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Monday, April 30, 2007

Sero-Sorting Works

posted by on April 30 at 11:15 AM

News from San Francisco

A homegrown version of HIV prevention known as “serosorting” has increased dramatically among gay men in San Francisco, according to a newly published survey providing a snapshot of the evolving epidemic a quarter-century after it appeared. Serosorting is choosing to have unprotected anal intercourse only with partners of the same HIV status — uninfected men having sex only with HIV-negatives, while infected men seek out only HIV-positive partners.

The practice evolved in the gay community without the kind of institutional support given to programs encouraging condom use and reducing the number of sexual partners…. Just how protective against HIV transmission the practice may be is unknown.

Or is it? At the same time that sero-sorting has been widely adopted in SF, HIV-infection rates are dropping.

While there was a ten percent decrease in total estimated new [HIV] cases, this seemingly modest decrease is actually a much greater prevention success than it appears.

From 2001 to 2006, the estimated number of gay men living in San Francisco increased from 46,800 to 58,343. The increase was likely due to real growth in the gay community and, potentially, in part the result of an underestimation of the population size in 2001.

When the effect of the increase in the population size of MSM is taken into account, new infections have decreased by an estimated 33 percent.

And who deserves credit for this “prevention success”? Average, rank-and-file, commonsensical gay men that adopted the practice without any “institutional support.” Credit shouldn’t go to AIDS prevention orgs—at least not until they adopt sero-sorting.

Via Petrelis.

RSS icon Comments


Bunch of wishy-washy wanting.

Look, there's a perfectly good HIV vaccine out thru Pfizer and another one on the way (both from the UW, of course).

None of this will help you if you went and got yourself infected BEFORE, though.

So, stick to the condoms and avoid the unsafe sex, no matter how you justify it in your mind.

Posted by Will in Seattle | April 30, 2007 11:24 AM

Not to rain on this apparent good news, Dan, but what the hell does Petrelis care about serosorting when he doesn't believe that HIV causes AIDS?

Posted by Matt | April 30, 2007 11:27 AM

Yeah. I was under the impression that this kind of behavior is what breeds new super resilient strains of the virus. Not that I'm any kind of expert.

Posted by Callie | April 30, 2007 11:28 AM

Look, there's a perfectly good HIV vaccine out thru Pfizer and another one on the way (both from the UW, of course).


what you just said above is a complete load of garbage. Looks to me like you're worried that Savage may be influenced by Michael Petrelis. Uh-oh!

Posted by BD | April 30, 2007 11:33 AM

Call me crazy, but anal is kinda gross enough with a condom. I mean, you can't avoid some contact with feces. I would think condoms would be mandatory regardless of someone's HIV status. But that's just me. I'm kinda feces-phobic...

Posted by Mike in MO | April 30, 2007 11:33 AM

Hey Matt,

I'm not sure where you're getting info on me, but you're very wrong about my beliefs regarding HIV. I'll state it again for the record; HIV = AIDS.

Posted by Michael Petrelis | April 30, 2007 11:33 AM

Newsflash, folks:

The drug companies are highly unlikely to create a "vaccine" that will eradicate "HIV".


"AIDS" is far far far too profitable for them to give up. Wake up and smell the real world.

If, they somehow are able to accomplish this feat, they'll be left with the monumental task of explaining just how their "vaccine" "works". That will be a very good time to ask some probing questions... questions most of us haven't asked in the past 23 years.

Posted by BD | April 30, 2007 11:43 AM

I only started learning about the opposition to sero-sorting in Dan's last post, and I'm still totally astonished that anyone who has HIV would even consider having unprotected sex with someone who doesn't. I mean, I guess if I were gay and my potential sex partners and I were more compatible with each other, and I could actually satisfy my sex drive, I don't know how carried away I'd get. But still, it's basically murder.

Posted by Noink | April 30, 2007 11:59 AM

Michael: my apologies if I've misstated your position. Given what I know of your history in SF politics, though, I'd have been hard pressed to come to a different conclusion:

Posted by Matt | April 30, 2007 12:08 PM


I believe what you're showing us is a classic example of guilt by association.

My understanding of Petrelis' AIDS politics is mostly about money...misused, squandered, and too much given to people doing too little. I'm sure there's more, as it's a rangy issue. But, I have yet to hear him state that HIV doesn't cause AIDS.

Posted by BD | April 30, 2007 12:21 PM

Matt: Thanks for the apologies. I just re-read Cockburn's column and didn't see anything in it that says I don't believe HIV causes AIDS. Maybe you didn't read it close enough and have confused me with my codefendant.

Posted by Michael Petrelis | April 30, 2007 12:24 PM

The goal of a relationship isn't to toss away the condoms; the goal of a relationship is the relationship. Right? Just checking.

