In the late ’90s, having lived with HIV for more than a decade, Robert Brandon Sandor found himself, thanks to the protease revolution, suddenly looking at a longer life expectancy-—and looking for love. Like many other HIV positive men, Sandor prefers to date and have sex only with positive men, both because he wants emotional support from someone who understands the strain of life with HIV and because he desires to once again engage in unprotected sex. However, short of wearing a T-shirt proclaiming his HIV status and romantic inclinations, he had few ways of locating other positive partners at the time. “There were no HIV-positive-only sex parties, socials, dating services or online hookup sites,” he says. So in April 1999, the resourceful Sandor placed an ad in NYC’s free gay magazine HX for a sex party he organized, called POZ Club—NYC (unaffiliated with this magazine). It was one of the first publicly advertised positive-only parties in the country. Sandor soon branded the monthly soiree Brandon’s POZ Party and took it digital, helping more men find the party’s dates and locations and letting them meet via an Internet message board.
Today, cyberspace offers dozens of options for positive people to look for casual sex or relationships, such as online profiles that allow them to anonymously proclaim their HIV status, positive or negative, before even swapping hellos. Since mainstream heterosexual-oriented hookup websites infrequently mention users’ HIV status, more and more straight people are pursuing HIV positive encounters on positive-only dating sites. “There is a greater sense of self-esteem, empowerment, belonging and support,” says Sandor of the benefits of same-status loving.
Many positive people have based sexual and romantic choices on serostatus since the beginning of the epidemic, but this type of personal choice has become known by its clinical label: serosorting. Same-status, or seroconcordant, love can alleviate pressures around things like disclosure, fears of infection and being with a lover who doesn’t understand life with meds and HIV. While some define serosorting as having only same-status mates, others define it as selecting sexual practices, such as condomless sex, based on knowing a partner’s status, whether the same or different. The latter definition is now supported by no less an authority than the San Francisco Department of Public Health (SFDPH) as an effective HIV prevention tactic, while other urban health departments, from Seattle to Denver to New York, are currently researching serosorting’s potential to drive down new infections.
SFDPH predicts that new HIV infections among men who have sex with men (MSM) citywide will be about 20% lower in 2006 than in 2001. The department attributes the phenomenon primarily to serosorting, which studies show has been on the rise among MSM in the Bay Area since the late ’90s. Despite such evidence, the SFDPH still shocked many AIDS advocates and people with HIV last November, when it plastered the town with psychedelic posters featuring giant silhouettes of buff naked men embracing in erotic poses with their HIV status—sometimes the same for each couple, sometimes opposite—branded on their shoulders. The caption read: STATUS-SORTING IS A PREVENTION STRATEGY.
It seemed that even before the glue could dry on all the posters, AIDS community members from across the nation had begun to weigh in on the campaign, the first in the U.S. to support serosorting as a prevention strategy. Some applauded that a big-city health department finally acknowledged that two decades of feeding gay men an all-condom- all-the-time prevention approach might not be realistic, especially in a post-HAART world. “The serosorting behavior our participants have reported could have reduced the number of new infections caused by people having random sexual occurrences by 99%,” says Jeff McConnell, project director of the Positive Partner Study at the University of California, San Francisco’s J. David Gladstone Institutes.
Others condemned the campaign, saying it supported a “viral apartheid,” a sexual and romantic fissure between positive and negative men. “This campaign is only going to encourage more discrimination. There are already negative people who look at us like we are killers,” says HIV positive San Diego resident Jim Leckliter, 34, who dates both positive and negative men. Still others found it rash to give up on a safe-sex-only message, believing men would take it as an endorsement of unprotected sex among same-status folk, a hazardous suggestion when risks surrounding reinfection with drug-resistant strains of HIV and coinfections with other STDs are not completely understood. Critics add that such a campaign could also create a false sense of safety among negative people who prefer to have sex with negative partners—but get bedmates who are positive and don’t know it.
As for the risks of positive/positive unprotected sex, scientists are still investigating how HIV mutates and are looking into the possibility of an entirely drug-resistant “superstrain” of HIV. Existing evidence does substantiate fears of positive people being “superinfected” with a strain resistant to some drugs and therefore having fewer treatment options throughout their lives. According to a 2005 study by pharmaceutical company GlaxoSmithKline, 17% of people starting HIV meds for the first time were found to have some drug resistance. Researchers report, though, that while newly infected people are highly vulnerable to superinfection, after one to three years of living with HIV—when most people have built up HIV antibodies—there is very little evidence of superinfection occurring. The risk of coinfection with other STDs, such as syphilis and hepatitis C, however, does not decrease. As for serosorting and HIV risk in negative men, 2.6% of the negative men who serosort and often have unprotected sex who got tested for HIV at Seattle’s University of Washington’s sexually transmitted infection clinic tested positive, compared with 4.1% of those who rarely took any preventive measure and 1.5% of those who regularly used condoms.
