The new sex police: with AIDS diagnoses on the rise and a scary new strain of HIV looming large, some activists are advocating radical methods to halt unsafe sex.

With AIDS diagnoses on the rise, more gay men having unsafe sex, and a potentially new "super-strain" of HIV discovered, Marc Cohen feels compelled to take drastic action. As president of Miami's United Foundation for AIDS, Cohen routinely visits Internet chat rooms for men who have sex with men. Using the screen name HIV-outreach Miami, he talks about the perils of contracting HIV, especially to those whose profiles list barebacking--having anal sex without a condom.

Some might say Cohen's method is unorthodox, even inappropriate, but he has enjoyed some success: He encouraged participants in a weekly sex party to end their barebacking practices and instead use condoms, and 40 of the 47 people in a crystal methamphetamine counseling program came from his group's online outreach. "It's done in a very approachable, nonjudgmental, nonconfrontational manner," he says. "My initial engagement is to build trust. Nobody is going to tell you anything until they trust you."

Many gay men nationwide might describe Cohen, though he shuns such a label, as a member of the new "sex police": AIDS activists who patrol chat rooms; online bulletin board "bloggers" who denounce anal sex in their forums; and pundits who propose solutions like universal HIV testing and the levying of medical-support payments against those who pass along HIV. The recent diagnosis in New York City of what could be a deadlier new strain of HIV, which is resistant to medications and progresses rapidly to AIDS, has caused some public-health authorities, activists, and others to advocate radical ways to police those most at risk for the disease.

The doctors who announced the stronger HIV strain said their "patient zero" used crystal meth at a sex party with multiple partners. The drug has been linked to risky sexual behavior. "We have to ask ourselves why we're using such a dangerous drug," says longtime AIDS activist Peter Staley, who spent $6,000 of his own money on ads that say HUGE SALE! BUY CRYSTAL, GET HIV FREE! The Institute for Gay Men's Health, a collaboration between New York's Gay Men's Health Crisis and AIDS Project Los Angeles, has come up with its own method for combating unsafe sex. According to director of education George Ayala, the institute is placing fake crystal packets in bars and bathhouses. Inside, patrons will find a risk-reduction message.

Perhaps most sensational among the new AIDS activists are those who campaign against anal sex. Bisexual blogger Jim Lynch describes it as "shit sex" and says the way to avoid the "supervirus" includes no longer depicting anal sex as erotic. "It's truly unfortunate that some folks perceived [me] to be antigay when nothing could be more pro-gay than keeping gay and bisexual men alive and healthy," Lynch says.

Bill Weintraub, who runs the Web site Man2ManAlliance.org, also encourages gay men to give up anal sex in favor of what he calls "frot," or frottage--rubbing bodies and genitals together. He remained HIV-negative without using condoms during his 13-year relationship with an HIV-positive man because they stuck to frottage, Weintraub says. He insists frottage is "hotter" because anal sex "cannot give you the same experience as direct genital-on-genital sex."

But psychologist Walt Odets says efforts to make anal sex unerotic reflect homophobia. "I think that anal sex has for gay men the same emotional significance that vaginal sex has for heterosexuals," says Odets, author of In the Shadow of the Epidemic. "No one would propose that we initiate a public-health measure by de-eroticizing vaginal sex. It would sound like a ridiculous idea. It's no less ridiculous for gay men."

Another strategy would be to rekindle the fear that has waned since the worst years of the AIDS epidemic, says Gabriel Rotello, author of Sexual Ecology: AIDS and the Destiny of Gay Men. "The basis of safer sex is fear," Rotello says. "It is now, and it always was."

Indeed, fear and urgency marked the AIDS epidemic in the 1980s and early '90s as it claimed the lives of hundreds of thousands of people, including many prominent stars, like actor Rock Hudson and Queen front man Freddie Mercury. Then in late 1995, researchers announced that a cocktail of antiviral medicines provided hope of turning HIV infection into a manageable illness, and the number of AIDS deaths declined greatly.

But that may be having a detrimental effect. "In many different communities of gay and bisexual men, safer-sex norms do not appear to be as important as they once were in the '80s," says Ron Valdiserri, MD, a top AIDS expert at the Centers for Disease Control and Prevention. The number of new HIV diagnoses among gay and bisexual men rose 11% between 2000 and 2003 in the 32 states studied by the CDC. Syphilis also increased. And a rare form of chlamydia has been seen in New York, Atlanta, and San Francisco. "We're creating the exact same disease settings ... that allowed AIDS to explode in the first place," says Dan Savage, a nationally syndicated sex columnist who recalls the most devastating years of the epidemic. "It's going to happen again."

