; prevention with positives; Asia

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