The San Francisco status-sorting ad campaign is part of a larger SFDPH effort dubbed the Disclosure Initiative, a plan to work with medical professionals and prevention and HIV counselors to get men and women, gay and straight, to talk openly with potential partners about HIV and STD risk before all sexual encounters. They hope this will normalize the HIV conversation, making it less embarrassing and defusing fears of stigma or the notion that HIV talk is a bedroom mood killer. “There is often fear and guilt [around the subject of HIV], and people are not as frank [as they should be],” says Les Pappas, who is gay, HIV negative and in a long-term, monogamous relationship with another negative man. He also heads up Better World Advertising, the agency that designed the San Francisco ad campaign.
Unlike many HIV prevention campaigns, which often discourage sex by discussing death or drug side effects and play on people’s fears of HIV, Pappas crafted the campaign to promote sex and to recognize HIV positive people’s right to have it. “The design is really sex positive and about healthy sex lives,” he says. As to criticism that the campaign could polarize the gay community, Doug Sebesta, director of the Disclosure Initiative, says, “We are not saying segregate by status. We are coming from where the community itself is and educating people on how to protect themselves and their partners in an empowering way.” Leckliter counters: “That’s not what I get when I see it. I get: Don’t date people with a different HIV status.” Sebesta also contends that without the honest talk the campaign promotes, assumptions prevail, with some negative people presuming anyone willing to have unprotected sex must be negative and some positive people presuming anyone willing to take the risk must already have HIV. In the U.S., an estimated 50% of new infections come from the 25% of positive people who do not know their status and the other 50% from the 75% who do know, meaning communication is indeed often failing.
Still, Randy Allgaier, 49, a positive San Franciscan, opposes letting serosorting govern the heart. “I’ve been with an HIV negative man for 18 years. If I’d serosorted, we never would have met,” he says. Then there’s Tony Valenzuela, 38, a Los Angeles–based HIV positive activist who is writing a book about gay men and unprotected sex. The longtime public proponent of positive men’s right to bareback (have condomless sex) says, “This campaign acknowledges our real sex lives, and it is an important shift. I always thought that I would end up with a positive guy, but then I met my current partner, Rob, who is negative, and that changed everything. So I don’t think advocating serosorting means closing yourself off.”
Many men contend that gay men’s view of serosorting varies by generation, saying that because HIV has been less a part of gay culture for the under-30 crowd, they are less likely to want to date a positive person when negative. HIV negative Joshua, who is 28 and lives in North Carolina, says he often meets dates online but limits himself to negative guys. “Having sex with a positive person would make me a nervous wreck, even though I know rationally that protection works,” he says. However, Mike Fitzpatrick, 60 and negative, says he has dated many positive men since the start of the epidemic. “Everyone is carrying some kind of baggage,” he says. “If you can deal with my high blood pressure, I can deal with your HAART regimen.”
While San Francisco’s new infections are steadily declining, the national news is less encouraging. New infections among gay men have been rising since 2001, increasing 8% from 2003 to 2004 alone. “Like with many things, San Francisco is different from elsewhere in the country, but it is also a marker of future trends,” says Sebesta, predicting that others could adopt the model. “The San Francisco City Hall flies the gay flag,” says Bill Stackhouse, PhD, director of the Institute of Gay Men’s Health in New York City, about why this particular campaign might not be so easy to export. “Our LGTB community is much more diverse in terms of age and ethnicity, and it’s harder to find one single message that will make a big difference.” He adds, though, that the focus on face-to-face communication could work in any city or town. “Even if people meet through the Internet and know [one another’s status], they still have things they need to talk about in real life to make sure whatever they do is safe,” he says. He adds that his organization already distributes pamphlets that discuss the risks involved in various sexual behaviors.
Dan O’Connell, director of HIV prevention at the New York City Department of Health (NYCDOH), says the department is currently researching serosorting and sees it as a promising prevention concept. He adds that NYCDOH is still trying to separate the “promise from the peril.” “As a public health agency we have a responsibility with understanding risk,” he says. While O’Connell does not envision images of giant naked men towering over Manhattan, he says that once more information is available, messages about serosorting and negotiated risk could be incorporated into existing ad campaigns, like the NYC-sponsored “HIV Stops With Me” ads, aimed at HIV positive people. Positive San Francisco resident Richard Broussard, 44, who prefers dating other positive men, agrees with targeting serosorting campaigns to positive people only. “Living and loving in a seemingly endless gray zone of uncertainty, many will seek easy assurances,” he says. “But how many guys will spread HIV unwittingly before they even know that they have it? Serosorting is best left to us positive guys looking for other positive guys.” However, many prevention advocates hope that the campaign will lead more men to be tested, since you can’t serosort if you don’t know your status.
