Part I: The Problem in America

The New York Times, November 27, 2003

By ANAHAD O'CONNOR

The number of new H.I.V. cases diagnosed in the United States is continuing to climb, and the most significant rise has been among Hispanics and gay and bisexual men, according to the Centers for Disease Control and Prevention.

The study by the centers, which appeared in its Morbidity and Mortality Weekly Report, looked at data from 29 states that included a confidential system that was started in 1999. The picture of H.I.V., the virus that causes AIDS, might even be much worse than the data indicate because states with the highest populations and possibly the highest rates of infection, like New York and California, were not included in the four-year study.

From 1999 through 2002, the number of new H.I.V. cases soared by 26 percent among Hispanics and by 17 percent among men who have sex with men, while the increase in new cases over all for that period was 5.1 percent, according to the study.

"Because more effective treatments are available, there seems to be a perception particularly in the gay community that H.I.V. is a manageable disease," said Dr. Robert Janssen, director of the division of H.I.V. and AIDS prevention at the centers. "Most of the increase in the Latino community is due to men having sex with men. I think the disease just doesn't have the fear that it once carried."

Several other groups also showed increases in the rate of diagnosis. African-Americans still make up the largest portion of new cases, at 55 percent, while whites accounted for 8 percent of the new cases, the study found. The numbers for men in general went up 7 percent.

Whether the study's findings reflect higher rates of H.I.V. infection is difficult to say because some cases are not diagnosed immediately.

But if that was a factor, Dr. Janssen said, the study would have detected more cases that had progressed to AIDS. Instead, he said, rates of testing have stayed about the same and many of the recently detected H.I.V. infections were caught in the earlier stages.

"We're seeing an increase in people with H.I.V. but not necessarily an increase in simultaneous diagnoses of H.I.V. and AIDS," he said.

The new findings reinforce the notion that there is a growing sense of complacency among groups at the highest risk for contracting the disease. Advances in AIDS treatments in recent years, some experts are saying, could be undermining efforts to promote safe sex. The latest figures, in that case, might reflect a more widespread willingness to engage in risky behaviors.

Earlier this week, for example, the centers released figures showing that rates of syphilis infections had risen sharply in 2002 for the second consecutive year. Gay and bisexual men accounted for a disproportionate number of those cases, Dr. Janssen said, and in most cities more than half the men involved in the outbreak also had H.I.V.

Dr. Jeffrey Laurence, program consultant for the American Foundation for AIDS Research in New York, said: "Even among populations targeted for outreach, it's as if people think they can become infected because there's a pill to take care of them. There needs to be a stronger message that it's not a picnic to be on these drugs and that even when you're being treated you can still transmit this disease."

Efforts to promote AIDS prevention and convey the gravity of the disease have not reached Hispanics and other minorities, experts say. Too often, Dr. Laurence said, AIDS education programs rely on blanket messages that are too weak to combat the widespread images of healthy, resilient AIDS patients in drug advertisements.

"There's such a striking disparity among Hispanics and blacks that we're obviously not doing a good enough job of targeting them and conveying the right idea," he said. "Here's a population that is not responding to the messages we're sending. Perhaps it is because that message is getting stale."

More than 850,000 Americans are infected with H.I.V., the greatest number since the AIDS epidemic started in the early 1980's. According to the centers, about 40,000 people in the United States are infected with H.I.V. every year.

[Additional content from The Washington Post, November 27, 2003:]

Several European countries and Australia have also seen a rise in the number of new HIV diagnoses in gay men in recent years.

Information about the course of the AIDS epidemic in the United States is surprisingly sketchy. Before the arrival of life-extending treatments in 1996, the number of deaths from AIDS each year gave a good-- if very delayed-- indication of the number of infections that occurred each year in the past. But since then annual AIDS mortality has been cut by about 90 percent. Because many HIV-infected people never progress to AIDS, death rates from the disease are no longer an indicator of annual infection rates.

In the early years of the epidemic, many states did not require mandatory reporting of people diagnosed with HIV. Some states, including California, have only recently begun efforts to collect HIV case statistics. Because all states do not collect this information and the data from states such as California are not considered reliable, epidemiologists cannot say whether the available data from states with confidential HIV reporting reflects national trends.

The CDC is setting up a program that will estimate the number of new infections each year through national sampling, but it is not ready.

Although the new HIV diagnoses in gay men reported by the 29 states are not necessarily all recent infections, CDC researchers believe most are. That is because the number of new AIDS cases each year is not rising substantially, indicating that the new diagnoses are generally not in people who are tested for the first time when their disease has progressed to AIDS.

Among the 29 states, the number of gay and bisexual men whose cases were newly diagnosed in 1999 was 9,988. It rose to 11,686 in 2002, an increase of 17 percent. Overall, 42 percent of people whose HIV was diagnosed in that four-year period contracted the infection through male homosexual contact, 17 percent through use of injection drugs and 35 percent through heterosexual contact, with the remainder unknown.

Epidemiologists estimate that one-quarter of the estimated 750,000 to one million Americans infected with HIV do not know they are infected with the virus.

[The New York Times, 11/27/03; Washington Post, 11/27/03]

By ERICA GOODE

SAN FRANCISCO -- He is safe most of the time.

Use-a-condom safe. Protect yourself and your partner safe. Are you positive or negative safe?

But there are also times when Seth Watkins, or Twilightchild, as he is known in the personal advertisements he places on the Internet, is not so careful.

For example, when he visits the back room of the Powerhouse, a bar on Folsom Street, and has unprotected sex with men he does not know.

Or, when, lonely and ''in a depressed state,'' he drinks too many Malibu pineapples and finds someone he hopes to see again, as happened one night last summer, he said, the night he believes he became infected with H.I.V., the virus that causes AIDS.

Mr. Watkins, 24, is an H.I.V. prevention educator and counselor in San Francisco. He knows how H.I.V. is transmitted and how to avoid becoming infected.

But like an increasing number of gay men in San Francisco and elsewhere, Mr. Watkins sometimes still puts himself and possibly other people at risk.

''I don't like to think about it because I don't want to give anyone H.I.V.,'' Mr. Watkins said. Yet his lapses also do not draw the concern and censure from his peers that they might have even a few years ago.

His friends, he said, all take similar chances. He is acquainted with more than a few men who practice barebacking, as unprotected anal sex has come to be called. And in the gay newspapers he reads, condom use, once a rallying call, has become a subject of controversy and debate.

Twenty years after the AIDS epidemic emerged in the United States, public health experts are facing a new and perplexing challenge: AIDS, once a bold and flamboyant killer, a ''T. Rex in the living room,'' as one expert put it, now seizes its prey more quietly. New treatments can keep the disease at bay, and hyper-vigilance is no longer always an easy sell.

So prevention workers in San Francisco find themselves desperately preaching to a choir they thought was long ago converted: gay men, who were among the first to contract AIDS in this country, the first to demand attention for the disease and money to fight it and the first to mobilize safe-sex campaigns to prevent the spread of the virus.

In many cases, the prevention slogans that galvanized gay men in the early years of the epidemic now fall on deaf ears. Many gay men remain meticulous in taking precautions, and many are in long-term monogamous relationships. But surveys of gay men in San Francisco and in other cities indicate that an increasing number, young and old, H.I.V. negative and H.I.V. positive, are engaging in high-risk sexual behavior.

Unprotected anal intercourse, which carries a high risk of transmitting the AIDS virus, is becoming more common in bars and in sex clubs, at so-called circuit parties, where illicit drugs are used frequently, and in private sexual encounters, many of them arranged over the Internet.

The complex psychology that underlies sexual risk-taking is in most ways no different among homosexual men than among heterosexuals, and informal surveys suggest that risk-taking is increasing for gay men in other urban areas, too. But public health experts here track new infections and high-risk sexual behaviors more closely than in many cities.

For example, one survey by the Stop AIDS Project, a nonprofit organization in San Francisco, found that the number of men who reported using a condom ''every time'' during anal sex dropped to 49.7 percent in 2000 from 69.6 percent in 1994. In that same time, the survey found, the number of men having such unprotected sex with more than one partner increased to 48.8 percent from 23.4 percent. One-third of those men said that they either did not know their partners' H.I.V. status or that they knew it was different from their own.

At the same time, public health officials say, a variety of indicators used to monitor the spread of H.I.V. suggest that, after years when new infection rates among gay men here were stable or declined, they are now on the rise. And nationally, studies have indicated that H.I.V. infection rates are increasing among young gay men.

''I think the promiscuity of the 1970's is back,'' said Dr. Virginia Cafaro, an H.I.V. specialist in San Francisco, who said she was seeing more men who were newly infected, and hearing more accounts of high-risk sexual behavior in the gay men she treated.

''The party scene is much more active, the sex clubs are back in bloom and the Internet is just an incredible avenue for people to meet,'' Dr. Cafaro said. ''They go on line, introduce themselves and an hour later there's a stranger at your door.''

In surveys and interviews, some gay men say that where once they received pressure from sexual partners to use condoms, they are now pushed to avoid them. At a focus group, convened in June by the Center for AIDS Prevention Studies of the University of California at San Francisco to try to understand why risk-taking is increasing, one man put it this way: ''You pull out a condom and they say, 'Why are you using that?' ''

Dr. Mitchell H. Katz, the director of the San Francisco Department of Public Health, said health officials were now dealing with a different problem that required more sophisticated prevention tactics.

''Certain death was a powerful motivator for safe sex,'' Dr. Katz said. ''If you don't realize that H.I.V. has changed, you wonder, How can these guys be doing this after all we went through, after all we've lost?''

Better Drugs, Less Fear

Only a few years ago, gaunt men in wheelchairs haunted the streets of San Francisco's Castro District. The dark blotches of Kaposi's sarcoma, a cancer linked to AIDS, flowered on cheeks and on forearms. Funeral homes struggled to meet the demand for their services.

With the advent of drugs that prolong lives, though no one knows for how long, those daily horrors have faded. Instead, there are men tied to endless pill-taking regimens, who may suffer debilitating, occasionally fatal, side effects. But they look healthy, and they have returned to offices, gyms, restaurants and bars, restored to full -- and fully sexual -- lives.

And as the obituaries have slowed, the balancing of safety and danger that is a theme in every life has shifted.

''If unprotected sex now equals longtime therapy,'' said Don Howard, who has been active for many years in AIDS-related issues in San Francisco, ''all of a sudden a lot of people who were scared are taking a whole lot of risk.''

In the years since protease inhibitors began extending lives, for example, a generation of young gay men have come of age without ever burying a friend or visiting a hospital room.

At the Cafe, a bar on Market Street that draws a younger gay crowd, a 21-year-old man says he has never known anyone who has died of AIDS. He worries about becoming infected, but he sometimes forgoes a condom anyway.

''It feels good,'' he said, ''because there's no rubber.''

For him, and for others like him, exhortations about H.I.V. are like cautions about cigarettes, illicit drugs or driving too fast, warnings from ''old people'' about distant dangers.

Older men have seen AIDS do its worst work, but some are weary -- weary enough to take bigger chances.

''The prospect of going through the rest of your life having to cover yourself up every time you want to get intimate with someone is an awful one,'' said John, 44, who found out in March that he was H.I.V. positive. John spoke on condition that his last name be withheld for fear it would cause difficulty on his job.

''Now I've got H.I.V. and I don't have to worry about getting it,'' he said. ''There is a part of me that's relieved. I was tired of always having to be careful, of this constant diligence that has to be paid to intimacy when intimacy should be spontaneous.''

He took his own precautions, he said, but almost never used condoms, though he had watched friends die of AIDS. ''There is no such thing as safe sex,'' said John, whose partner is also H.I.V. positive. ''If people want to use condoms they can. I didn't go out and purposely get H.I.V. Accidents happen.''

But later he added, ''I guess I could be seen as getting too comfortable with the level of risk I was willing to take.''

Or simply trying, perhaps, to deal with an unending fear.

''Gay men are out there wanting to meet people and every encounter is fraught with anxiety,'' said Dr. Thomas Coates, the director of the AIDS prevention study center here. ''The equations that people use are often idiosyncratic and hard to understand.''

Among men who are H.I.V. positive, most go to great lengths to avoid transmitting the virus.

''I would sooner cut off my arm than expose my lover to H.I.V.,'' as one man put it.

But there are some infected men who argue that it is not their obligation to help prevent the spread of H.I.V. This is a view shaped in part by the practice in public health of aiming AIDS prevention campaigns only at the uninfected, in the belief that H.I.V.-infected men, already stigmatized, should not be further burdened.