And I wouldn't presume that "sero-sorting" is the only factor in any decrease in new HIV cases. It's an aspect of safer sex education, but not the only one.

Posted by Boomer in NYC | April 30, 2007 12:45 PM

I'm not sure why you guys are all bent out of shape about this? Gay men know how HIV is spread. It's not a mystery anymore. Shall we start treating Gay men like adults and hope they will begin to act like adults? Good.

Posted by Sargon Bighorn | April 30, 2007 12:56 PM

Michael: I think BD (above) raises an excellent point.

You're right that the Cockburn piece has nothing to say about your stance on the etiology of AIDS. I made an inference based on his association of you with your codefendant, coupled with his description of the two of you as "dissidents", a term commonly used to denote those who dispute the generally accepted causative model for AIDS.

Patricia Nell Warren, in an impassioned and articulate defense of your cause (which, I should say, I support myself), also refers to you and Pasquarelli jointly as "AIDS dissidents".

Cockburn quotes at length a letter by Chris Farrell, which supports you and Pasquarelli but also refers to your combined actions as "activities of ACT UP San Francisco" -- an organization which is predicated on the notion that HIV does not cause AIDS.

It's very unfortunate that so many people eager to defend you so publicly would mischaracterize your position, or conflate it with Pasquarelli's, in the process. I plead that my confusion is only adjunct to theirs.

Posted by Matt | April 30, 2007 1:03 PM

Serosorting is fine for HIV+ men. But when people start promoting it for HIV negative men, it's total BS. Many, many neg guys are putting "HIV- UB2" in their ads as though they can screen out guys with HIV! ANY discussion of serosorting must emphatically state that it works ONLY for positive guys.

Posted by Mark | April 30, 2007 1:07 PM

Callie said I was under the impression that this kind of behavior is what breeds new super resilient strains of the virus. Not that I'm any kind of expert.

It has the potential to do something very close to this. (Search for superinfection in the medical literature.) It can lead to much faster disease progression, and to transmission of drug resistant virus from one partner to another.

There are nonzero costs associated with those things, but of course nonzero benefits to serosorting. So whether or not we ought to support serosorting needs to come down to a principled cost-benefit analysis of reduced new infections vs. these costs.

I suspect the net result will be pro-serosorting - in fact, I suspect it will be resoundingly pro-serosorting - but you're right that poz-poz unprotected sex is not risk free.

Also, Will in Seattle, you are almost certainly thinking of HPV, not HIV, for which your statement is largely accurate. There is absolutely NOT an HIV vaccine on the market, though there are some candidates in trials.

And Mark, immediately above: why is serosorting BS for HIV negative men? Why is is bullshit to NOT want to come into contact with HIV? Seriously, what possible justification can you have for saying that it's wrong for HIV- men to PROTECT THEMSELVES FROM HIV?

Posted by Doc2B | April 30, 2007 1:12 PM


Posted by Mr. Poe | April 30, 2007 1:16 PM

Seriously, what possible justification can you have for saying that it's wrong for HIV- men to PROTECT THEMSELVES FROM HIV?

Well, it encourages HIV+ men to lie about their status, and it may create a false sense of security that would make it easier to ditch condom use.

Nearly everyone I know who has HIV got it from someone they believed to be negative. If you are negative and use condoms religiously, serosorting probably confers additional protection. But if you lull yourself into complacency to the point where you're getting fucked raw by someone who only says they're negative, then serosorting is rather pointless.

Posted by Tony | April 30, 2007 1:39 PM

I understand why a lot of poz guys serosort: no fear of infecting someone, a mutual decision to not use condoms for buttfucking because feels better and/or is easier to keep wood without a rubber. But if I were poz I wouldn't make it a regular practice: STI rates are high among poz gay guys in many cities and if you're immune system is already struggling, an STI (esp. syphillis) can be a challenge to treat.

For negative guys, not so much. Not because we queer men can't trust one another...what "HIV negative" means varies widely. Some "neg" guys were tested a decade ago; some never. So a guy who says he's "neg" could really be saying "I've never had an HIV test." Some guys who's test results are a bit dated might have only slipped up with respect to condom use only rarely. Or been really trashy only once. Etc.

I am a promiscuous, raunchy gay guy (sample size N>1,000). Outside of my husband, serosorting ain't gonna happen. The minor improvements in pleasure don't outweigh the risks. HIV/AIDS isn't cured and treatment failure/intolerance increases markedly year after year. I love getting poked and poking other men. I'm not willing to die for it. Any wood problems related to condom use have been assuaged thanks to cock rings, ED drugs, and the sight of a sexy man with his legs spread...

And if I use condoms with everyone (except my husband) I can continue to have hot, piggy safe sex with poz, neg or ? guys.