Savage says that anyone who transmits HIV through unsafe sex should be required to make anti-HIV-drug support payments, just as straight men pay child support for impregnating women. "You often hear from people defending the indefensible-defending people infecting other people--that no one jumps on straight people when they have unsafe sex and they get other people pregnant," Savage says. "You get somebody pregnant and she doesn't have an abortion, you're fucked because you're going to have to make child support payments. So why not be on the hook for drug support payments?"

Many states are increasing efforts to track down and warn sexual partners who may have been exposed to HIV so they can get tested. Known as "contact tracing," the practice began in the 1930s to control syphilis after the advent of penicillin. But widely held privacy concerns have stalled most efforts to apply the practice to HIV transmission. California, for example, began partner notification for HIV just seven years ago. "There is a recognition [now] that HIV is subject to the same public-health techniques that other diseases are," says Sue Blank, assistant commissioner for New York City's Bureau of Sexually Transmitted Disease Control. Increasingly, the Internet is part of the notification process. Health departments, for example, have been working with Manhunt.net to notify any Manhunt member who met through the site someone who tests positive. "This is really an opportunity to do some very proactive partner notification but also maintain someone's privacy and anonymity," general manager Stephan Adelson says.

So is this all too much? A "fairly small segment" of gay and bisexual men are actually having unsafe sex, argues Fred Dillon, San Francisco AIDS Foundation's policy and communications director, and many of those men are grappling with problems of mental health or substance abuse. "I don't think we're going to address those problems with a quick-fix approach of going into sex establishments and serving as sex police," he says. Others call recent ideas about sex policing homophobic. "Whether [the New York City case] is cause for this kind of alarm or alarmist reaction is unclear," says Joseph Interrante, executive director of Nashville CARES, an AIDS set-vice organization.

Perry Halkitis, director of the Center for HIV/AIDS Educational Studies and Training, says many gay men need to find new role models. "We have a very clear standard of what is hot in the gay community," Halkitis says. "And hot right now is circuit boys with big pets who are probably doing steroids and are probably doing crystal and are probably having unsafe sex. We need to say there is a different kind of role model we want to go after. This role model is the many gay men who are financially stable and educated and have very, very functional lives that don't depend on these substances."

RELATED ARTICLE: The politics of post-exposure.

In recent years it's become possible for someone exposed to HIV through an incidence of unsafe sex to be given a monthlong regimen of AIDS medications right away to ward off infection. The two- to three-drug regimen--which may be accompanied by side effects--must be started within 72 hours after exposure. Yet previously, federal health officials wouldn't endorse it. Official recommendations for the preventative treatment, known as post-exposure prophylaxis, had been reserved for health care workers accidentally exposed on the job. However, on January 20 the Centers for Disease Control and Prevention issued new guidelines for the treatment that include people exposed to HIV through unsafe sex or drug use.

Within days of the CDC's announcement the California Department of Health Services followed suit. New York, Rhode Island, and Massachusetts have also issued PEP guidelines, as have several countries across the globe.

While most gay men heralded the official endorsement, some wondered why it took so long. "My understanding is that development of the CDC guidelines was well under way and almost completed by the end of 2000, but all progress stopped under the Bush administration," says Democratic California state assemblyman Paul Korotz, a longtime proponent of PEP. "I think it was very much both politics and general discomfort [with] talking about sexual exposures to HIV that probably kept this from being released for several years, and without a doubt caused the deaths of a certain number of people."

Ronald Valdiserri, MD, deputy director of the CDC's National Center for HIV, STD, and TB Prevention, defends the delay. "Anytime the federal government is developing guidelines that involve multiple agencies, it's typically not a quick process," Valdiserri says. "But more importantly, from the public health--science perspective, these guidelines were not issued until the scientific evidence was there to support their effectiveness." A recent study by the Medical College of Wisconsin showed that the PEP regimen costs about $1,200 per person, and found that when the treatment was given to gay men who were exposed to HIV through unsafe sex, it was effective enough to result in a net savings in future medical care costs for those in the study group.

Some health officials and AIDS activists have worried that PEP might be seen as a kind of "get out of jail free" card. As the new California guidelines go to great lengths to point out, it's critical that the drug treatment aspect of PEP be accompanied by prevention counseling. "In San Francisco we've chosen to call it 'post-exposure prevention,'" says Michelle Roland, MD, one of the nation's top PEP researchers and the primary drafter of the California recommendations. "If PEP is provided without a broader prevention piece, providers will have missed the opportunity to really help the person stay HIV-negative."

Valdiserri echoes that concern. "This is not, by any stretch of the imagination, meant to be a 'morning after' pill or a substitute for consistent risk reduction or safer behaviors," he says. "But clearly we recognize that accidents happen, and in those kinds of very limited circumstances where there is a high-risk exposure, this kind of prophylaxis can provide a safety net."--Dan Allen

Henneman has written for the San Francisco Chronicle and the Los Angeles Times.