''There is a huge continuum of sentiment about whether H.I.V.-positive men have any responsibility toward people who are negative,'' said Dr. Andrew Forsyth, a health psychologist at the AIDS prevention studies center here.

Dr. Forsyth added: ''In any other virus you'd involve people who were infected. Here, there's this sense that you don't involve people who are positive.''

Arguing Acceptable Risks

Some gay men argue that with drug therapy prolonging lives, H.I.V. has become just one of many hazards and that unprotected sex is a calculated risk, not unlike others that rational people take every day.

''There is an interesting dialogue going on in the gay community,'' said Dr. Ronald D. Stall, chief of the behavioral intervention research branch of the H.I.V. prevention branch at the Centers for Disease Control and Prevention, which convened the National H.I.V. Prevention Conference in Atlanta Aug. 12-15.

''What we're seeing is a voicing about barebacking,'' Dr. Stall said. ''But the larger issue is helping gay men find strategies that are going to allow them to have full sexual lives without transmitting H.I.V.''

Some gay writers blame public health officials for continuing to rely on a ''sky is falling'' approach that, they say, deals neither with a changed epidemic nor with the realities of men's sexual lives.

For example, Michael Scarce, a writer in San Francisco and the author of a controversial 1999 article in POZ magazine titled ''A Ride on the Wild Side,'' contends it is unrealistic to expect gay men to use condoms every time they have sex for the rest of their lives.

Barebacking, Mr. Scarce pointed out, in many cases involves H.I.V. positive men having unprotected sex with men who are also positive, a practice many people might see as a reasonable risk, though some scientists have speculated that this practice might transmit more virulent strains of the virus.

But in any case, Mr. Scarce argues, safe sex was originally promoted as a stopgap measure, a temporary solution until medical experts ''figured out what's going on.''

''We've never really gotten back to gay men and said, 'Medical science is not going to have a cure around the corner and what does this mean for safer sex to become a permanent part of your life,' '' he said.

In fact, on the X-rated Web site Barebackjack, the site's host compared the decision of an H.I.V. negative man to have unprotected sex to skydiving.

And some men -- a tiny minority, according to public health experts and advocates for AIDS prevention -- actually court infection with H.I.V. or transmit the virus to others who express a wish to be infected, practices that have been called in the press ''bug chasing'' and ''gift giving.''

Yet to Jeff Getty, a founder of Survive AIDS in San Francisco who has lived with H.I.V. for two decades, any rationale for unprotected sex is incomprehensible.

''I can't imagine someone being H.I.V. negative and taking risks with this disease,'' Mr. Getty said. ''This morning my back is out again, I have sciatica, I have a herpes shingle going right up my back. I'm just now finishing all my drugs. Yesterday I had to take injections to make my bone marrow grow, and my life is no fun. Sometimes I wish I were dead.

''If somebody was H.I.V. negative, and I could transport them into my body for a few days and let them feel the pain, I think they'd have a whole new understanding about the risks they're taking.''

Strong Emotions, Human Lapses

On a kiosk at the corner of Market and Castro Streets, a poster that is part of a prevention campaign by the San Francisco AIDS Foundation, shows two men in a sexual embrace.

''He'd tell me if he's negative,'' one man is thinking.

''He'd tell me if he's positive,'' the other man thinks.

''How do you know what you know?'' the poster asks.

Fatigue, denial, rebellion or political philosophy may underlie some high-risk sexual encounters.

But far more common, say psychologists who study risk behavior, are the simple lapses of human nature and the elaborate rationalizations the mind is capable of producing.

Many men, like Mr. Watkins, who said he always carried condoms in his pocket and had them at his bedside the night he believes he became infected with H.I.V., have every intention of staying safe, yet are derailed by a night of loneliness, a plunge into depression, a beer too many, too much speed or cocaine or a sexual attraction so powerful they are, at a critical moment, caught off guard.

Such missteps are hardly the exclusive province of gay men; they are familiar to any woman who has left her diaphragm in the dresser drawer, to any former smoker who decides to have ''just one,'' to any partygoer who, knowing he is intoxicated, still gets behind the wheel.

Lines are drawn, then crossed. Assumptions remain unquestioned, questions remain unasked. Promises are made, then broken.

Joseph Simons holds a degree from Northwestern University, speaks four languages fluently and as ''a good Catholic boy'' growing up in St. Louis he prayed the rosary after Mass every Sunday.

But one night, recovering from the breakup of a relationship and driven by anxiety and compulsion, he donned his Levi's and butterscotch vinyl jacket, drove to an adult bookstore, paid $3 to enter a grimy, dimly lit booth with a hole in the wall and had unprotected sex with two men.

''I certainly didn't look at my calendar and say tonight's the night I'm going to the bookstores,'' Mr. Simons said.

But he wonders how his ''highly functional'' self fits with the man who had sex ''in a dark booth on Folsom Street.''

Mr. Simons said he used to have nightmares about AIDS. Once, he woke in a cold sweat, turned on the lights, retrieved a can of red spray paint from the closet and wrote ''K.S.,'' for Kaposi's sarcoma, on his bedroom wall, as both a reminder and an exhortation.

He takes antidepressants now, and they help. But they can do nothing about the virus now in his body, which he is convinced he contracted that night at the bookstore.

For Vince, a vice president of an online services company, who spoke on the condition his last name not be used, risk came with a spur-of-the-moment impulse to visit a sex club after seeing a movie with friends.

''I was definitely in a period of depression,'' he recalled. ''I've always used a condom previously. I also have been very, very conservative sexually just in general because so much is unknown still.''

But with the man he met that night, he acted differently.

''I'd never actually experienced unprotected sex before,'' Vince said. ''And there was just something about that particular circumstance and that particular person. I don't know how to describe it. It just appealed to me; it made it seem like it was all right.''

He was terrified afterward, as was Justin Lampe, a 30-year-old nurse who, late one December night, believing he might have become infected with H.I.V., wrote with red ink in his journal: ''Red means stop. If I am, I have to find the strength to find hope and happiness in my life. If I'm not, never let me forget this red ink and the feelings of terror I'm going through.''

Both men sought treatment at a clinic at San Francisco General Hospital, which offered antiviral drugs and counseling to people who had reason to believe they had just been exposed to H.I.V. In some animal studies, such prompt treatment has been shown to prevent infection. And in health workers exposed to H.I.V., such preventive treatment has been found to reduce infection by 81 percent. Both men remain H.I.V. negative.

Dr. Michelle Roland, an assistant professor at the University of California at San Francisco and a principal investigator in a study of post-exposure prevention, said that many men who sought such treatment were depressed, and that depression often underlay their ambivalent behavior.

''They're all walking in expecting to be told that they've been bad,'' Dr. Roland said, ''and instead I tell them, 'I'm so glad you came in, we can really help you.' ''

She drew an analogy to women's often-conflicted feelings about their use -- or failure to use -- birth control and to other efforts that people make, in the face of strong temptations, to bring their behavior in line with their best interest.

''In my own experience,'' Dr. Roland said, ''once you let yourself cross that line even for a second, you've screwed it up completely. It's extremely difficult to stay clear.''

Studies indicate that a variety of circumstances increase people's vulnerability to sexual risk-taking. For example, gay men who were sexually abused as children, a study by Dr. Jay Paul and his colleagues at the AIDS prevention studies center here suggests, are more likely to engage in unprotected sex as adults. Drugs and alcohol play a large role.

And in one study, still unpublished, Dr. Grant Colfax, the director of H.I.V. Prevention Studies at the San Francisco Department of Public Health, and his colleagues found that men who met sexual partners on the Internet were more than four times more likely to have unprotected sex with a partner of unknown or opposite H.I.V. status.

In addition, many men, like many women, have little skill in negotiating condom use, and little desire to interrupt an amorous encounter for a technical discussion of the chances of being infected with H.I.V.

''For the positive guy, the fantasy is that he's not infected and he's not a danger to other people,'' said Dr. Walt Odets, a clinical psychologist in San Francisco and the author of ''In the Shadow of the Epidemic: Being H.I.V. Negative in the Age of AIDS.'' ''For the negative guy, the fantasy is that his partner's not infected and the negative man is not putting himself at risk.''

And sex without condoms exerts a strong attraction.

''There are natural, important, powerful feelings about having unprotected sex,'' Dr. Odets said. ''No one has ever liked condoms, men or women. They make a statement in the middle of this potentially intimate act that you might kill each other.''

For a man to disclose that he is H.I.V. positive, Dr. Odets said, involves delicate timing and complicated emotions -- including the fear or being rejected or appearing weak.

Mr. Watkins, for his part, said that neither he nor the man he took home that night brought up the subject.

''We were just so attracted to each other,'' he said, ''and we wanted to have sex. Neither of us was in a state to really want to discuss it.''

Afterward, when the man, still very drunk, went home, Mr. Watkins said he cried a little because he felt lonely and wondered what he had done and why he had done it. He cried again when he learned he was infected.

''I have had to come to terms with the fact that I wasn't always practicing what I was preaching,'' Mr. Watkins said.

He tries to draw the lines more firmly now. He has his rules, the things he will and will not do.

But he is only human. ''I came to realize I was just another gay man,'' he said, ''and I was allowed to make mistakes too.''

AIDS at 20: Taking Risks

Chart: ''Gambling with H.I.V.''

A recent survey of gay men in San Francisco found that the percentage who reported having multiple partners and unprotected anal intercourse had increased.

'94: 23.6

'95: 25.1

'96: 28.1

'97: 33.3

'98: 36.8

'99: 43

'00: 47.1

(Source: Stop AIDS Project)

The Boston Globe, November 4, 2003

Reported by Bella English and the Globe Staff

It was two weeks after Nate Longtin's checkup that the doctor called and asked him to come back to the office. Longtin was worried, but his roommate brushed it off: "She just wants to charge you for an office visit, man." But when the young man arrived for his appointment, his heart began to race and he broke out in a cold sweat. Cancer, he thought. It had to be cancer. His father had a brain tumor in his 20s, and his grandmother had recently died from cancer.

The doctor came in and sat down. "Nate, I don't have good news," she said. "You're HIV positive."

Longtin was stunned. Yes, he was gay, and yes, he'd had "unprotected" sex. "Still, it was the last thing I expected," he recalls. "I had not been promiscuous. When you're 23, you just don't think this is going to happen. You think you're invincible. It's like drinking and driving: You never think you're going to crash the car."

A generation after the AIDS epidemic cut a devastating swath through the gay community, the number of gay young men who are newly infected with the virus is alarming. Despite 20 years of warnings about "unsafe" sex-- and seeing the deadly results of the plague-- gay men between the ages of 18 and 24 do not seem to be getting the message.

The new face of HIV is not the old face. Thanks to the "drug cocktail" that can keep opportunistic infections and full-blown AIDS at bay for years, many people today with HIV are living with it, not dying from it. So the message received by a new generation of gay men is that HIV is just another sexually transmitted disease-- that, like syphilis, it's treatable, not life-threatening.

As a result, risky behavior is up. According to the Massachusetts Department of Public Health, 13- to 24-year-olds made up 8.7 percent of new HIV cases in Massachusetts in 2002, compared with 6.1 percent in 1999-- an increase of more than 40 percent. And in a two-year HIV vaccine trial conducted in Boston, doctors found the rate of new infection among young males more than double what they had anticipated.

"The reasons are very complicated," says Larry Kessler, founding director of the AIDS Action Committee of Massachusetts. "It's a new generation, and they didn't witness the devastation of the '80s and the first half of the '90s. The second thing is, there are drugs now, and I think that has added to an illusion that this is not a serious disease."

It is this complacent, even cavalier attitude toward a still-deadly disease that worries those who work with gay men. Dr. Kenneth Mayer, medical research director at the Fenway Community Health Center, recently ran a study that showed substantial levels of "unprotected" sex among young gay men.

"I think what happens with a lot of young men is that they grow up with AIDS as a given, but a manageable given," says Mayer, who also directs Brown University's AIDS program. "In a country like this, where there are medicines and a high level of education, two decades into the epidemic, the numbers are very distressing."

When Longtin told his roommate he had HIV, the man responded: "Phew, I thought you were going to tell me you had cancer."

Longtin himself was not so sanguine. "It just blew me away," he says. "I had thought about [getting HIV] a few times, and fantasized that I would just run away, maybe drive my car off a cliff, Thelma-and-Louise-style."

