Available evidence does not support serosorting as an HIV risk reduction strategy: author's reply
Cassels, Susan; Menza, Timothy W; Goodreau, Steven M; Golden, Matthew R
University of Washington, Seattle, Washington, USA.
Received 30 December, 2009
Accepted 19 January, 2010
Heymer and Wilson offer four critiques of our study , concluding that serosorting may be more harmful than helpful in many settings. We address each critique below.
First, they were concerned that our model does not consider how strategic positioning and negotiated safety ‘change with or without disclosure of HIV status’. We did not explicitly model HIV status disclosure. However, we randomly assigned nondisclosers serostatuses based on local prevalence and partitioned strategic positioning and negotiated safety behaviors accordingly. Thus, our model considered both behaviors, parameterized using our 2003 RDD study data of men who have sex with men (MSM)  and with weighted averages across nondisclosing and disclosing serodiscordant couples, hence avoiding bias.
Second, they express concern that, given 16% HIV prevalence, our ‘model would require partner acquisition rates among HIV-positive men to be much greater than among HIV-negative men’. We did not assume a priori that HIV-positive men have higher partner acquisition rates; rather, men with higher partner acquisition rates were more likely to become HIV-positive.
Third, our colleagues ‘question the relevance of using equilibrium prevalence to gain insight into the effect of a recent phenomenon on an epidemic where there is increasing incidence’. We interpret this as favoring a focus on the immediate effects of serosorting to an individual, as in Heymer and Wilson's recent study . We find value in understanding both short-term individual and long-term population effects, and explored both in our study. For the latter, equilibrium prevalence is a commonly used metric with cross-study comparability; its use does not imply that researchers expect behavior to remain constant indefinitely. Both calculations supported our conclusion that in Seattle MSM, serosorting is more protective than not serosorting, all else equal. Additionally, overall HIV incidence among Seattle MSM appears to be stable .
Perhaps most importantly, Heymer and Wilson question our decision to parameterize our model assuming that MSM test one to two times per year, an estimate they believe exceeds common rates. We derived our testing estimates directly from the Seattle RDD study , where men reporting one anal sex partner and more than one anal sex partner in the previous year reported testing a median of 12 and 6 months prior to interview, respectively. Mean intertest interval was 18 and 10 months. Among MSM tested in five US STD clinics, the median intertest interval was 243 days . Few US data are available on the proportion of HIV cases that are undiagnosed, and the representativeness of what data we have is mostly unknown. However, the 2008 National HIV Behavioral Surveillance System (NHBS) survey conducted in King County, Washington, found that 13% of MSM testing HIV-positive were unaware of their infection (H. Theide, personal communication). Data from the same survey in San Francisco, California, found that 14.5% of HIV-positive MSM were undiagnosed (W. McFarland, personal communication). A 2001 population-based survey of California MSM found nearly 10% of HIV-infected MSM were undiagnosed . These numbers are at odds with national data from the 2005 NHBS survey and a CDC estimate that 24.5% of HIV-positive US MSM are undiagnosed [7,8].
We believe there is evidence to support our estimate for Seattle. However, the USA is a large, heterogeneous nation and there are almost certainly regions where testing is less frequent and a greater proportion of infected MSM are undiagnosed. To assess that issue further, we explored the effect of serosorting under a wider array of testing frequencies (Fig. 1). In our model, serosorting has no impact on equilibrium HIV prevalence or the risk of HIV acquisition when high-risk and low-risk MSM test every 1.5 and 3 years, respectively. Serosorting has a small deleterious effect at lower testing frequencies.
We agree with Heymer and Wilson that the benefit of serosorting is highly context-specific and depends on testing frequency, accurate disclosure and behavior. Our findings suggest that, in Seattle, serosorting, as practiced, probably somewhat protects MSM both at the individual and population levels, a finding supported by empirical observation [9,10]. However, that may not be true throughout the USA and should not be construed to suggest that we are promoting serosorting. We believe that our modeling study and Heymer and Wilson's  have some similar conclusions. Serosorting would be protective if the proportion of HIV-infected MSM that are undiagnosed is less than 20% (as shown in Fig. 1 ), and serosorting can potentially increase risk when the population does not test frequently. These concordant findings should reinforce the importance of increasing the proportion and frequency of MSM testing for HIV.
1. Cassels S, Menza TW, Goodreau SA, Golden MR. HIV serosorting as a harm reduction strategy: evidence from Seattle, Washington. AIDS 2009; 23:2497–2506.
2. Brewer DD, Golden MR, Handsfield HH. Unsafe sexual behavior and correlates of risk in a probability sample of men who have sex with men in the era of highly active antiretroviral therapy. Sex Transm Dis 2006; 33:250–255.
3. Wilson DP, Regan DG, Heymer K-J, Jin F, Prestage GP, Grulich AE. Serosorting may increase the risk of HIV acquisition among men who have sex with men. Sex Transmit Dis 2009; 37:13–17.
4. HIV/AIDS Epidemiology Unit PH-SKC, and Infectious Diseases and Reproductive Health, Assessment Unit WSDoH. HIV/AIDS Epidemiology Report. 2004; 64.
5. Helms DJ, Weinstock HS, Mahle KC, Bernstein KT, Furness BW, Kent CK, et al. HIV testing frequency among men who have sex with men attending sexually transmitted disease clinics: implications for HIV prevention and surveillance. J Acquir Immune Defic Syndr 2009; 50:320–326.
6. Xia Q, Osmond DH, Tholandi M, Pollack LM, Zhou W, Ruiz JD, Catania JA. HIV prevalence and sexual risk behaviors among men who have sex with men: results from a statewide population-based survey in California. J Acquir Immune Defic Syndr 2006; 41:238–245.
7. Campsmith ML, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006. J Acquir Immune Defic Syndr 2009. [Epub ahead of print]
8. Centers for Disease Control and Prevention. HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men: five U.S. cities, June 2004–April 2005. MMWR Morb Mortal Wkly Rep 2005; 54:597–601.
9. Golden MR, Stekler J, Hughes JP, Wood RW. HIV serosorting in men who have sex with men: is it safe? J Acquir Immune Defic Syndr 2008; 49:212–218.
10. Philip S, Donnell D, Yu X, Vittinghoff E, Buchbinder S. Serosorting, but not seropositioning, is associated with decreased risk of HIV seroconversion in the EXPLORE study cohort. 15th Conference on Retroviruses and Opportunistic Infections; Boston, MA; 4 February 2008.
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