HIV transmission risk reduction strategies depend on the serostatus of each partner engaged in a sexual exchange. Serosorting is one of these strategies and consists in selecting sexual partners according to their HIV serostatus. Besides, other strategies exist and may be included with serosorting in the broader concept of seroadaptation.

DESCRIPTION
In 2004, the serosorting concept appeared in public debates as one explanation of the leveling off in new HIV infections in the city of San Francisco while STDs had risen (1). Health officials observed a new phenomenon : increase of unprotected anal intercourse (UAI) amongst gay men and at the same time a decrease of UAIs in a situation of serodiscordance. Although such a phenomenon may have existed before, new studies undertaken since then were too focused on a strict definition of serosorting as “choosing a same status partner in order the have UAI”, instead of observing how gay men manage their prevention behavior regarding the information they get about their partners status (perceived or given status). However the San Fransciso phenomenon was offering a new idea : gay men may adapt their prevention practices instead of strickly looking for seroconcording partners. They tend to avoid discordant UAIs, but do they always reject their partner when HIV concordance is not possible ? Or do they use a condom in these situations ? Is desire totally driven by a question of serostatus ?

That’s why, in 2006, the activist Olivier Jablonski (Warning) and the sociologist Jean-Yves Le Talec (Toulouse-2 University) introduced the concept of seroadaptation in France. Seroadaptation means adapting prevention strategies and sexual practices regarding one’s own HIV status and the knowledge one has of one’s partner’s status.

Thus, in the context of possibly condomless sex, an HIV+ person may choose to have sex only with same status persons (serosorting), and/or may pay special attention to undetectable viral load and to possibly concurrent STDs (cf the “Swiss Protocol”, Bernard Hirschel et al. (2)), and/or may negotiate selected sexual risk limiting practices such as withdrawal (no oral or anal contact with semen), soft sex versus hard sex (no contact with blood). An HIV- person may also decide to “negotiate safety” with a regular HIV-negative partner and choose to have unprotected sex. On an individual level, none of these procedures is 100% safe, but their combination considered as a global process of seroadaptation may reduce HIV transmission, should it include protected or condomless sex. It depends on the context, the available biomedical information, and the negotiation process between partners (regular as well as casual) or the lack of negotiation.

This new vision has several advantages :

  • On the epidemiological level : it is more accurate to study seroadaptation than serosorting, because seroadaptation can help to understand the dynamic of harm reduction strategies in more situations than serosorting. In both strategies, gay men try to act in relation to their serostatus, but considering seroadaptation, they use this knowledge to adapt their prevention behavior and not only to select their partners. Selection of the partner is not an easy strategy : when one wants to have sex, one may prefer to engage in condomless practices rather than refuse protected sex, or on the contrary, prefer to engage in protected practices if the partner asks for it.
  • Serosorting is not a valid HIV-prevention strategy for HIV negative people during casual sex. Actual sexual practices which we have observed in the field reflect the way gay men act regarding risk reduction and serostatus of their partners (unknown, known or given) (3).
  • Seroadaptation is a pertinent concept in order to improve HIV prevention and sexual health for all gay men and MSM.
  • Serosorting is controversial in gay communities. The controversy comes from the diversity of definitions people give to serosorting and from ethical issues such as “discrimination” (even if it is a wide spread practice which some HIV+ gay men enjoy).
  • As serosorting sometimes conflates with barebacking and unprotected practices, the term is once again controversial. Refering to seroadaptation, a behavior which seems at first glance “risky”, may be in fact analyzed as a “rational and calibrated risk behavior” (4)
  • At last, from a “Public Health” point of view, seroadaptation offers a more global approach that addresses negative and positive gay men, is audible and easily understandable and can be shared by every and all MSM. Seroadapation gives an enlarged vision whatever the serostatus and the sexual practices.

LESSONS LEARNED
Seroadaptation may be understood as a framework which better describes actual behavior and practices, and a process model in order to design information and risk reduction campaigns. It involves promoting testing, support to HIV+ people, and encouraging negotiation between partners.

NEXT STEP
As a broader concept, seroadaptation should replace serosorting. It has been already adopted by some researchers and institutions, such as San Francisco Department of Public health (5).

Notes :

1 – http://www.natap.org/2004/newsUpdates/052504_02.htm

2 – http://www.thewarning.info/IMG/pdf/swiss_english2008.pdf

3 – Le Talec J.-Y., Cook E. et Martinet M.-L. Réduction des risques sexuels chez les hommes gais : représentations et réalité. Rapport de recherche, Toulouse, Aides 31 et Université de Toulouse 2, 2008.

4 – About “calibrated and rational risk behavior”, see Peter Keogh from Sigma Research (http://santegaie2005.thewarning.info/eng/ppt.html)

5 – POI Motions regarding seroadaptation, SDPH, Nov. 8, 2007, http://sfhiv.org/community_hppc_full_council_2007.php

 

Jean-Yves Le Talec

Sociologist specialist in health and sexuality / gender studies at the University of Toulouse, France (Certop-Sagesse UMR 5044), Jean-Yves Le Talec has been working for several years on the issues of HIV prevention and gay men. His last research refers to barebacking, sexual risk reduction and &#8220 ;Acute hepatitis C in VIH+ MSM&#8221 ; (see poster THPE0850).

Latest book : Folles de France, Paris, La Découverte, 2008.

letalec at univ-tlse2.fr

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Olivier Jablonski

President of WARNING, a French Gay Men’s Health think tank. Because we were dissatisfied with how HIV prevention was done in France, we launched WARNING in late 2003 in order to elaborate new ideas about gay men and their physical and mental health while taking into account the changes in LGBT lifestyles in a post-AIDS crisis Western society.

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