Posted by jawnbc | April 30, 2007 2:04 PM

As Tony posted, this is making the extremely naiive and dangerous assumption that everyone is going to be honest about their HIV status. Give me a break! What utopian world do you have to live in to believe that? I can't believe that anyone would actually think that this would work.

Posted by Peegee | April 30, 2007 2:19 PM

#13 said something of value...why is everybody getting so bent?

Gay men have been educated on HIV/AIDS for over twenty years, but we act like we're trying to have "the talk" with an exceptionally dull ten-year-old.

The discussion further degrades into hysteria about "transmission"...that strangely, rarely involves discussion of both participants as being involved in a consenting act. It almost always relies on there being a victim or potential victim (that unfortunately must somehow be completely unaware of HIV/AIDS) involved in this consensual act.

After 23 years, are gay men still in need of the most basic education regarding HIV/AIDS? Do we all need to have "the talk"?

this is making the extremely naiive and dangerous assumption that everyone is going to be honest about their HIV status

Something I harped about on one of Eli's AIDS threads recently is personal responsibility. In this age of AIDS, we've created a culture where gay men's sex lives are EVERYBODY'S business and concern...but strangely, NOT their own. We're all so busy playing nanny to gay men, that we absolve them of the role of taking care of themselves. Maybe we should quit worrying about what the gay guys down the street are doing in their consensual sex acts, and let them take care of themselves. It's the new Puritanism, really, it just looks like everybody's trying to "help".

Posted by BD | April 30, 2007 2:52 PM

I "sero-sort" for relationships - not so I can bareback or swallow a load of jiz, but because I prefer having sex with men with whom I have a commonality of life expirience(s). I also refuse to fuck Republicans, anyone who enjoys watching American Idol for the singing, or, along the lines of our feces phobic author, anyone who doesn't DOUCHE their ASS.
I would like to claim that my SERO SORT is completely self directed, but have found that the fastest way to send a disco twinky running is let 'em know the biohazard tattoo is there for a reason.
I'm POZ U B 2-and if you treat any hook up as anything but POZ, you WILL join my available to date list. See you at the pharmacy, hope you are buying rubbers and not Sustiva!

Posted by poz4same | April 30, 2007 3:23 PM

JawnBC: you are the voice of reason. Your mister and your tricks are all lucky men.

Poz4Same: you presume 'em to be disco twinkies, they presume you to be a biohazard. Would love to say everybody wins--but somehow I think you're all losers.

I'll say it again: I'm negative, my mister is positive, we use condoms and our sex lives don't want for nuthin'.

Posted by Boomer in NYC | April 30, 2007 3:32 PM

... people are seriously using serosorting as a way to avoid having to use a condom? Hell, I thought it was just a way to help reduce risk.

Maybe I'm just way too naive, but how recklessly bloody stupid would you have to be to do that? "I'm sure he's totally honest/correct about his HIV status!"

Posted by wench | April 30, 2007 6:04 PM

you gay guys kee-rack me up! take a tip from het women: no rubber, no rubbin'. non-negotiable.

good luck, fellas.

Posted by scary tyler moore | April 30, 2007 6:26 PM

Anyone out there have a response to Callie's post (#3)? I also read somewhere that unprotected sex between HIV+ men can worsen the condition of a guy if he's infected with a different strain of the virus than the one he already has, and that it could lead to more virulent forms of HIV.
Anyone out there know what the real story is?

Posted by CD | April 30, 2007 7:13 PM

CD(pharma rep),

you're correct. Not even HIV+ men should have unprotected sex together before they die.

HIV, in all of it's angry, malevolent wisdom has seen fit to punish HIV+ gay men who have unprotected sex by hastening their deaths. HIV is very aware of the morals of this culture, and helps to carry them out on the microbial level. Can't fool HIV!

Now for the non-sarcastic response to your "question": hogwash.

Posted by BD | April 30, 2007 8:44 PM

CD(pharma rep),

maybe Eli Sanders can chime in on this issue, or perhaps Dr. Wood, as it seems to be closely-related.

It's been a while since we heard about that "drug-resistant-strain cluster". Quite a stink was made over it. And it sounds really scary. Where's the follow up?

C'mon, Eli, you're not going to scare us with a superstrain story and then just leave us hanging? Are you? That patient zero dude is probably running all over Seattle, sticking his dick God-knows-where, getting more and more of Seattle's gay community infected with a superstrain. Save us from patient zero, Eli!

Or maybe patient zero is dying somewhere, what with all those different HIV's mixing and matching to form even MORE superstrains! Oh. My. God!

Posted by BD | April 30, 2007 9:10 PM

Oh, come on. I have to admit the CD comment seems a little off, however, I think saying that it's just scare tactics to talk about whether different combinations of HIV might create more resistant strains is an overreaction in the opposite direction. It's a virus, they are generally well known for adaptation and frequent mutations.

