New treatments, old behaviors.

AIDS prevention has always been a difficult sell. But how do you convince gay men to stick with safe sex when HIV looks less and less like a threat?

Increasingly that's the problem facing AIDS educators. The much-touted advances in AIDS treatments brought about by protease inhibitors, a powerful new class of drugs, could be aggravating a continuing crisis in new HIV infections. Even as the possibility arises that AIDS could become a chronic, manageable disease, experts worry that anything that lessens the threat of HIV infection could only lead to more of it.

"The potential is there for a resurgence of transmission," says Tom Coates, director of the Center for AIDS Prevention Studies at the University of California, San Francisco. "People get the idea that treating HIV is no big deal." Some gay men refer to the latest HIV treatments as "a morning-after pill," says Dan Wohlfeiler, education director of STOP AIDS Project San Francisco, an HIV prevention agency. "What we have to make clear is that it's more like 30 morning-after pills, every morning, midday, and evening for the rest of your life."

There is ample reason for concern. According to a study released last November, one in six men aged 18 to 29 living in the South Beach section of Miami Beach, Fla., is now HIV-positive. Even more ominous is the finding that nearly 76% of the 157 gay and bisexual men surveyed had had unprotected anal sex during the past year. Indeed, says William Darrow, the Florida International University professor who conducted the Miami Beach survey, "significant numbers of gay men may believe that there is a cure."

They are, of course, sadly mistaken. AIDS education, not treatment, continues to be the frontline defense against the spread of the epidemic.

The good news is that, after years of concern that AIDS prevention messages were not sinking in, experts say they now have come to a better understanding of what type of program works, especially for young gay and bisexual men, one of the groups at highest risk for infection. Young gay men "want HIV prevention as part of a program that meets a lot of different needs," says Coates. At the Relate...HIV prevention workshops at the Los Angeles Gay and Lesbian Center, for example, participants talk with one another about homophobia, relationships, and substance abuse. "HIV is a back-door issue," says Danny Jenkins, youth services director at the center. "The underpinnings of unsafe sex are cultural issues and, ultimately, homophobia, which drives same-gender sexual experience underground. At the very end it comes back around to HIV."

Another trend is a new emphasis on the responsibility of HIV-positive men in helping reduce new infections. "Up to now we've tended to keep a false separation, where prevention is about negative men and treatment is about positive men," says Wohlfeiler. "Prevention has to be about both."

Wohlfeiler says that some HIV-positive men whose viral loads have dropped to undetectable levels as a result of the new treatment are asking if they can dispense with condoms even if their partner is HIV-negative. "They all leapt to the conclusion that a low viral load in the blood correlates to a low viral load in semen," he says. "That's not necessarily the case." Research has yet to pinpoint the relationship.

Overall, infection rates for gay men continue to stand around 1.5% to 2% annually. "It's still too high," says Coates, "but it's better than it was."

At the same time, however, the rates are skyrocketing among minority communities, particularly among African-American males, through same-sex encounters, sharing needles, or both. And here, critics say, is where prevention efforts are getting short shrift. "If you look at gay men of color and their rates of infection, you realize there is a disconnect between the strategies that are funded and the people being infected," says H. Alexander Robinson, who chairs the prevention subcommittee of the Presidential Advisory Council on HIV/AIDS. Part of the problem, he says, is the government's unwillingness to address such issues as needle-exchange programs and condom distribution in prisons: "Our current federal prevention efforts are timid. "We know what works, and we haven't done it."