It's not that he didn't know about the disease or how it is contracted. In bucolic Bennington, Vermont, his high school taught health education, which included sessions on HIV/AIDS. But mostly the message was about heterosexual sex and how a teen pregnancy would ruin your life, he recalls. When he came out to his parents after graduation, they were loving and supportive. "My dad said, 'Just be careful. HIV is prevalent among gay men.'"

Longtin didn't give it much thought; he hadn't yet had a sexual partner. His senior year in high school, he'd interned at a local radio station, and he took a job there upon graduation. In 2001, he moved to the Boston area and went to work at Radiocraft in Southborough, where he helped produce syndicated radio shows.

He soon settled into what he considered a serious relationship. They were together nine months but broke up in the spring of 2002. "I started going out and drinking a little more," says Longtin. He met a man at a bar. After a few dates, they had sex.

"A couple of weeks later, he stopped answering my calls," says Longtin, who is now 24. Among his friends, Longtin is known as thoughtful and careful: He doesn't cruise bars or go online looking for an anonymous hookup. "My preference is a monogamous relationship," he says.

Mayer, who has worked with HIV-positive patients for 20 years, notes that the infection rate for older gay men is also up, though not as drastically as for younger men. He recently heard a young man declare that "having HIV is like having herpes. It's just something you live with." To Mayer, such thinking is dangerous. He stresses to his patients that the drug cocktail are "a miracle" but not a cure. For the drugs to be effective, they must be taken every day, which many of his patients fail to do.

"If you're not 95 percent adherent, you are at great risk for the virus becoming resistant," he says.

Then there are the physiological complications and the longterm effects of the drugs. "We're concerned about other malignancies and liver and cardiovascular disease," he says. His message to young gay men: The epidemic "ain't over, and you can avoid this."

The message comes too late for Longtin, but not for his brethren. After his diagnosis, he decided to make another life change. He quit his job in radio and went to work for a nonprofit health-care agency. As a client advocate for JRI Health in the theater district, he works with HIV-positive and at-risk youth. He's a man on a mission: to spread the word that gay men need to disclose their status to sexual partners. Longtin's own partner failed to do so, even though he knew, according to a mutual friend. "He didn't say anything, and I didn't ask, stupidly," says Longtin.

So strongly does he feel about disclosure that he has become one of five Boston "spokesmodels" to participate in a national media campaign titled "HIV Stops With Me." At a recent kickoff at Club Cafe, the models each talked about why they've gone public with their status. Longtin told the crowd of gay men, some in business suits, some in muscle shirts, "I was infected needlessly. I don't think people should have to go through what I go through. If I can prevent one person from being infected, that's all that matters to me."

His poster, which is being displayed in gay bars and publications, bears the slogan "Rejection is better than infection." Since he looks and feels well, he believes he is a good model. "My message is: 'You can look healthy and not be.'" His other message, he adds sheepishly, is: "I'm a perfect example of stupidity at work."

To Longtin, disclosing one's HIV status to a sexual partner is a moral and ethical no-brainer. "I think it's just wrong not to," he says.

Not all gay men feel the same way. At a recent support-group meeting for young HIV-positive men at JRI, two of the men say they would not tell sex partners-- even though they had been infected by men who failed to tell them.

"You're known as a 'gift giver' if you have it," says one man. "There is definitely a stigma."

Another man, Lee-- he didn't want his last name used-- was infected by a man who lied about his status. "You get tired of telling people," he says. "If a person doesn't ask me and doesn't use protection, why should I care? People should protect themselves."

As the men say they won't disclose their status, Longtin shifts in his seat. Clearly it bothers him, but he later says he tries not to be judgmental. "I don't want to chase clients away," he says. "We're trying to reach them, discuss things, and let them come to the right conclusion on their own."

As for Longtin, it has been a year since his diagnosis, a year of not living dangerously. His new life includes taking his drug cocktail twice a day and living with the side effects: some dizziness and vivid dreams. He eats more healthfully, exercises more, no longer goes to bars alone, and is adamant that his message of disclosure gets out into the gay community. Most of all, he has disclosed his HIV status to any potential partners, and he will only practice "safe" sex.

"I choose to continue living my life," he says. He pauses. "But it's still a terminal disease."

[The Boston Globe, 11/4/03]

Reversal of Fortune

POZ, November 2003

by Tim Murphy

[WARNING: Strong language.]

Although VaxGen's much-hyped HIV vaccine flopped, the nearly 5,000 HIV negative gay men who tested it got excellent safe-sex counseling and support during the trial. So why did almost 300 of them end up positive anyway?

Four years ago, both Richard* and AIDSVAX were hopeful. The first HIV vaccine to reach Phase III trials, AIDSVAX was finally enrolling thousands of HIV negative gay men in 60 cities across North America (a few hundred women signed up as well). For several years, many had regularly reported the details of their sexual behavior, been tested for HIV and received safe-sex counseling as part of a massive study meant to prime just such a cohort. When the AIDSVAX trials finally opened, the participants were lauded as anonymous heroes in the search for a cure. "Rolling Up Their Sleeves to Take On a Killer," proclaimed a New York Times headline, while another publication cheered "Silent Soldiers: The AIDSVAX Army."

One enlistee was Richard, then 34. The handsome Manhattan architect and his equally handsome boyfriend, both HIV negative, shared a chic apartment and partied with the gay A-list. They didn't use condoms with each other but did when they "had sex with different people every weekend," Richard says. "It was always safe." Still, his open relationship qualified him for the AIDSVAX trial. Richard got his first shot in May 1999. "I figured it was better than not trying something," he says. "And they told me it was totally safe."

But times have changed. In February, VaxGen, the California biotech company that developed AIDSVAX, released long-awaited data showing that the vaccine did not significantly reduce the risk of getting HIV: 5.7 percent of the subjects who received it got HIV-barely less than the 5.8 percent who took a placebo. When the company suggested that the vaccine might have worked better in the small number of black and Asian enrollees, whites accused VaxGen of trying to salvage a failed vaccine, and nonwhites accused whites of indifference to promising results for minorities. Data from an AIDSVAX study in Thailand, expected by year's end, may yield more insight.

Richard found out he'd tested positive at his final study visit, in June 2002 on his lunch break. "I thought it would be like all the other times [I'd gotten results]," he says. "I was in denial."

His seroconversion-and the nearly 290 others in the AIDSVAX trials-raise prickly questions. Mere participation in the study suggested these men already had a heightened awareness of HIV. Trial coordinators firmly told them that there was absolutely no guarantee that the vaccine offered any protection against the disease. And subjects were regularly and rigorously tested, queried and counseled in what many would call the gold-standard in prevention. Even if 290 seroconversions out of 5,000 participants doesn't seem dramatic, in such a special group, why did anyone seroconvert at all?

STATS AND SLUTS

The AIDSVAX study embodied an ethical dilemma that will bedevil all HIV vaccine trials to come: It was obligated to counsel rigorously against unsafe sex, but researchers needed participants to have unsafe sex in order to weigh the vaccine's effectiveness against a placebo. "Many of these men [who enrolled] tend to be engaging in risky sexual practices," says Robin Miller, PhD, formerly of New York City's Gay Men's Health Crisis and now a psychology professor at the University of Illinois. "Men often came to GMHC hoping to learn that some breakthrough meant they didn't have to use condoms religiously anymore." His remarks echo a 2002 Canadian study finding that "gay and bisexual men who expressed willingness to participate in an HIV vaccine trial were more likely to be sexually risky." Ricardo, a thirtysomething San Francisco bartender who seroconverted in the AIDSVAX trial, puts it this way: "Sluts make better study subjects."

True? VaxGen rep Lance Ignon acknowledges that "high-risk behavior" was a desired criterion for participation-two out of five subjects initially reported regular unprotected anal sex with partners they knew to be HIV positive-but strenuously denies that VaxGen tacitly condoned unsafe sex. What's more, trial researchers said from the beginning that earlier prevention studies left them expecting a certain number of infections, at the very least in the placebo arm. "If counseling alone was enough," says Robert Hagerty, who helped run the trial site at New York University Medical Center, "we wouldn't need a vaccine."

Nor is it likely that the counselors, many of whom had long worked in gay men's prevention, planted a mixed message. "I was told this was not an invitation to be unsafe," says Jason, 25, a New Yorker who tested positive in the trial. The National Institute of Allergies and Infectious Diseases (NIAID) monitored VaxGen, and found that "all participants were strongly encouraged and supported in their efforts to reduce at-risk behaviors." Corey, 30, one of the vast majority of participants who stayed HIV negative, says his San Francisco trial counselor "helped me work out a lot of thoughts" around his discomfort with anal sex-and realize, in the end, that "I'd much rather suck dick anyway." VaxGen's own data showed that the percentage of participants who first reported unprotected anal sex fell 50 percent by the study's end.

Nonetheless, Walt Odets, a San Francisco psychotherapist and author of the 1995 book In the Shadow of the Epidemic, which has deeply influenced gay men's HIV prevention, argues that rational thinking competes with "magical" thinking during sex. "We all have fantasies of omnipotence," Odets says. "When you add to that even a tiny bit of a fact"-in this case, the off-chance of a protective vaccine-"it supports the fantasy." Prodded, Jason says he may have felt "a little bit invincible, deep down."

Odets, moreover, doubts "that these guys [in the trial] were exposed to very good prevention work. I would think it was conventional, informational-redundant for most of the guys in the trial." For his gay male patients, he says, staying negative over the long term involves "talking about sex, death, love, longing-complicated stuff. Let's say [the men in the study] had a half-hour of counseling every three months. That's not much of an intervention."

PLOT COMPLICATIONS

"He was so hot, I was drunk and stoned, it didn't seem to matter." That's how Jason describes what he believes to be his moment of HIV exposure. Ricardo also downplays his infection. "I just don't like condoms," he says. "I'm so over having my sex life regulated." But Hagerty warns against such simple explanations. "The way gay men have sex," he says, "is very complicated." Countless studies have documented the connection between HIV transmission and alcohol and drugs (crystal meth use in particular has surged among gay men). Then there's intimacy and relationship issues, depression, the mood of the moment, and the feelings attached to the other person. Says Hagerty, "You simply can't be 100 percent safe 100 percent of the time."

Consider Richard, so scrupulously safe when he joined the trial. A few months later, he and his boyfriend were so deep in their addiction to crystal-fueled group sex that they were tossed out of their Fire Island summer share. By March of 2000, there was "such a big curtain between us sexually" that they broke up. Richard found himself alone, depressed, barely holding down his job, doing more crystal than ever. For the first time, he let someone he knew to be HIV positive come inside him. When he showed up for his study visit and HIV test a few weeks later, "I was a mess...even though the results were negative. 'I hope this scares you,' my doctor said. That little pep talk worked for a week. Then my denial came back. I thought, 'Maybe the vaccine is working, or I'm fooling around with guys who are undetectable, or I have that special genetic trait.'" Richard believes his seroconversion happened the February after 9/11, after "an all-night orgy with two guys I allowed to fuck me several times, with orgasms." Serostatus was never discussed.

Or take Frank, 30, a New York City realtor who lost his job and then his apartment shortly after enrolling in the trial. "I fell into a black hole," he says. "Nothing seemed important. I might as well have died, for all I cared." He went on a long drinking binge, having unsafe sex with lots of men whose names he never knew. "It was like Dr. Jekyll and Mr. Hyde. During the day, I'd go to NYU to get my shots and dose of counseling. And at night, I was at [the Manhattan bath house] the West Side Club."

By studying these scenarios, researchers are forging new avenues of HIV prevention. Hagerty and his colleagues at NYU have started a follow-up study to the AIDSVAX trial to explore "the connection between depression and risky sex in gay men." With the help of 110 HIV negative volunteers, all of them AIDSVAX veterans, they're trying to find out if treating clinically depressed men with an antidepressant and counseling can help them stay safer. "If we find that treating depression helps people reduce their HIV risks, then this...could become part of standard HIV testing and counseling," Hagerty suggests.

GOING DEEPER

Still, these new insights arrive at a queasy time for traditional gay men's HIV prevention, as infection rates rise and the Centers for Disease Control and Prevention (CDC) proposes moving federal prevention money from community organizations to a national HIV-testing initiative. Do the experiences of Richard, Jason, Ricardo and Frank-who seroconverted despite the very sort of counseling many community groups offer-support the oft-heard claim that prevention as we know it has failed? Or do they suggest that prevention must address a changed world?

