Dr. Tom Coates, director of UCSF's Center for AIDS Prevention Studies, talks to Gay.com about the future of HIV prevention, a rise in bareback sex and why Viagra works, when safe-sex campaigns don't.

Gay.com: Despite so many efforts, everyone working in prevention seems to be at a loss. Are new infections happening mostly among young gay men?

Dr. Tom Coates: Yes, in almost all the big cities they are occurring among young gay men. In San Francisco, we are seeing new infections across every age group.

What can we do to stem the spread of AIDS in the gay community?

Well, maybe we should just stop. Maybe we should just make lots of condoms available, keep informing people where the STD centers are and just accept that every year there will be a certain percentage of people who will get HIV.

I'm not being facetious. Before, a person with HIV had 12 to 15 years to live. Today, maybe it is 20 to 25. AIDS just is not the dreaded disease it once was in the gay community, and, perhaps, people are taking risks because they have other priorities such as feeling loved, feeling desired and getting laid.

Are you sure you want to be saying this to the press?

Yes, I think it needs to be said. There is, of course, another option, which is to do more careful analyses of who and where the transmissions are taking place. Researchers need to focus attention and energy on smaller groups such as we do today in our work with HIV-positive men.

The PEP (Post Exposure Prophylaxis) Project is a very interesting one, because we see people right at the moment of a possible infection. There is a lot happening during those hours.

What has changed since the beginning of the epidemic?

In my heart of hearts, I really think the community response we saw was integral to the gay community. It was closely tied to civil rights and loss of civil rights, as well as fear of discrimination. As much as I hate the term "AIDS, Inc." that some people use accusatively, we have these organizations almost beating on the community to get it to change its behavior. They are not perceived as part of the community. And quite frankly today, AIDS/HIV is not the heart and soul of the community like it once was. But what the community doesn't realize is that this infection is eating away at its very heart: its health."

What needs to happen?

We need to fill in this lack of leadership from within the community.

Do you mean for instance bridging the age gap, bringing younger and older people together?

It's not just the fact that young people don't know any older people with HIV. The image of HIV itself isn't bad anymore. We don't walk through the streets like we used to and see people so sick they can hardly walk. Today, people with HIV are buffed, they have boyfriends, they are doing things. It's just not such a terrible thing anymore.

So how do we bring health back into the community's priorities?

How do drug companies do it? By promising they'll have a longer life and feel good. What people want is freedom from some immediate problem. The best health interventions are always the simplest ones that require the least effort.

There are three different approaches. You give sanctions, as in the case of a ticket when you run a red light. You make the healthy thing easy to get, such as we see today with low-fat food and low-salt foods. Finally, we make sure the product we give them rewards people with something they really want. Viagra works because it gives people hard-ons.

So we have to figure out a way to accomplish these three: Make doing it easy, make not doing it hard and make it feel really good.

We tried to eroticize condoms and made them available everywhere back when everyone was convinced they were absolutely necessary. But today the taboo has been broken and lots of people are advertising for bareback sex. What can we say or do so that deep within the heart of the community people believe that it is bad to spread HIV?

Online cruising actually seems to allow for a lot more negotiating, since people put directly in their ads that they want it with or without a condom. At least it's being talked about.

How do we go about finding leadership? Do we find leaders and train them?

That's an idea, but it probably wouldn't work. No, we raise the discussion and allow it to happen. We ask the community: "Is this something you care about? Do you see this as a challenge to the community?" In the same way nonprofits got the community interested in equal rights.

What about trying to develop interest within the gay community over HIV issues in poor countries? In France several of the big agencies, led by Act-Up Paris, are working on treatment access issues in Africa.

Once again we need to raise the discussion level around this. There are some examples of actions like this.

I think the logical parallel to what you describe in France would be Puerto Rico and the Caribbean for New Yorkers and then Asia and Mexico for people on the West Coast. There are just traditional ties there that would be a good foundation and that we can build on. But the leadership has to come from the community.

Response from Bill Weintraub:

Dear Dr. Coates,

I read with interest your interview on gay.com about HIV prevention, in which you suggested "maybe we should just stop."

In an email I sent you on 9/17/01, I suggested an alternative to "just stopping." And that was looking at the underlying cultural values and messages which promote anal sex and unsafe behavior in the gay male community, and changing those messages.

You have not responded to that email or to a follow-up telephone call.

I agree with you when you say that "infection is eating away" at the very heart of the community.

But I don't understand your seeming obliviousness to the cultural factors which promote those infections, cultural factors which CAPS itself identified at least as long ago as 1997, if not earlier.

You note that people have other priorities, "such as feeling loved, feeling desired, and getting laid."

But there are many ways to meet those priorities.

Implicit in your statement is the idea that only anal sex will answer those needs.

That's culturally-dictated nonsense. There are tens of thousands of gay and bi men who have passionate and sexually fulfilling lives and relationships in which anal sex plays no part whatsoever.

So there is an alternative to throwing in the towel. And that is to show gay and bi men other realities, other ways of being both sexual and deeply loving.

You suggest: "make doing it easy, make not doing it really hard and make it feel really good."

That's exactly what the frottage movement is doing -- we're saying to our fellow gay and bi men that frottage is natural, easy, and very very hot -- that it feels really great -- and that anal is dangerous.

But Dr. Coates, you have resources that the frottage movement does not. You speak of "AIDS, Inc." -- and I think that's right. You have at your command money and staff to develop and deliver messages about non-anal alternatives on a far greater scale than we can.

And you have the ear of the press -- great access to the media.

You say, "we raise the discussion and allow it to happen."

That too is exactly what we in the frottage movement have been trying to do. But the gay press freezes us out: Advocate/PlanetOut.com, gay.com, Genre, POZ -- won't do either opinion pieces or simple news stories.

So we are relegated to little internet ghettoes.

And that's ridiculous. If the gay community stopped exalting and romanticizing anal sex, and simply treated it as one sexual option among many, there would be less anal sex, and less unsafe anal sex.

And such a change would have profound implications not simply for this epidemic, but for a myriad of gay male health problems both present today and waiting to emerge down the road.

The frottage movement is not going to go away. We know that there is among the gay and bi grass roots growing resentment and anger at the unrelenting pressure to have anal sex.

So we will continue to speak to that anger, and continue to show men another way of living joyful and passionate lives.

But we do not think the way we've been treated by the gay establishment, including "AIDS, Inc.," is right, fair, or in the best interests of the msm community.

We ask you at the least to start a dialogue with us. We ask you to read our oral histories, and to recognize the realities of our lives.

And we ask you to acknowledge the role of cultural messages in promoting anal sex, and to work with us to change those messages.

Best regards,

Bill Weintraub

after two more emails, with copies sent to Sean Strub of POZ and Larry Kramer, Coates responded that "i agree -- alternatives are another way to go"

i then asked him to work with us on ways to promote those alternatives

he never responded

in my experience, there's a degree of contempt for the community among "AIDS professionals" that's almost beyond belief

but see for yourself:

Dr. Coates email address is tcoates@psg.ucsf.edu

If you would like to see a change in emphasis in AIDS prevention programs, write him.