I'm not going to say that HIV+ folks shouldn't be having sex with each other, that'd be silly. But I think it's a bit blind to say that this type of behavior, plus the assortment of antivirals and vaccines, plus whether everyone's taking their drugs correctly... is not going to have an effect on the virus. People should not consider themselves to be safe just because they have the same disease as someone else.

Serosorting is an excellent addition to condom use. It doesn't replace it by any stretch of the imagination.

Posted by wench | April 30, 2007 9:57 PM

@22- A Bio-Hazard tat! Why didn't I think of that?
I've sero-sorted since testing + in '87. IT'S ONLY COMMON SENSE. As for a super-strain developing from POZ-POZ contact, that's been conjecture since 1st mention, and no study has yet to prove otherwise. POZ men have been told so much BS about their status since '82, much of which has since been dis-proven. If two guys have the death sentence all non-POZ folks think we have, then any advice from you re: sex (short of don't fuck anyone who's not POZ) is just more BS. I plan to enjoy as much condomless sex as I can until I drop. All the POZ men I know do too- we didn't get POZ by using condoms. We have limited our number of contacts, for the same common-sense reasons- STD's are hard on the immune system.
As for NEG guys- fucking without a condom is the quickest road to POZ there is- Sero-Sorting and BB'ing is for POZ-only men. There are plenty of hot POZ men out there- no need to play with NEG guys, and if it's helped reduce HIV/AIDS, you can thank us POZ Sero-sorters.

Posted by POZSeroSorter | April 30, 2007 10:28 PM

It's a virus, they are generally well known for adaptation and frequent mutations.

viruses don't adapt. Bacteria do, as they are living things.

Somewhere, somehow, somebody stole a page from bacteriology and superimposed it onto HIV/AIDS.

Viruses can mutate. But they don't adapt unless it helps the pharmaceutical companies make more money...then yes, they do "adapt".

Posted by BD | April 30, 2007 10:35 PM


The debate over whether viruses are truly alive is not closed.

Viruses do have errors in their replication. These errors are typically known as mutations. The more successful viruses seem to have higher rates of copying errors.

And mutuation is key element of evolution and can lead to adaptation.

Posted by gnossos | May 1, 2007 12:13 AM

Hi, Dan. If you look at the two articles in the American Journal of Public Health neither really addresses the effectiveness of serosorting. While it makes some intuitive sense that serosorting could reduce the incidence of HIV transmission we don't have evidence of that yet.

There are a couple of factors that could limit the protective effects of serosorting or even go so far as to result in a net increase in transmission. People with HIV are most likely to transmit the virus to others while they still test negative, before they've mounted an antibody response. So if you're having unprotected anal sex with casual partners who claim to be negative and getting tested every three months, that first month or two following infection you're going to be far, far more infectious than you will be after you've got antibodies and (hopefully) gotten on antiretrovirals.

And even if serosorting is going well and everyone's disclosing his serostatus the best he knows how and skipping condoms when a twosome think it's appropriate, serosorting does nothing to promote condom use when it is appropriate--when it's not fairly certain that the partners are seroconcordant. There also seems to be reasoning that if seropositives and seronegatives can just have unprotected sex with seroconcordant partners they'll be less likely to have it with serodiscordant partners. I'm not sure that's the case.

The SF Chronicle article merely speculates that serosorting might be reducing HIV prevalence in San Francisco; it does not state that it does. Nor is there good evidence the scientific literature. It absolutely merits further study but in my opinion it's early to recommend it as an alternative to condom use with casual partners, and possibly misguided.

None of this is to say that it's unreasonable to forgo condom use in a partnership where both partners sought out testing together, are seroconcordant and not having unprotected sex outside the partnership. But for casual partners, things begin to get tenuous.

Posted by Ted White | May 2, 2007 4:35 PM

I always remember things biking home. Oh, well.

If, as the source you cite states, HIV prevalence among gay men decreased among gay men in San Francisco during the same years that serosorting became more common, its effects must be studied. However, correlation is not causation. The factors that go into a population's HIV seroprevalence are many and interconnected, and the causality of a single factor cannot be plucked from the air.

Ten years ago there was a decrease in AIDS diagnoses and deaths in the U.S. Many cheered--safe sex was working to save lives. It wasn't long though, before epidemiologists realized that the decrease in AIDS diagnoses and deaths was likely far more a product of the saturation of gay male populations ten years before that. In essence, HIV inundated the population and in a matter of years the number of men susceptible to the infection dwindled. We saw the echo of that in the mid-90s.

Being too quick to attribute a decrease in HIV seroprevalence to serosorting risks the same sort of error, but this time a potentially dangerous error.

Posted by Ted White | May 2, 2007 8:29 PM


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