Ten years ago, there was no Internet to facilitate sexual encounters, no crystal-meth epidemic to disinhibit a generation of men who grew up terrified of condomless sex, and no med cocktails to lessen HIV's near-certain death sentence. "I knew things were different even when I started the trial," Richard says, "and while I had no desire to get HIV, I never thought I'd drop dead." Says Ricardo, "So now I have to take a few pills. Fine."

His remark may infuriate longtime HIVers who've suffered despite and because of those few pills, but it suggests a re-examination of why someone would want to stay HIV negative today. Especially young men, who may not think about their lives beyond the next few years. "I ponder this a lot," Odets says. "The incentive is reduced. But I have young patients who abhor the idea of contracting HIV. I think they would experience it as a failure and embarrassment in terms of family and friends." AIDSVAX vet Corey says he's glad he's still negative and intends to stay that way: "I won't have to deal with meds, the stigma attached, the emotional baggage."

That's a message more HIV negative men need to hear, says Odets. "We've normalized having HIV, which I think is helpful to positive men, but then what's the basis for telling other people to avoid it?" He says that for HIV prevention to stay effective it needs to push beyond "information" campaigns and tackle issues that belong more in the realm of the therapist's couch, like self-esteem and internalized homophobia. "When people feel better about themselves," he adds, "about their potential for a meaningful relationship or work, they take better care of themselves."

Group-oriented models-which pull gay men out of isolation and into a community-are another approach. In such settings, Odets says, gay men "learn about how they affect people, how people affect them, how to communicate-it's a little model for society." He says the San Francisco prevention group Stop AIDS Project (www.stopaids.org ) has asked him to lead a group for HIV negative men this fall. And he points to the Seattle agency Gay City Health Project (www.gaycity.org ), which invites gay men to not only sign up for its campaigns but to help create them.

Fred Swanson, Gay City's executive director, recalls a recent conversation with a program volunteer, a 32-year-old HIV negative man who'd been having risky sex. Says Swanson, "He told me that before he got involved [with us], he hadn't understood what it meant to be part of the gay community, that his only way of finding the connection that he longed for was hooking up. He felt like his life wasn't valuable. Gay City showed him that he belonged to something greater. He's had a loss of desperation."

Still, Gay City's approach demands frank talk about gay sex-the kind of candor that many say has led conservative lawmakers to goad the CDC into conducting two aggressive audits in the past year of the federally funded Stop AIDS, also known for its provocative programs. Cherishing its freedom, Gay City has stopped requesting federal funds, getting by on state and city dollars, plus research grants. But other groups may not survive without that money, especially those serving low-income gay and bisexual men of color, whose rates of new HIV infections make AIDSVAX's 290-some seroconversions look like small change.

Meanwhile, Richard has lost his own desperation, which he credits to the wake-up call of his HIV diagnosis. The next day, he entered recovery. Today, he's happily employed again, attends church weekly, and has started a "mature, loving and completely monogamous" relationship with an HIV negative man.

Does he regret getting HIV? "It's hard to regret something that's had such positive outcomes," he muses. "I'm not on meds yet. Ask me that when I have my first side effects or signs of the disease. Right now I'm just sort of benefiting from it."

* some names have been changed

The San Francisco Chronicle, May 4, 2003

by Christopher Heredia, Chronicle Staff Writer

The use of crystal methamphetamine has reached epidemic proportions among gay and bisexual men, and San Francisco health officials are warning that the mantra of HIV prevention-"safe" sex-- has been drowned out by a raucous scene of loud party music, cheap meth and reckless intercourse.

Health experts estimate that up to 40 percent of gay men in San Francisco have tried crystal meth, a powerful form of what's commonly known as speed. Even more alarming, a Health Department study last year found that at one high-risk clinic, 25 percent to 30 percent of those with new HIV infections reported crystal meth use in the previous six months.

At a meeting about crystal meth in Sacramento last month, California's top HIV prevention officials came up with the smoking gun of all statistics: Gay men in California who use speed are twice as likely to be HIV-positive than gays who don't use it.

To be sure, the problem of methamphetamine use is not confined to gay and bisexual men who like to party. Law enforcement officials say meth use has spread to the suburbs, particularly among teens facing boredom, peer pressure and undiagnosed psychological problems. Yet nowhere is the meth concern greater than in the gay community and its teeming subculture of partygoers who attend weekend-long events dominated by alcohol, drugs, sex and ramped-up dance music. Dancers become one with the pulsating beat, their bodies turned into wildly rhythmic instruments of vibration.

Dr. Jeffrey Klausner, director of sexually transmitted disease prevention and control for the San Francisco Department of Public Health, is convinced of the dangers. "We have all sorts of levels of evidence," he said, "and it's all pointing in the same direction: The crystal meth epidemic is playing an important role in increasing sexual risk behaviors, and that is leading to new HIV and STD infections."

San Francisco officials are planning a televised hearing at 6 p.m. Wednesday on crystal meth use in the gay community. The City Hall gathering will include public health authorities, recovery program officials and members of the gay community.

There are various reasons why the demand for the drug has grown among the Bay Area's gay community. It's cheap - $30 for a high of several days - easy to get, and powerful. It increases sexual stamina and eases the pain of depression or loneliness. Others find it makes them feel invulnerable - if only for a night.

After cigarettes, alcohol and marijuana, speed is the most commonly used drug in the gay party scene. Known also as "crissy," "tina," "tweak," and "crank," crystal meth is a powdery substance that can be swallowed, injected, snorted or smoked.

It appeals to men along any paths of life: lawyers to waiters, stockbrokers to health-care workers - all have succumbed to the drug, a stimulant that mimics the body's natural adrenaline. Derived in the early 1900s from amphetamine, it was first prescribed, then made available over the counter, in decongestants and bronchial inhalers.

Illicit makers quickly learned how to manufacture the drug cheaply and in mass quantities. The chemical make-up of meth is similar to that of amphetamine, but experts say meth has a stronger effect on the body's central nervous system. Like amphetamine, it brings about heightened activity, reduces hunger, and temporarily promotes a sense of well-being.

"It's the perfect drug for gay men," said Michael Siever, director of the Stonewall Project, a speed recovery program for gay men at UC San Francisco. "What else allows you to party all night long whether you're dancing or having sex? ... at least, at first - before it becomes a problem."

More and more, the dance is becoming a dance of death. For when the music stops, there'll be more HIV-positive men than there were, say, before the evening began. There'll be more meth users who've found they've crossed into addiction - it's a tough drug to kick. More immune systems of HIV-positive men will have been compromised, abused, treated harshly. More doses of medicine will have been forgotten, or just ignored.

The question is not, is crystal methamphetamine being used in the gay community? The question, said Dr. Grant Colfax, director of HIV prevention studies with the San Francisco Department of Public Health, is instead, can the use of speed go much higher?

It could be said that Colfax belongs to an elite circle of health workers who maintain the most knowledgeable insights into the sex habits of the gay community and who track the progress of AIDS like a security guard on maximum alert. And his chilling, current-day viewpoint is this: "We have a dual epidemic - a speed epidemic and an HIV epidemic that are both increasing."

Klausner not only blames crystal meth for new HIV infections, but also for the increase in syphilis and gonorrhea. According to Klausner, 25 percent of gay and bisexual men testing positive for syphilis reported recent speed use. In addition, HIV-negative gays who used meth were three times more likely to have rectal gonorrhea than nonusers.

Yves-Michel Fontaine, coordinator of substance abuse counseling and education at the Gay Men's Health Crisis in New York, said: "We are seeing more cases of crystal meth use than in the past. We're definitely concerned about it, as are the gay men who are coming in for counseling."

In California, a statewide study found that among the gay and bisexual men tested in 2001 and 2002 at publicly funded clinics, 7.1 percent of meth users were HIV positive, compared to 3.7 percent of those who didn't use meth. Of the total 63,098 gay and bisexual men who were tested, 10.5 percent, or 6,637 men, reported meth use.

Researchers found that condom use was lower among gay men who use speed. For receptive anal intercourse - the riskiest form of sex - officials found that 39.2 percent of gay non-meth users "always" use a condom, compared to 24.6 percent for meth users.

Consider one sure-fire indicator of the presence of crystal meth: the number of people asking for help getting off it. Say you seek help in San Francisco - anywhere in San Francisco. Your name goes on the bottom of a long waiting list. You have to wait at least a full month.

Three crystal meth treatment programs operate exclusively for gay and bisexual men in San Francisco. Meanwhile, Narcotics Anonymous chapters, complete with their time-tested 12 steps, are sprouting up in this city, as well as in Seattle, Palm Springs, Atlanta, Philadelphia and New York.

Experts have shown that heavy methamphetamine users, those who do two to four grams a week, can suffer serious brain damage. Heavy meth use has been shown to be the equivalent of 40 years of aging, affecting movement and memory.

Although speed creates a sense of euphoria, it is actually knocking out the brain's ability to produce dopamine, which is how the brain naturally creates the sensation of pleasure. The addict then becomes desperate for his fix because the drug offers a sense of well-being.

"People are using the drug to feel better," said Dr. Nora Volkow, the new director of the National Institute on Drug Abuse, "but they are literally selling their soul to the devil."

While the effects of infrequent use of methamphetamine are unknown, experts say the good news is that studies show that heavy users who quit regained some of the brain's ability to produce dopamine.

A San Francisco Department of Public Health study, published in February, of gay and bisexual men who frequented late-night dance clubs, parks after hours, sex clubs, and adult bookstores found the incidence of recreational drug use extremely high:

. More than three-fourths of the 350 men in the street-based survey reported use of non-injection drugs. Half said they had tried methamphetamine in the previous three months.

. Three-quarters of the men said they had had 'unprotected' anal intercourse in the same time period.

. Nearly one-third of the men surveyed either said they already had HIV or tested positive for the first time, which indicates they possibly had transmitted HIV to casual sex partners while using drugs.

The study's authors concluded that the late-night party set is clearly contributing to the rise in HIV infections and there is "urgent need" for heightened HIV prevention outreach at these venues. "We're continuing to see guys who have been HIV-negative for years start using speed," Colfax said, and subsequently contract the AIDS virus.

Crystal meth is anathema to 'safe' sex. It leads to rougher sex and uninhibited, risky sex; condoms are failing, or men simply aren't using them. Men on speed say that meth tends to make them "instant bottoms" - the receptive position in anal sex - because the drug induces temporary erectile dysfunction.

"We're trying to de-link substance use from risk behavior, to get guys to be safer while using substances," Colfax said. "People use it and they're not able to assess their risk behavior. We have a lot of work to do."

Colfax concedes that not all men become addicts, but says even the occasional or weekend user puts himself at serious risk for contracting HIV.

He wants the full array of programs - treatment, counseling, prevention - tailor-made to the occasional user. Members of that audience fall below the drug-dependency radar, Colfax said, and walk around believing they're risk-free.

But the pitfalls of addiction lie just around the corner. "Guys start with weekend use and it accelerates," said Board of Supervisors President Tom Ammiano, who is co-sponsoring the crystal meth hearing Wednesday with Supervisor Bevan Dufty. Both Ammiano and Dufty are gay and said they're now hearing of incidents in which men can't function at work because they're still under the influence of meth from their weekend parties.

Abstaining from speed doesn't induce the severe withdrawals or vomiting associated with heroin, but those who stop taking meth often face depression, agitation and intense cravings for the drug. What's more, experts say, speed's strong association with sex and partying make it all the harder to kick.

The police have stepped up narcotics enforcement at late-night dance clubs and on the Internet to staunch the wave of speed flowing into the party scene. But in San Francisco, possession of methamphetamine is only a misdemeanor-- a frustration to police who want to mandate that people get treatment.

All one has to do to find speed is log onto several Web sites, where speed is traded using code words. In the clubs, men exchange what are known as "bumps," or snorts, on the dance floor or in rest room stalls.

"It's extremely prevalent," said Capt. Tim Hettrich, head of the San Francisco Police Department's vice unit. "We're trying to kick a- as much as we can. We go out to the clubs and make a buy. That's one guy. Once others see that happen - we're dead in the water for that club for the rest of the night. We're trying to get the major suppliers."

San Francisco prosecutor Liz Aguilar-Tarchi, who leads the district attorney's narcotics unit, says the problem is exacerbated by sex club and dance club owners who turn their backs on drug use.

"How can it be that the club owners' security does not know?" she says. "They are aware. 'Culpable' is a strong word. I haven't seen any evidence they are involved, but they sort of shut one eye to it."

