issue description lessons learned next step

POSTER N°WEPE 0311
Jean-Yves Le Talec
Sociologist specialist in health and sexuality / gender studies at the
University of Toulouse, France (Certop-Sagesse UMR 5044), JeanYves 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 “Acute hepatitis C in VIH+ MSM” (see
poster THPE0850).
Latest book: Folles de France, Paris, La Découverte,
2008.
[email protected]
AIDS 2008 - Mexico
THE WARNING
JANVIER 2007
SEROADAPTATION
Fiche info : la séroadaptation chez les hommes gays
Ce document est destiné en priorité aux acteurs de prévention VIH
En tant qu’acteur de prévention VIH, vous pouvez être amené
à discuter avec des gays qui vous
questionnent sur la séroadaptation
ou ce qui est aussi décrit par le
terme anglais de
serosorting.
Certains d’entreeux sont peut-être
déjà dans cette
attitude, d’autres
en ont entendu
parler au travers
de la presse et des débats dans la
communauté. Vous avez
probablement rencontré des gays
qui n’utilisent pas toujours la capote et vous vous interrogez sur
l’intérêt de la séroadaptation
comme outil de réduction du
risque.
Cette fiche d’information
vise à présenter ce
qu’est la séroadaptation et peut
donc vous servir de
guide dans vos
entretiens de
prévention. Le but
est d’aider les gays
et bisexuels à mieux connaître les
enjeux du débat et à mieux
évaluer par eux-mêmes leur
niveau de prise de risque.
Qu!est"ce que la s#roadaptation ?
La d!finition pos!e par le sociologue Jean"Yves Le Talec et Warning
est tr#s simple. La s!roadaptation est l$adaptation des pratiques
sexuelles, prot!g!es ou non, en fonction de son statut s!rologique et
celui du partenaire. S!roadapter, c$est donc d!cider le type de prati"
que sexuelle %p!n!tration anale ou pas, fellation...& et le type de pro"
tection %avec ou sans pr!so, strat!gies de r!duction des risques& en
fonction de son statut et celui qu$on per'oit ou que l$on conna(t de
son partenaire %voir ci"dessous&. ) l$!tranger, on utilise plut*t le
terme serosorting, dont la d!finition peut varier selon les pays. On en
parle de plus en plus notamment du fait de la situation de l$!pid!mie
VIH + San Francisco. Les responsables de sant! ont !voqu! la s!roa"
dapation pour expliquer un ph!nom#ne qu$on observait dans la ville.
Alors que depuis plusieurs ann!es les relations anales non prot!g!es
!taient en augmentation, on constatait dans le m,me temps que cel"
les avec partenaires de statut diff!rent ou inconnu !taient, elles, plu"
t*t + la baisse. Ceci pourrait expliquer l$arr,t constat! de l$augmenta"
tions des contaminations VIH et l$effet plateau qui s$est install!.
S#roadaptation et s#rochoix, est"ce"la m$me chose ?
Non. Le s!rochoix %ou s!rotriage&, c$est choisir de ne coucher qu$avec
des mecs de m,me statut, parfois par peur, par pr!f!rence !motion"
nelle ou tout simplement pour pratiquer le nocapote. Dans le vraie
vie, il y a des tas de crit#res qui font qu$on couche ou pas avec un
mec, parfois avec pr!so, parfois sans. C$est l+ qu$entre en jeu la n!"
gociation.
[email protected]
www.thewarning.info-
Eléments clés
pour tous les gays et bisexuels
1 - Connaître son statut
sérologique. Si un mec veut
séroadapter dans ses relations, il
devrait se tester plusieurs fois par
an. Avoir eu une IST récemment,
une relation avec un partenaire de
statut différent ou inconnu devrait
inciter au dépistage tous les 3
mois. L’usage du poppers est dans
plusieurs études, associé avec des
prises de risques (conseiller alors
aussi un test tous les 3 mois).
2 - La séroadaptation
seule n’est pas une
stratégie parfaite. Elle
est préférable à
rien du tout, mais
est semée
d'embûches.
3 - La séroadaptation dépend
d’un dialogue honnête et précis
entre les partenaires au sujet du
statut.
4 - Le préservatif reste à l’heure
actuelle l’outil le plus efficace
contre la transmission VIH.
5 - Les préservatifs protègent
aussi contre les IST, et contre la
surcontamination.
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.
[email protected]
www.thewarning.info
pour tous les hommes séropositifs
1 - En cas de doute sur le statut
de votre partenaire, il est
préférable d’utiliser un préservatif
ou d’adopter des pratiques sans
risques.
2 - La séroadaptation ne protège
pas des IST. Une IST peut
occasionner de sérieux problèmes
de santé. Le préservatif diminue le
risque de transmission des IST.
3 - La séroadaptation ne protège
pas de la surcontamination en cas
de relation nocapote.
PAGE 1
Seroadaptation instead of serosorting:
a broader concept and a more precise process model
ISSUE
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 Truong H-H M. Increases in sexually transmitted
infections and sexual risk behaviour without a
focused on a strict definition of serosor- concurrent increase in HIV incidence among men
ting as “choosing a same status partner who have sex with men in San Francisco: a sugin order the have UAI”, instead of ob- gestion of HIV serosorting? Sex. Transm. Inf.
serving how gay men manage their pre- 2006;82;461-466
vention 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).
(1)
(2)
(3)
(4)
(5)
http://www.natap.org/2004/newsUpdates/052504_02.htm
http://www.thewarning.info/IMG/pdf/swiss_english2008.pdf
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.
About “calibrated and rational risk behavior”, see Peter Keogh from Sigma Research (http://santegaie2005.thewarning.info/eng/ppt.html)
POI Motions regarding seroadaptation, SDPH, Nov. 8, 2007, http://sfhiv.org/community_hppc_full_council_2007.php