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I was having drinks with a friend of mine — we’ll call him Patrick here — this weekend when the subject of having sex with HIV-positive men came up. “Oh, I would never have sex with an HIV-positive guy,” he casually remarked — as if such a thing were already obvious. I was shocked not just by Patrick’s statement, but also by the categorical bravado in his delivery. To have sex with HIV-positive men, as he went on to explain, was to expose himself to unnecessary risk of infection. I’ve been replaying this conversation again and again in my head. How could he be so outrageously calculating in his cooIly expressed exclusionary strategy? Today I want to spend a few moments reflecting on these kinds of statements, because I think many people would uncritically read them as legitimate prevention strategies. I will argue here, however, that in reality that these kinds of strategies that are totally bankrupt in terms of actual risk reduction. Moreover, what I think this kind of statement actually tends to do is not actually promote any real reduction in risk, but rather to reinforce and reproduce harmful stigma against HIV-positive people.

Before we get into a discussion of the ethics of “serosorting” — the practice of choosing to engage in sex with only sero-concordant men — I think we should bracket my friend’s comments as existing only at the very periphery of this term’s broad meaning. While taken at face value, it does indeed seem that my friend is practicing serosorting. But correct me if I’m wrong here, but it seems to me that serosorting was more intended to describe men who were seeking to minimize risk of transmission while engaging in sex without condoms. For my friend, this wasn’t the goal of his strategy — condom use was still part of his risk reduction strategy with other HIV-negative men. This is a very important distinction. What I’m going to be talking about here is men who report consistent condom use, but who continue to latch onto serosorting discourses that discourage serodiscordant sexual practices.

Because of these important differences, I want to suggest that Patrick’s comments cannot possibly be said to be purely a method of risk reduction. To explain why I think this is so, we need to evaluate whether or not there is actually any risk worth avoiding by excluding HIV-positive men from your pool of eligible partners. Thus, to help illustrate this, let’s attempt to assess the risk of transmission between a known HIV-positive partner and an HIV-negative partner when condoms are used. There is no data to suggest that many HIV infections occur in these contexts, absent condom failure — rates of which are outrageously low (between 0.4% and 2.3%, depending on who you ask). If we take a generous account, let’s presume that rate is 2%. In a single incidence, then, the risk of potential exposure is 1:50.

But exposure does not equal transmission. You can be exposed to the virus and not actually seroconvert. Thus, we need to add into this equation the risk of transmission per sexual encounter in the absence of condoms,which vary depending on a number of factors: whether the poz guy is insertive or receptive, his viral load, genital ulcerations, etc. Let’s say the poz guy is doing the fucking, for example’s sake. The generic risk in this scenario for a receptive HIV-negative man is 1:122 — that is, statistically speaking, there is a 1 in 122 risk of seroconversion after getting fucked once without a condom by an HIV-positive man (see here for a summary of this data). If we multiply these two risks together, we get something like a 1 in 6000 probability — give or take. According to risks of death statistics, this puts a person’s risk of seroconversion in this abstract, theoretical scenario somewhere between their risk of death by electrocution (1:5000) and their risk of death by drowning (1:8942). Obviously, this is a gross use of statistics — but I think it helps illustrate the point: the risk of transmission between serodiscordant couples in one sexual encounter when using condoms is EXTREMELY low. Just about negligible. And this example likely grossly overestimates the risk, due to the fact that condom failure is not the same as sex without condoms. Many people will quickly realize the condom has broken, leading to a much smaller window of possibility for exposure. Thus, the 2% exposure rate included in this example is likely much, much smaller in practice.

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