Prosecutor Jim Hammer said the solution is getting more people into treatment programs early on. At a late-night dance club, he pointed out to a friend that there was no line for alcohol. "You could get a beer without standing in line," Hammer recalled. "Yet when you walked out on the dance floor, people were obviously on something. I think it's a terrible tragedy, especially for the younger people coming out."

Gay dance party promoter Don Spradlin said he had gone to great lengths to keep drugs out of his events, which include the annual Gay Pride dance party in City Hall and the Halloween Hell Ball in October. But invariably the drugs get in, past the pat downs of security guards, past the roving eyes of bouncers with flashlights. So Spradlin also posts health pamphlets and provides plenty of condoms at the club.

Spradlin, 56, a gay man, said health officials and the gay community must address issues of self-esteem and addictive behavior. The "use-a-condom-every-time" message of the 1980s doesn't work anymore, he said.

The danger of crystal meth has been kept under cover, most agreed, by its cloak of shame. Gay men have stopped talking about condoms, and crystal meth use among friends is kept quiet.

A forum on the subject last fall at the Gay, Lesbian, Bisexual and Transgender Community Center was sparsely attended, much to the regret of outreach workers.

"It's unraveling our community," said Jed Herman, a Stop AIDS Project worker who has heard of meth's destructive toll on not only the user but also on lovers, friends and families. "I don't know what the answer is. The obvious problem is getting people in the door who are clearly at high risk for HIV transmission."

Herman said the Stop AIDS Project's Crissy campaign, which encouraged men to get help if they thought they had a problem, quickly ran out of money. One of the dangers of crystal that hasn't been broadcast widely is that mixing it with Viagra can raise heart rate and blood pressure and lead to death. Men on speed commonly use Viagra to counteract the erectile problems caused by meth.

Dufty, the supervisor, is hoping the City Hall hearing will further discussion to combat speed addiction. "To the untrained eye, it's invisible," Dufty said. But it's also widespread. It's a currency that's being traded like dollar bills all around our community. It's impacting people in their 20s, 30s, 40s and 50s."

The Dallas (TX) Observer, November 13, 2003

By Mark Donald

"I hear AIDS isn't so bad," says the boy. "You just take some medicine, and they give you lots of free stuff."

He can't be more than 18 or 19, brown hair, tight T-shirt, tighter jeans, light blue eyes that have yet to be deadened by the street. It's obvious what he wants: a quick hustle, sex for money, drugs, his next meal. Yet he approaches Neal Shaffer with some caution. Maybe he pauses because of the time and place: a balmy September afternoon behind "the strip" on Cedar Springs Road in the parking lot of the AIDS food pantry. Maybe it's Shaffer's gait, which is slowed considerably by nerve damage that even morphine can't relieve. Or maybe it's Shaffer's black tote bag, standard issue for all pantry consumers and the mark of an AIDS survivor on the dole."Hey, can I talk to you for a second?" the boy finally says.

"Why? I don't have any money. I am here for the food pantry."

"Oh, this is that AIDS place, isn't it?" says the boy, referring to the AIDS Resource Center sign posted on the rear of the mostly pink brick building.

Shaffer nods his head, wondering if playing dumb is part of the kid's come-on.

"If I go in there, will they give me free food?" asks the boy.

"It's not that easy," Shaffer says. "You have to have AIDS before they let you have food."

"I hear AIDS isn't so bad," says the boy. "You just take some medicine, and they give you lots of free stuff."

Shaffer may be feeling fatigued, but a look of shock still registers on his face. "Believe me, it's not a good thing. It hurts; it hurts a lot. Don't be fooled. It's not something you want to get."

The boy smiles coyly. "The only thing I'm going to get fooled by is fucking someone and not getting paid for it."

"You do what you have to do," Shaffer tells him. "Just make sure you wear protection."

"But then I can't feel it," says the boy, obviously trying to entice. "I like to feel it."

There was a time when Shaffer had both the strength and the inclination for this kind of play, but not anymore. He has been sick too long, he has been celibate too long, and he begins to walk away. "Trust me," he says. "AIDS sucks."

By the end of 1996, the news was good. HIV, the AIDS virus that had left more than 300,000 people in the United States dead, created chaos within the gay community and scared the hell out of everyone else, might be on the verge of being eradicated. Cover stories in such national publications as Newsweek ("The End of AIDS?") and The New York Times ("When Plagues End") made it seem almost a certainty. "Something profound has occurred within the last few months," claimed Andrew Sullivan, the Times writer, who is HIV-positive. That something was the availability of a new class of drugs in the AIDS pipeline, protease inhibitors, which suppress the irascible human immunodeficiency virus to undetectable levels in the blood, particularly when mixed in combination with another class of antiretroviral drugs already on the market.

These "cocktails" weren't a cure, but the drugs seemed to bring the dead back to life. HIV-positives whose disease had progressed to full-blown AIDS and who had been wasting away--their emaciated skin marked by legions of lesions, their internal organs an opportunity for parasites of all persuasions--got their cocktails and got better. Overnight, it seemed, man had conquered nature, and gay man, whose friends and lovers were the first and foremost to be decimated by the disease, reaped the benefits. Although prohibitively expensive, these powerful medications gave hope to all positives--primarily gays, IV drug users and recipients of tainted blood. Told they had only months to live, they were suddenly reborn by a medical miracle that might renew their lives for 30 years or better.

The numbers told the story: According to the Centers for Disease Control and Prevention, in two years following the introduction of the cocktails, AIDS-related deaths in the United States dropped a startling 62 percent. Hysteria over the epidemic began to wane as prevention messages began to sink in. A condom for all occasions became the unyielding mantra of safe-sex advocates, and new AIDS cases began to level off at 40,000 a year down from a peak of more than 80,000. The disease seemed to be someone else's problem, that of poor souls in Africa, where a devastating strain of the virus was killing millions and rates of infection staggered the conscience. What was once a death sentence in this country had become a manageable, chronic illness like diabetes or high blood pressure. Or so we were told.

What was left largely untold was how difficult the virus was to manage. The new medications might save lives, but they were a bitch to take. Cocktails required strict adherence to a daily regimen of about 20 pills. Miss a few doses, and the virus was unforgiving. It might multiply and mutate, this time roaring back by the millions to stalk the immune system with a strain resistant to the original therapy. New cocktails would have to be ordered with the hope that science would always stay one step ahead of the disease.

Because the Food and Drug Administration had humanely fast-tracked its approval (under pressure from AIDS activists), not much was known about the medications' side effects, and what was known was downplayed. Nausea, vomiting and intractable diarrhea made life with cocktails (also known as highly active antiretroviral therapy, or HAART) as unpredictable as it was unpleasant. Killer opportunistic infections such as Kaposi's sarcoma and pneumocystis carinii pneumonia (PCP) seemed a tragic footnote in AIDS' brief history, but with cocktails came freaky tales of fat redistribution and increased risks for diabetes and heart attack as well as renal and pancreatic damage.

Assisted by steroids, cosmetic surgery and renewed determination, patients often kept these toxic side effects from public view. What was seen instead were positives returning to work, getting off of disability and managing just fine. In controversial ads, drug companies portrayed positive men climbing mountains, riding bikes and engaging in romantic liaisons--just like everyday queer folk.

But it wasn't just the drug companies that depicted the life of an HIV-positive as nothing out of the ordinary. An entire culture of AIDS service agencies grew up around the epidemic, dedicated to bringing normalcy to economically disadvantaged positives by providing them with food, clothing, counseling, housing, transportation and medical care.

Not only had the disease galvanized the gay community like never before, it began to whittle away at old homophobic hatreds. While some heterosexuals continued to stigmatize and discriminate, others became more accepting of gays, their rights and their relationships. "The victimization of gay men by a disease paradoxically undercut their victimization by a culture," wrote Sullivan in his Times article. "There was no need to kick them, when they were already down."

A new mythology grew up around the disease and its new drugs, one that bred complacency as well as denial. Because the next generation of gay men didn't know many people who had died from AIDS, their fear of the disease seemed diminished. "There is a false complacency that comes from seeing your friends on meds and they are doing well," says Melissa Grove, the executive director of the Legacy Counseling Center, the largest provider of HIV counseling services in Dallas. "And you start to think, 'Hey, if I get the disease, it wouldn't be the worst thing.'" If getting AIDS was as normal as depicted, why even worry about safe sex, especially when you could pop a few pills and feel fine?

Other men, gay and straight, tired of safe-sex messages and found rationales to swear off condoms: a need for intimacy, a fear of rejection, a sense of invincibility. Certainly for some in the gay community, there was a push toward monogamy, but for others, illicit drugs, the Internet and a willful blindness about transmission all conspired to justify a return to the promiscuity of the past, where anonymous and casual sex were no big deal. And denial ran deep in minority communities where the stigma from the disease was as daunting as the disease itself. (That stigma is still enough of a concern that all the HIV-positive individuals interviewed in this article except one agreed to participate only if given pseudonyms.)

By 2002, the numbers began to tell a different story: For the first time in a decade, the number of AIDS cases rose in the United States. From 2001 to 2002, new HIV infections among gay and bisexual men in the 25 states with long-standing HIV reporting procedures increased by 7.1 percent. More than 50 percent of all new AIDS cases were in the African-American community, and more than 64 percent of women with AIDS were black. Based on findings released in September by Dallas County Health and Human Services, new HIV infections have grown steadily since 1999 in Dallas County, which now records the greatest number of new cases in the state. Some epidemiologists believe it's too soon to tell if the disease is resurgent, while many speak with growing alarm that the plague is staging a comeback.

And yet no pristine epidemiological category--men having sex with men, IV drug users, women of color, heterosexual men--can capture the anguish and the actuality of the disease. Life with cocktails is messy and rigid and irrational and tragic. It saps the spirit and the bank account and magnifies the stress of everyday living exponentially. And it can best be told not through cold numbers, but rather through the lives of the people who live it.

The Survivor

There is a brief window in the morning when he feels good--good about himself, good about his health, good about not dying. It only lasts a few minutes, until he starts taking his medications. That's when Neal Shaffer begins swallowing his 19-pill cocktail, a combination of protease inhibitors (PIs), nucleoside analogues (nukes), non-nucleosides (non-nukes)--the three classes of antiretroviral drugs, which attack the virus' ability to reproduce.Some doses are taken in the morning, others in the evening, some before meals or after. His nausea, headaches and vomiting arrive early or not at all. It's the not knowing that's the worst, not being able to anticipate whatever side effects his regimen might bring. "It's what keeps me from getting a real job," he says. "Sometimes the best I can do is to get back into bed."

At 43, Shaffer is a long-term survivor, which is the true source of much of his pain. "People who began treatment 10 to 15 years ago are in the worst shape today," says Dr. Louis Sloan, a Dallas infectious disease specialist with a high volume of HIV/AIDS patients. "Not only because their immune system may be more damaged, but also because we didn't have the medicines back then that we do now."

When Shaffer was diagnosed with AIDS in 1993, he was a marketing director for a physical therapy clinic. He had no symptoms but agreed to get tested to induce his best friend, who he felt was "very promiscuous," to do the same. "He turns out to be negative, and I am the one who was positive," Shaffer says. "I was devastated."

He then submitted to another blood test, which counts the number of T-cells in a drop of blood. T-cells are a type of white blood cell that directs the immune system to fend off disease-causing bacteria, parasites and viruses. HIV, a cagey virus, hides from these T-cells before seeking them out and invading them. The virus then forces each infected cell to do its bidding by making millions of deadly copies of itself. It then mercilessly kills off each infected T-cell, whose reduced numbers indicate the amount of damage done to the immune system. A normal count is anywhere from 500 to 1,500 T-cells in a cubic millimeter of blood (about a drop). A person with a T-cell count below 200 has already progressed to full-blown AIDS. Shaffer tested at 150. "I was told I had six months to live."

He had gone to great lengths to minimize his risk, as did the vast majority of the gay community whose obliging response to the safe-sex message was a triumph for public health in this country. Although he never believed public pronouncements that AIDS was a "gay plague," he stopped drinking and doing the club scene, stopped having anal sex, unprotected or otherwise, and started dating married men exclusively. At least 20 of his friends would die from the disease, and his daily habit of perusing the obituaries made him treat everyone as if they were positive. "Before I went out with anyone, I would ask to see their test results."