HIV Stops With Me fits under the Centers for Disease Control’s (CDC) Prevention for Positives campaign, which focuses on getting people tested, then educating those who test positive about the risks of transmitting HIV. AIDS advocates have criticized the CDC campaign for placing the responsibility for prevention solely on positive people—instead of encouraging everyone to take responsibility for personal safety—a stance that possibly exacerbates the stigma and blame positive people face. The CDC has yet to promote serosorting, but Richard Wolitski, chief of prevention research at the CDC, says, “As part of prevention for positives, the CDC recommends abstinence, mutual monogamy with same-status partners and consistent condom use. So serosorting for positive people fits.” He adds, “Serosorting is likely more effective than [having] sex without regard to HIV status. But at this time, we don’t know how effective and need additional information before we can make conclusive statements about its risks and benefits.”
The San Francisco campaign encourages all gay men, regardless of status, to talk about risk and HIV and sex. “For years, prevention has been just about giving people instructions that they were never going to follow,” says Walt Odets, PhD, a psychologist in Berkeley, California, who specializes in counseling gay men. “New prevention [efforts] should help people learn and talk about their emotional life and figure out a lifelong sexual strategy that works for them.” McConnell says evidence from his studies suggests that effectively serosorting and negotiating sex based on a partner’s status are learned skills, something many positive men pick up over the years. “And so far, they have learned it without any help from public-health messaging,” he says, adding that he hopes campaigns like San Francisco’s will help more people learn serosorting skills and learn them faster.
Serosorting as a public prevention strategy relies on many conditions found in urban hubs with a large HIV community. McConnell refers to such places as having a “mature epidemic,” meaning that testing is widespread, stigma is low and information about risks involved in different sex acts is easy to find, as in San Francisco. “If all that exists, this campaign could help build a culture of disclosure and discussion,” he says. Until recently, even large cities—including SF—weren’t ready for a campaign relying on such openness. “Five or ten years ago, negative men wouldn’t talk about it,” says Odets. “But now there is less stigma, and negative men don’t feel like they are adding to positive men’s burden.”
In most rural areas, positive people (and people who are open about their positive status) are scarcer, making it difficult for them to date only other positive people, and stigma is often more prevalent, meaning that other conditions needed for a successful serosorting campaign may not exist. Dyane Haddock, 42 and HIV positive, has never really considered her preference for dating only positive men a prevention strategy. It just seemed to make sense. “I haven’t met a negative man who can deal with all that’s involved in dating a positive woman,” she says. She adds that in her small Florida town she could find only positive men to date online. “I often end up dating men I wouldn’t date if I wasn’t positive,” she says, adding, though, that she recently moved to Santa Rosa, California, just north of San Francisco, and remains hopeful that the larger dating pool will offer better prospects. Indeed, positive heterosexuals seeking another positive partner face limited options nationwide and often travel long distances to pursue a prospective mate met online or elsewhere.
Serosorting is still controversial in urban gay communities, due not just to fears of its divisive implications but also to positive men’s desire to have unprotected sex with other positive men. When Valenzuela first spoke at a 1997 HIV convention about the appeal of barebacking among positive people in search of a fulfilling sex life, activists attacked him, lambasting his recklessness after so many years of fighting for people’s lives, effective treatment and safer-sex education. While the subsequent decade has seemingly brought recognition that a positive person has the right to make such choices, a 2005 “superbug” scare in New York City, which turned out to be unfounded, caused many in the gay community to speak out against unprotected sex between two positive people. Gay journalist Charles Kaiser told the New York Times, “A person who is HIV positive has no more right to unprotected intercourse than he has the right to put a bullet through another person’s head.” However, despite the occasional backlash, many believe that the gay community is becoming more open to the idea. Odets says his positive patients used to avoid acknowledging to him that they had condomless sex, due to feeling guilt or shame. “Before, there was a denial about the desirability, but people were always doing it. It became obvious that there is a value in [admitting] it, and that finally overwhelmed the denial.”
Tony Ademaj, 34, was diagnosed with HIV in 2003. In late 2004, he started frequenting Sandor’s sex party. “I was [having little sex] at that point, and the party was an important step in normal living—well, as normal as a sex party can be.” He says that some guys at the parties use condoms, but most don’t and adds that while he does feel it limits him romantically, he prefers to date or have sex with only positive guys, even outside the party. “I’m feeling guilty about possibly infecting someone, and they are feeling guilty about being scared or repulsed. It kills intimacy,” he says. “Plus, you have to cover your ass legally, with the government trying to criminalize creating risk, much less actual transmission.”
Last September, Sandor organized a New York City forum to promote same-status sex as a prevention strategy, but also pushing condom use for negative people in casual encounters—though not for positive people. He claims, “Serosorting stops new HIV infections 100%, guaranteed.” In November 2006, he met with NYCDOH staff to brief them on its benefits. O’Connell attended both the forum and the health department meeting. “I listened to people speak movingly about how they have overcome so much and that the idea of never again having unprotected sex just doesn’t work for them,” he says. “But it wasn’t something they took lightly. They believed that they had a responsibility to not put anyone else at risk but that they could take calculated risks themselves.” Indeed, when it comes to navigating love by partners’ HIV status and people determining what health risks they are willing to take in the pursuit of sexual pleasure and intimacy, nearly all agree on one thing. As Stackhouse, of the Institute of Gay Men’s Health, puts it, “It’s very personal.”