Little did he realize that he was already positive, had been since the mid-'80s. He had come out when he was a teenager, he says, when being gay was more like entering a secret society, one with its own language, culture and nightlife. He was drawn to that life, dancing until morning at Bayou Landing, a popular Dallas club where gays and straights mingled without inhibition. Too possessive to have a long-term relationship, he instead had a long string of lovers. He used sex as a challenge, a celebration, a way to feel good about himself. "It was like a game with me," he says. "I knew how to fix myself, and that was through conquest." He met new men wherever he went: at gas stations, in grocery stores, outside clubs. It fed his ego to have them; it also gave him AIDS.

His first symptoms nearly cost him his life. Two months after testing positive, he developed an opportunistic infection in his intestines that required surgery. He could no longer work and went on disability. His former employer continued to carry him on its health insurance for a year, but the insurance provider refused to pay for a new medication on the market, AZT, which it considered experimental. AZT (a nuke), the first drug developed to fight HIV/AIDS, works by interfering with an enzyme that the virus needs to create new copies of itself. Suddenly there was a wonder drug that could save Shaffer's life, but he couldn't afford it. The state had devised a lottery to dispense the drugs to a fortunate few, but he couldn't wait. "I bought some through the black market," Shaffer says. "There are patients out there who refuse to take their medicine and need money. You just have to find them."

Regrettably, AZT was not the medical miracle it promised to be. During the three years he took it, Shaffer's T-cell count dropped to six, and he fell victim to pneumocystis carinii pneumonia (for which he was hospitalized four times), tuberculosis (for which he was quarantined), shingles, anemia and neuropathy so unbearable even morphine failed to ease the burning and stinging in his nerve-damaged feet. "Some people thought the AZT was killing us," he says. "Too many people were dying while they were on it."

The problem was, AZT was no cure and acting alone not particularly good medicine. For a time, it would compromise the virus, but it would never completely suppress the viral load--the number of copies of the virus in a drop of blood. Eventually, HIV would mutate into another strain that was not only resistant to AZT but was also cross-resistant to similar drugs within the same nuke class that were being rapidly developed.

Because of his resistance, Shaffer qualified for a clinical trial to test the effectiveness of Norvir, one of a new class of drugs called protease inhibitors. Much like AZT, these drugs prevent the virus from replicating by inhibiting the action of protease, another vital HIV enzyme. When taken as part of a HAART cocktail of nukes and later non-nukes, they would blast the virus into submission. Though the virus still remained hidden in "safe sanctuaries" such as the brain and the lymph nodes, these cocktails could make HIV virtually undetectable in the blood. "Protease inhibitors literally saved my life," Shaffer says. "For the first time, I wasn't susceptible to opportunistic infections."

Protease inhibitors were initially so effective, it seemed as though an entire generation of AIDS patients were suddenly resurrected. "They would go from cadavers to looking like normal human beings," says Dr. Stacy Broun, a Dallas clinical psychologist who has worked with AIDS patients since the onset of the epidemic. "A lot of my patients, who were told they were going to die, had spent everything and gone on these wonderful cruises and vacations. Suddenly they were told they were going to live. They had no plans for the future. Life didn't hold out a lot for them." She counseled many patients who were depressed, even suicidal, others who felt guilty that they had survived their lovers and friends. "The good news was, they were going to live," she says. "The bad news was, the drugs might make them feel like crap."

Over time, the use of protease inhibitors became associated with a bizarre side effect called lipodystrophy syndrome. Patients reported odd accumulations of fat behind the neck (buffalo hump), around the abdomen (protease pouch) and on the chest (breast enlargement). "I looked like I was pregnant," Shaffer says. "I had a thick ring of fat around my neck and a double chin, but my legs looked thin, like a runner."

"We don't know what causes it, whether it's the drugs or the disease or a combination," says Dr. Dolores Peterson, an HIV researcher at UT Southwestern Medical School who has studied the syndrome. "We do know that between 20 to 50 percent of patients experience some form of the syndrome after they have been on HAART treatment for as many as five years. That is when we get the highest numbers."

Shaffer says he lost the excess fat after he developed a resistance to Norvir and discontinued its use. Every two years or so, despite his austere regimen, his virus multiplies and mutates. The new resistant strain must be beaten back with a different HAART cocktail. "Even if completely adherent, people who started on meds when AZT was all there was tend to develop resistances quickly," Dr. Peterson says. "In the old days, we didn't do combinations, and then the combinations we did do weren't powerful enough to suppress the virus completely. Those people still have it rough."

Shaffer has no job, no health insurance and no money. The Texas HIV Medication Program pays for his cocktails, which would otherwise cost him an estimated $16,000 a year. Despite his morphine-numbed neuropathy and a hip replacement that still causes him severe pain, he has no choice but to stand in long lines and wait: for food at the AIDS pantry, for medical care at Parkland Memorial Hospital's Amelia Court Clinic, for his medications at the county's outpatient pharmacy. It's the life of a subsidized AIDS patient--someone who is fearful that an overwhelmed bureaucracy is out to screw him, someone who is fighting for a future that seems out of his control. "I am just one step away from being hungry, homeless and having the lights turned off."

To Shaffer, complacency isn't about having unprotected sex, it's about people who wrongly believe the AIDS crisis is over, who have no clue that 15 people a month die an AIDS-related death in Dallas County alone. It's about AIDS agencies lacking funding because of a perceived lack of urgency and a 9-11 mentality that makes people too uncertain about their own future to be charitable to someone else's. It's about a budget-cutting Texas Legislature that last session tried and failed to reduce the rolls of HIV patients eligible for free medication, and will no doubt try again. And it's about an indigent health-care system that has told Neal Shaffer that he has run out of free pharmaceutical options if his medications fail him again.

And they will.

Boys at Play

At 24, Barry Warner's only exposure to the AIDS epidemic was watching the movie Philadelphia. He was too young to know anyone who had died one of those horrible AIDS deaths. His friends were gay, and they never talked about AIDS, never seemed to worry they might catch it. And if they did, so what? There were pills you could take, the next best thing to a cure. But that was nothing that concerned him, not until July when he learned he was infected with the virus.His laissez-faire attitude toward the illness was several years in the making. After he came out at 18, he immediately left home and moved in with Jon, an older man who insisted on wearing condoms if he insisted on sex at all. Jon blamed his low sex drive on Warner, claiming Warner was "fat and unattractive" despite his classic good looks. Living with Jon wasn't easy, but neither was living with his adoptive parents, who wanted "the perfect child," says Warner, and instead "got a gay, alcoholic, drug-addicted one."

For three years, Warner remained monogamous, although Jon held no similar compunction, which might account for why he acted so "responsibly." The day Jon told him to leave, Jon had another lover in waiting. Warner was devastated and escaped to New Mexico, where he delivered pizza and got stoned simultaneously. "It was the best job I ever had," he says.

After nine months, he moved back to Oak Lawn, got a job waiting tables and immersed himself in the world of late-night clubbing, after-hours parties and drugs. "I used to have this saying," he recalls. "I have to go to work so I can buy some drugs so I can stay awake so I can go to work so I can buy some drugs so I can stay awake so..."

When you're speeding like a freak at four in the morning, there are just so many places you can go. If Wal-Mart got too boring, Warner might wind up at a local bathhouse known as Grandma's. "It was a playground for people who were totally fucked up on crystal meth and GHB," he says. "It was like a Candyland of unprotected sex."

But why risk infection when "use a condom every time" was still the clarion call of every AIDS prevention message? "We are talking about an epidemic connected to sex, and sex isn't always rational," says Douglas Shehan, an HIV researcher at UT Southwestern who coordinated an extensive survey of young gay men in Dallas. "Seventy percent of the guys surveyed didn't even perceive they were at risk for HIV infection, despite their risky behavior." A surprising "18 percent of the gay men surveyed in Dallas between the ages of 23 to 29 were infected with HIV, more than any other city studied, including New York." Fifty-three percent reported unprotected anal sex in the past six months, "an alarming marker of risk-taking," Shehan says.

Yet there is a growing feeling, particularly among younger gay men, that condom absolutism is as unreasonable as it is unpleasurable. It has created a "barebacking" backlash, which celebrates skin-on-skin sex as being more spontaneous and intimate than latex sex. Although this younger generation is still AIDS-aware, time and medicine have made them less terrified of the disease, less likely to use a condom because someone a decade ago didn't and died. Even for the fearful, a lifetime of safe sex could seem unrealistic and overly rigid. "When everything is prohibited and dangerous, people throw in the towel because adherence is impossible," says Dr. Walt Odets, a Berkeley, California, clinical psychologist and AIDS prevention expert.

With an estimated 300,000 people in this country who are unaware they are infected, the idea of qualifying the safe-sex message is an epidemiologist's worst nightmare. But the truth is, even unprotected anal intercourse carries no risk of HIV transmission if neither person is infected. The chance of getting HIV through oral sex is less likely than being struck by lightning. The risk of contracting HIV from someone testing positive is greatly reduced if his or her viral load is undetectable. "People take risks all the time for things they value," Odets says. "But the whole assumption behind prevention is that sex between men is some kind of recreational, superfluous activity, and it's not worth any risk at all. But gay men know it's emotionally completing and a very important, human part of their lives."

Barry Warner saw no value, however, in having sex at Grandma's--unprotected or otherwise--because he still felt vulnerable after his breakup and didn't want to risk rejection, even in a public bathhouse. He went deeper into his addiction, turning from using methamphetamines to selling them until he began mainlining his profits and found himself homeless and broke. "My life had turned to shit, and it was nothing I ever imagined for myself," he says.

He had just enough relationship left with his parents that they agreed to pay for his rehab, and he spent the next eight months among the newly sober. That's when his life began to change, he says, as well as his self-image. "I stopped thinking of myself as unattractive and started dating again."

Because he had "a hard time separating love from sex," he chose not to have sex with the men he dated. Instead, he began cruising the Internet, meeting men in chat rooms and leaving his apartment for late-night liaisons. These clandestine parties seemed a throwback to a more closeted age, but their anonymous nature made things more erotic and dangerous. No test results were compared before bodily fluids were exchanged, and no one talked about whether they were negative--or not.

"It is both parties' responsibility to disclose, as it should be in any sexual act," says Dr. Stephen Tankersley, a Dallas psychiatrist who has been treating HIV patients since 1984. "But if the person who is positive is not comfortable disclosing, he should make sure the sex is safe."

Warner claims he always wore protection, and besides, as long as he was the one on top, it was impossible to contract HIV--or so he thought. The truth is, it's less likely but still possible, particularly if the "asserter" has cuts or open sores on his penis.

In May, Warner chatted online with several men who were partying at the Oak Cliff house of a man named Gary, someone Warner had previously met on the Internet. That's why he felt comfortable going over there, even though "everyone was watching porno, talking online and getting sky-high on drugs." Warner remained sober and after a while paired off with another man. Preoccupied with getting a blow job, he says, he didn't see Gary, who "came out of nowhere and surprised me from behind." Gary wasn't wearing a condom and, in the heat of the moment, neglected to discuss his HIV status.

Three weeks later, Warner felt feverish and chilled, his head pounding with pain. When his symptoms didn't abate after five days, he went to the doctor, who suggested he might have HIV. Testing later confirmed his suspicions: Warner's viral load was soaring at a million; his T-cell count was down to 150.

While his numbers looked as though he had full-blown AIDS, he was suffering from acute retroviral syndrome (ARS), which occurs when the body goes from negative to positive. Although ARS typically resolves itself after a few weeks, with T-cells rising and viral loads falling, research suggests that if the virus is attacked before it can lodge in the harder-to-reach sanctuary sites, there is a better chance of staying healthier longer. People can live with HIV for an average of 10 years before their immune systems become seriously impaired.

Because Warner carries no health insurance, his doctor enrolled him in a clinical trial that provides him with free medicine for 18 months. He now takes an adherence-friendly cocktail--three tablets once a day--that would make pill-fatigued long-termers such as Neal Shaffer envious. Warner's prognosis is not unlike many of the newly infected. Assuming he adheres strictly to his regimen, doesn't develop drug resistances and the meds he uses aren't later discovered to cause any long-term toxicity, he should live a normal life. "So far, my side effects have been minimal," he says. "I do get really fatigued, and my stomach gets upset if I eat fatty foods, but I can live with that."

After the initial shock of his illness subsided, he met with friends at Starbucks and told them about his status. They were furious with Gary, but in true 12-step fashion, Warner took full responsibility for his risky behavior. He even went to dinner with Gary, who acted upset, claiming he just assumed Warner was also positive. Why else would he have put himself in that situation?

Not only did Warner forgive Gary, they also began to date. Warner felt a level of comfort and intimacy that came from their both being positive. There was no fear of the rejection that full disclosure might bring. They spent a lot of time together and grew closer, more trusting. With Gary, Warner felt he didn't have to worry about spreading the virus; there was a certain relief in knowing they were just two positives having unprotected sex.

Then a friend told Warner to log onto a Web site called barebackcity.com. He needed to check out the personals section, which included a posting from Gary. Next to his photograph, Gary wrote a description of himself, saying that he enjoyed bareback sex and was HIV-negative.

"I broke up with him after that," Warner says. "I knew he had infected other people."

The Supermoms

He was a big hulk of a man who played football at the Los Angeles junior college they both attended. She had never been with anyone else, and she thought she would be with him forever. But when Shalonda Henderson (her real name) turned up pregnant, he wanted nothing to do with her, and she decided to have the baby on her own. Six months into the pregnancy, her doctor ran some tests and questioned her about the father, who was African-American, the same as her. Was he an IV drug user? Absolutely not. Could he have been gay or bisexual? She didn't think so. Did she know anyone who had pneumonia? She paused and said yes, the father; he'd been hospitalized with pneumonia a month earlier. The doctor said it was likely the father had HIV and had infected her as well.Two years later she ran into him--she wanted him to admit what he had done. He only copped to being sick, said his new girlfriend and their baby also had the disease, claimed it was some kind of genetic blood disorder. "What kind of fool did he think I was?" she says. Since then, she has met many women who were infected by men, and "found out later that they were bisexual, which is probably what happened to me."

The problem of male-to-female heterosexual transmission is particularly daunting in the black community, and most notably in the South. People of color--African-Americans and Latinos--continue to fuel the epidemic, accounting for 70 percent of all new infections between July 1999 and June 2000, according to the Centers for Disease Control. The disease is also the leading cause of death for black women between the ages of 25 and 34.

"Let's cut to the chase," says Don Sneed, executive director of Renaissance III, a Dallas AIDS service agency primarily targeting black men. "There's a lot of internalized homophobia, guilt and shame revolving around same-sex behavior in the African-American community. It can be traced to the black church and culture, which treats homosexuality like the greatest sin since blasphemy. It keeps folks in denial, makes people less likely to test or seek treatment until they wind up in the emergency room."

"Men on the down-low," those who do not "self-identify" as gays or bisexuals but who secretly enjoy sex with other men, "comprise the majority of HIV transmissions to African-American women," says Sneed, who is also a member of the Presidential Advisory Council on HIV and AIDS. "Homosexuality and AIDS are still a very uncomfortable conversation in the black community in 2003. We would prefer to talk about women and children with AIDS; it's more pleasant because there's a true victim."

But in 1992, being pregnant and HIV-positive felt totally isolating for a young African-American woman. "No one in the black community was talking about AIDS," Henderson says. "It was still considered a gay man's disease." Her family was supportive, but they lived in Dallas. If there were HIV support groups for women--black, Anglo or otherwise--she didn't know about them. There were no medications to protect her unborn child from exposure, and she wasn't allowed anything to keep her virus in check. The only comfort she received was from prayer, she says, which must have been enough. Her son was born HIV-negative.

Rene Ryan wasn't quite so fortunate. She learned her husband had infected her only after their newborn son had caught a cold in an Austin day-care center. It was apparent that his elderly pediatrician had misdiagnosed the illness, but few people had seen pneumocystis carinii pneumonia in a 3-month-old baby in 1989. Tests taken in the ICU, however, confirmed the baby had full-blown AIDS.

The Ryans were just a couple of white kids who had grown up together in a small Hill Country town, fallen in love after he went off to college and married too soon after deciding they just had to be together. Before marriage and monogamy, they were both young and promiscuous, which must have increased their risk of exposure. Now none of that mattered, not after the doctors told them their baby had only six months to live. "We were just hoping we could take him home to die," Rene says.

They had a glimmer of hope when their son was accepted in a Houston drug study, which tested AZT on children. Every two weeks for two years they would travel to Houston until the virus finally overwhelmed his body. "We got to take him home for an early Christmas," she says. "He was such a strong and brave little boy--happy right until the end."

The death of their son strained their marriage as they cycled between anger, counseling and cocaine. None of these helped them stay faithful to their AZT regimens, although she was better about taking care of his medical needs than her own. "It didn't help when I had side effects like diarrhea. I was running to the bathroom at work every five minutes, and I was trying to keep it a secret from my boss." She developed a strain resistant to her meds and was forced to switch regimens more than once.

Drugs and bitterness finally took their toll, and the couple decided to separate. She moved to Houston to be close to her brother, who was also dying of AIDS. Her husband grew worse, his illness progressing faster than hers. A year later, she got the phone call: He was in a hospital bed, comatose and dying. "I was there when he passed away. I loved that man for a third of my life, but we ran out of time to work things out."

Shalonda Henderson also took AZT, until she could hardly walk from the neuropathy it caused. The medications she took to prevent her from getting pneumonia made her face "blow up like I had been beaten up." In 1996, her doctor wanted to start her on protease inhibitors. She decided to wait until she and her son returned from Dallas. They would be spending Christmas with her family.

In Dallas, she developed a migraine so painful that she started seeing double. Rushed to Parkland hospital, she was diagnosed with cryptococcal meningitis, a fungus that lodged on her spinal cord and produced pressure on her brain. She slipped into a coma, and the doctors encouraged her mother to "pull the plug." Her mother insisted on waiting, and after 32 hours, Henderson opened her eyes. She was blind, other than being able to discern light from dark. Her T-cell count had dropped to two; she had virtually no immune system left. Her hair had fallen out, and her skin looked as though she had been burned beyond recognition. "Still, I was glad to be alive," she says.

Her doctors put her on a three-drug cocktail, two nukes and a protease inhibitor. One of the nukes caused her to have more neuropathy--bad muscle spasms and numbness in her feet--but her viral load and T-cell count both headed in the right direction. She and her son moved into her mother's house until 1998 when AIDS Services of Dallas found them an apartment at one of its HIV housing projects for the poor. AIDS Arms helped her with clothing; AIDS Interfaith helped her with transportation; AIDS Resource Center helped her with food; and Bryan's House helped her with child care. "I had case managers up the butt," she says.

AIDS Interfaith also ran the Daire Center, a place where HIV-positive adults eat lunch and chat, and where Henderson met her future husband. "We just started talking and became friends," she says. "He was positive through drug use and multiple partners. We exchanged phone numbers and later got married."

At first, the sex between them was safe; neither of them wanting to risk re-infecting the other. "It's not real common, but it can happen," Dr. Sloan says. "There are cases of patients whose virus is under control, and all of a sudden, there is a huge viral change that corresponds to the virus the partner has. One predominate virus will usually win out, but you may have to treat both."

As their relationship progressed and Henderson's viral load didn't, they decided to have a child. They consulted a doctor who said that with the HAART therapies now available, there was less than a 1 percent chance their baby would be HIV-positive. "Thirteen weeks after the fetus' organs develop, the woman begins treatment with a cocktail," Sloan says. "And when the baby is born, he or she gets AZT."

On December 8, 2000, Henderson gave birth to a healthy baby girl. But her husband, who was using again, tempered her joy. "My blindness may have heightened my other senses, but it didn't take much intuition to figure out that he was doing drugs," she says. "Not when the dope man came around looking for his money." She would have none of that around her children and told her husband to pack up and leave.

Stressed over her marriage, she let her health slide and stopped taking her medications. "When there's a lot of stuff on your mind, sometimes you don't feel like swallowing 40 pills a day," she says. Her viral load shot up 10,000, and her T-cell count dropped to 130. She felt fatigued, bone-weary and developed resistances to two medicines. Getting adherent with a new cocktail took some persuading, but she managed it with the help of The Kitchen Table, an HIV women's support group affiliated with the AIDS Resource Center. She talked freely to women in the same situation, women who had contracted the illness from working the streets or IV drug use or a husband in denial. "But I'm the only blind woman," Henderson says. "I think that gives the others strength."

Rene Ryan became a founding member of the group in 1999 after she moved to Dallas. Through friends, she had met a "highly empathetic" HIV-negative man whom she would eventually marry. "Not many men would go into this with their eyes wide open," she says.

They understood it was more difficult for a woman through vaginal intercourse to transmit the virus to a man than the reverse. Nonetheless, she insisted he wear a condom, at least at first. It was his choice, however, to have unprotected sex, knowing that any virus he might contract could be a more virulent strain, replicating with her same drug resistances. Still they were cautious: He would get tested every six weeks, and they would have unprotected sex only if they knew her viral load was undetectable.

She didn't know if she could even get pregnant and felt conflicted when she finally did. She could never replace the child she lost, yet she wanted to be a mother again--desperately. She knew the risk of exposing her baby was negligible but grew concerned others might judge her: What business did an HIV-positive woman have getting pregnant when taxpayers were paying for her medications? Then again, she had lost a son, a husband, a brother, her own health to this epidemic. Wasn't she entitled to some happiness?

Ryan decided to continue her pregnancy and delivered a healthy baby girl. Four years later, she had a boy, who is also HIV-negative. "I never thought I would be a mother again, which alone brings me the greatest joy in the world."

Yet she can never forget the fragility of her existence, the worry that she could contract an opportunistic infection from a cold her child might catch, the angst that her latest cocktail might fail her or her immune system finally just might give out. "I feel like a frog jumping from one lily pad to another before it starts sinking," she says. "I stay as long as I can, but I'm not sure how many lily pads are left."

Introductory note from Roland Foster of The Children's AIDS Fund.

Thailand has often be cited as an example of an HIV prevention success story by AIDS advocates who have praised the nation's so-called "100 percent condom use" policy. Thailand was hailed in the 1990s for an unabashed national publicity drive encouraging condom usage. Here are the results, according to the latest reports:

o Less than one-in-four teen boys report using condoms regularly.

o Boys are having sex at younger ages-- 14 is now the average age of sexual debut.

o HIV is on the rise among teenagers.

o Prostitution is increasing. Prostitution and the sex trade are fueling the rise in HIV in the central and eastern regions of Thailand.

o Gonorrhea is increasing.

o Gay men in Thailand have the highest HIV rates in that community in the world.

Here are the full length articles:

Agence France Presse

November 16, 2003 Sunday

Thai teenagers shunning condoms, health ministry warns

DATELINE: BANGKOK, Nov 16

Thailand's teenagers are shunning the use of condoms in an alarming trend, the health ministry warned Sunday as it called for more campaigns to encourage their use for protection against diseases like HIV-AIDS.

A survey of 350 teenage boys in northeastern Kalasin province found that only 24 percent of them regularly used condoms as they believed it was safe to sleep with someone they knew, it said in a statement.

"Sexual relations among teenagers now are happening between people who have known each other for a while, so they believe that they can trust one another more than a condom," ministry spokeswoman Nittaya Chanreung said.

"That's a worrying problem," she added.

Thailand was hailed in the 1990s for an unabashed national publicity drive encouraging condom usage, which slashed infection rates of HIV-AIDS.

But the three-year survey demonstrated that most teenage boys today are only using condoms when they sleep with sex workers, which occurs relatively rarely, Nittaya said.

"Campaigns aimed at preventing sexually transmitted diseases have worked well among sex workers and clients, who use condoms. But for teenagers we need to carry out more campaigns to promote their knowledge of this," she said.

The survey also found that the average age of boys having sex for the first time had dropped from 16 years of age in 1998 to 14 years, due at least partly to their exposure to a more permissive society.

More than 700,000 people are living with HIV-AIDS in Thailand, and some 300,000 have already died of the disease.

The impact of the disease is expected to grow here as many sufferers contracted HIV a decade ago and are beginning to sicken and die, with lack of access to effective anti-retrovirals worsening the death rate.

Life expectancy in the kingdom has dropped 1.4 years to 68.9 due to the high number of young people dying of AIDS, the United Nations said in July.

Agence France Presse

January 2, 2003 Thursday

SECTION: International News

Rate of HIV infection grows among Thai teenagers

DATELINE: BANGKOK, Jan 2

The rate of HIV infection among Thai teenagers has jumped from 11 to 17 percent over the past year, Thailand's health ministry said Thursday as it vowed to make condoms more freely available to the young.

"Teenagers form a high risk group, with less than 50 percent of them using condoms, so we need to promote them as a way of preventing sexual disease," the ministry's Communicable Disease Control Department director general Charan Truenwudhipong said in a statement. "The rate of increase has been higher over the past year, jumping from 11 to 17 percent."

Charan said the department would buy 26 million condoms worth 23 million baht (534,883 dollars) to distribute at health offices across the country this year in a bid to promote their usage.

More vending machines would also be installed in public places to boost the availability of condoms, he added.

Thailand's National Aids Prevention and Control Commission however reportedly complained this week about authorities removing such machines, or refusing to install them as they feared they promoted promiscuity.

According to United Nations figures for 2001, 1.3 to 2.0 percent of Thai females aged 15 to 24 are infected with HIV, the virus that causes AIDS, while 0.9 to 1.3 percent of males in the same group are infected.

The growth rate of HIV infection among pregnant women, meanwhile, had dropped by 0.1 percent to 1.2 percent, health minister Sudarat Keyuraphan said.

"The rate is very low. We can say that it is in the lowest group in the world and I am confident that the rate will be lower this year," she said.

One million Thais are believed to have been infected with HIV-AIDS, and a third of them have already died.

Thai Press Reports

October 15, 2003

AIDS CONCERN FLAGGED AS PROSTITUTION RISES

A doctor from a hospital in the North has warned a team from the Global Fund for AIDS, Malaria and Tuberculosis that the rise of the sex trade is creating huge aftermath in Thailand's success in curbing the growth of the HIV virus.

Dr Wirat Klinbuayaem from San Kamphaeng Hospital in Chiang Mai said that new incidents of AIDS in the province had fallen dramatically, but at the same time, there had been a rise in the number of new cases in the central and eastern regions of the country due to an increase in prostitution over the past 10 years. With customers coming from across the country to use these prostitutes, AIDS was spreading at an alarming rate, he said, noting that few people realised that they were infected until it was too late, and in many cases, they had already passed on the virus to other people.

At the same time, prostitutes were moving from town to town to offer their services, spreading the virus with them, he said.

The doctor expressed the most concern over the spread of AIDS among young people, saying that the government's social order campaign to lead young people away from nightspots, had led these teenagers to turn to sex instead.

Frequent changes of sexual partner and failure to use condoms meant that AIDS was increasing among these groups, with gonorrhoea also making a comeback, he said.

Gay Thais have highest Aids rate in world: study

The HIV-infection rate among Thai gay men has soared more than fourfold over the past decade, making it the highest rate among gay communities in the world, according to the latest study by the US Centres for Disease Control and Prevention.

Some local experts are, however, sceptical of the study, saying it was based on a sampling that does not truly reflect Thailand's gay community.

The rate of HIV-infection among Thai gay men has risen from 4 per cent 10 years ago to 17 per cent now, said S Sarkar, the inter-country adviser to the Joint United Nations Programme on HIV/Aids (UNAids) Asia-Pacific, at a press conference yesterday.

Globally, the average infection rate among men who have sex with other men is between 4 and 5 per cent, according to the Thai Disease Control Department (DCD).

Sarkar said the HIV tests in the CDC study were carried out on gay men at gay meeting venues such as cruising parks and saunas.

Local experts have said the study is not reflective of the gay-male community in Thailand because the sample group was restricted to men who frequented gay saunas and cruising parks.

'The study cannot represent the whole gay population in Thailand, considering the specific sample group used,' said Dr Charan Trinwuthipong, director-general of Thai DCD.

The study was conducted solely by the US CDC, he said.

A UN official said Thailand should target more HIV/Aids-prevention programmes to gay men and intravenous drug addicts.

The incidence of HIV infection among intravenous drug addicts had risen from 40 to 50 percent here, said Dr Nafis Sadik, the special envoy to the UN secretary-general for HIV/Aids in Asia.

The main factor causing the rise in the infection rate among IV drug users was that the activity was illegal, she said.

Thai gay men were also driven underground by a misconception that homosexual acts are criminal, she said.

She called for an urgent extension of intervention programmes to stem the growth of infection rates among the two groups.

Apart from government treatment and care programmes, non-governmental groups are being encouraged to come up with schemes to help reduce the number of infections in these two groups, without the need to wait for the laws to be amended and social attitudes to change.

Charan said the Public Health Ministry was gathering information about the CDC study and would hold a press conference on the topic as soon as possible.

There has also been criticism from a group of gay activists involved in the HIV-testing programme.

One, who asked not to be named, said the testing was questionable and unusual. He said the process was kept secret by the study team until the results were revealed.

'Why did they choose only those who are at high risk and why not let the public know about what they are doing?' he said.

Sarkar, however, insisted that the test had been carried out in a scientific and proper manner.

He would hold a press conference to explain the study in detail and its results on October 27, he said.

While the pace of the battle against AIDS is picking up, efforts to stem the epidemic are "entirely inadequate" for the health emergency, which is "continuing to spiral out of control," the director of the United Nations AIDS program said yesterday.

The epidemic shows no sign of abating, said the director, Dr. Peter Piot, adding, "Measured against the scale of the global epidemic, the current pace and scope of the world's response to AIDS fall far short of what is required."

The toll from AIDS this year is expected to be the highest ever, with the virus infecting 5 million people and killing 3 million, he said. Comparable figures for 2002 were 4.8 million infections and 2.7 million deaths.

The agency said it used more precise measures in revising downward its estimate of the number of infected people around the world, to 40 million, from 42 million in 2002. The revision does not signal a decline in the epidemic, the report said.

In releasing the agency's annual report in advance of World AIDS Day on Monday, Dr. Piot acknowledged that more money and stronger political commitments had moved the battle into a higher gear.

But he chided nations that were way behind in tackling AIDS - though not, in every case, by name. "Many countries do not take AIDS seriously, and that is particularly the case of Russia, all the countries of the former Soviet Union, and several Asian countries," Dr. Piot said in a teleconference.

An estimated million Russians are infected and "the epidemic is growing at a fearsome rate," the report said.

Russia did not make the political commitment other countries have made against the disease, Dr. Piot said, noting that it budgets "only a few million dollars for AIDS and still deals with it at the level of a deputy minister of health."

The spread of AIDS to about 4.5 million people in India is "the biggest concern in Asia," he said. Although India's overall infection rate is small, it has reached a worrying 5 percent in some districts, he said.

The United Nations is encouraging health officials in India to improve their methods to monitor H.I.V. infection rates so they can focus on prevention efforts.

The report describes serious outbreaks in China, and Dr. Piot noted that the shock of the SARS epidemic had encouraged China to monitor the virus more closely.

Among other concerns, Dr. Piot said, is that in many countries, "the people providing the services are dying while the demand for services is increasing because of AIDS."

He warned that "the most devastating social and economic impacts of AIDS are still to come" and said the focus on treatment could cause prevention efforts to be overlooked.

The report also said only 1 percent of pregnant women in heavily infected countries had access to the testing and counseling services needed to protect them and to prevent mother-to-child transmission.

But there was some positive news.

"For the 12th consecutive year, in Uganda H.I.V. prevalence was lower than the preceding year," he said. Another favorable sign was the stabilization of the prevalence of infection in Cambodia, at 3 percent.

Thailand's push for condom use has made the sex industry safer and reduced the incidence of new infections by 85 percent.

But there is an increase in virus transmission among young people and drug addicts who use needles.

"So it shows the fantasy of thinking that one can control the AIDS epidemic by just focusing on so-called high-risk groups," Dr. Piot said. "We need to do both."

Dr. Piot said he was encouraged by the increased spending from affected and donor countries, which is expected to reach $4.7 billion this year. But that is less than half the $10 billion that economists say is needed.

Dr. Piot said he welcomed the South African government's new plan to provide antiretroviral drugs to patients, as well as an earlier announcement by former President Bill Clinton that he had brokered an agreement with drug companies to lower the price of AIDS drugs for many countries. The World Health Organization plans to deliver antiretroviral drugs to three million people by 2005.

For a number of reasons, the epidemic and the increased money to fight it are aggravating a shortage of nurses in many affected countries, and leaving some clinics with no nurses, Dr. Piot said.

Some nurses have stopped working because they are distraught over seeing patients die for lack of antiretroviral therapy. Many nurses, lacking sterile needles and other equipment, fear getting infected.

In Kenya, the United Nations found that 4,000 nurses were not practicing because of ceilings on the number of public service employees, Dr. Piot said.

Worsening the shortage, some nurses have gone to help fill shortages in the United States and elsewhere, leaving nonprofessionals to care for patients.

"This crisis will get worse and worse," Dr. Piot said. "We have to look far beyond medical solutions. This is going to become a fundamental political problem."

Information about the number of infections in Africa has improved because several countries "have become very aggressive in expanding" monitoring for H.I.V., particularly in rural areas, Dr. Piot said.

The highest ever number of new HIV infections and deaths around the world was recorded in 2003, reveals a new UN report. The update, by the Joint United Nations Programme on HIV/AIDS (UNAIDS), warns that the global AIDS epidemic shows no sign of abating. Five million new infections of the deadly virus were recorded globally in 2003, and three million deaths, up from 2.7 million in 2002.

"It is quite clear that our current global efforts remain entirely inadequate for an epidemic that is continuing to spiral out of control," said Peter Piot, executive director of UNAIDS, at the report's launch in London, UK, on Tuesday.

The disease "remains rampant" in sub-Saharan Africa. The region accounted for over three million of the new infections and 2.3 million deaths in 2003. It is also "threatening a whole new tier of countries" such as China, Indonesia, Russia and Eastern European nations.

A total of 40 million people worldwide are now living with HIV. The figure has been lowered from the 42 million estimated in 2002 after more accurate analysis. Of these, 26.6 million live in sub-Saharan Africa.

"In two short decades HIV/AIDS has tragically become the premier disease of mass destruction," says Jack Chow, assistant director general for HIV/AIDS, TB and malaria at the World Health Organization (WHO). Piot stresses that the epidemic is worldwide. "The epidemic has become a global epidemic. This is not an African problem," he says. He warns that the Caribbean has the second largest percentage of infected individuals in the world. And that "there is a continuing spread of HIV" into other countries.

China, which is a country at the "very, very beginning" of its AIDS epidemic, has roughly 1.5 million infected individuals. "But the number of new infections has progressed by 30 per cent per year over the last three years," he cautions.

Estimates have suggested that the epidemic may be stabilizing in some parts of Africa. But Piot notes this appearance of stabilization is because the number of new infections are now being balanced by the huge numbers of people dying.

However, Piot is optimistic that it is now "a time of unprecedented opportunity in the 20-years-plus history of this epidemic". Tackling AIDS is much more on the political agenda, as well as having more financial backing. But crucially, he says: "There's a momentum of evidence that prevention can work even in poorer countries."

Some urban areas in East Africa have managed to cut their rates of new infections with strong prevention programmes. For example, Uganda cut its number of new infections in 2003 for the 12th consecutive year. In the capital, Kampala, the rate is 8 percent, compared with 30 percent a decade ago. Uganda's ABC prevention approach emphasizes abstinence and being monogamous with condoms as a last resort.

Ugandan AIDS Poster

LONDON (Reuters) - New infections of HIV, which causes AIDS, have risen in Britain by 20 percent since 2001, bringing the number of people living with the virus to nearly 50,000, health experts said Monday.

High-risk sex among gay and bisexual men and an increase in sexually transmitted infections (STIs) have contributed to the increase, according to the Health Protection Agency, which monitors infectious diseases.

"The group most at risk of contracting HIV in the UK remains gay and bisexual men, accounting for about 80 percent (1,500) of the new diagnoses in 2002 that were likely to have been acquired in the UK," Dr. Kevin Fenton, an AIDS expert at the agency, said in a statement.

Cases of gonorrhea among gay men have nearly doubled from 1,842 in 1999 to 3,363 in 2002. Syphilis infections rose from 52 to 607 during the same period.

Both infections facilitate the spread of HIV.

Fenton said the number of heterosexual infections of HIV/AIDS has also risen from 147 in 1998 to 275 in 2002 and is also linked with STIs.

"These figures make depressing reading," James Johnson, of the British Medical Association (BMA), said in a statement.

The increase in STIs is putting extra pressure on British clinics where some patients have to wait weeks to get an appointment. "The country now faces a very serious public health threat from STIs," Johnson added.

The latest HIV/AIDS figures were released ahead of World AIDS Day on December 1.

"The earlier people are diagnosed with HIV, the greater chance they have of living a longer and healthier life. Awareness of their HIV status also enables people to make informed choices about their sexual behavior and practicing safer sex," Fenton said.

Addendum
Homosexual Behavior in the Animal Kingdom