When rubbers hit the road: HIV infection among gay men is on the rise. This time, it will take more than condoms to stop it.

FIRST THING MOST MORNINGS, WHILE it's still dark, before I swing my legs out of bed to get ready for the gym, I reach for the phone and call one of the many dial-a-boy phone chat services that cater to gay men. On these lines, I leave a message describing myself and what I'm looking for, and then listen to others' messages. If I hear one I like, I can send the originator a private message or initiate an online chat with him. Judging from the number of other men accessible on these lines, there are a lot of gay men who are looking for sex, titillation, or (like me, most times) just the chance to hear another man's voice as a balm to loneliness before getting up.

Most of the men who call say they do it because they're feeling a little randy. But if that were the only reason for calling--given the time or the money involved--it would be smarter to take the Joycelyn Elders approach to lust and avoid the hassles and cost. No, my guess is that despite denials, most of these guys are as lonesome as I am and want not only the eroticism which goes with sex, but the human contact, if only for a few minutes or hours.

Alas, this loneliness sometimes leads me, and I suspect many others, to take risks I know I shouldn't take. By this I mean having unprotected anal intercourse. I'm not proud to admit that the last time I did this was just last month.

My excuse? I don't have one.

For two years, I actually lived with an HIV diagnosis, and then was granted a reprieve: I wasn't HIV positive after all. (The county health department, apparently, had given me someone else's results.) During those two years and the four that followed, when I worked for an HIV study run by the University of California, I gave dozens of talks about HIV's causes and effects, read mountains of literature, talked with experts on HIV, and became extremely knowledgeable.

When I go in for my irregularly timed HIV antibody tests, public health workers tell me multiple sex partners and unprotected anal sex are the surest routes to HIV infection. "It only takes once," they caution. They know I know that. Yet occasionally--only a dozen or so times in over 15 years--I still slip. In retrospect, I see that the public health community's message, focused almost solely on encouraging condom usage, was bound to fail over time, and that my (and others') slipping into unsafe sex practices, however rare, was inevitable.

There have always been gay men who refused to practice safer sex, but between the advent of AIDS and the late 1990s, barebacking--anal sex without a condom--was mostly practiced on the fringes of gay society. Plenty of evidence suggests, however, that over the last few years barebacking has become common, if not de rigueur, among gay men in general.

Certainly, the advent of new drug treatments has contributed to this trend, as has the loneliness that seems inherent in gay life. But those factors don't explain everything. Also driving the increase in barebacking is the peculiarly amoral nature of the dominant gay culture, which springs from a well-articulated ideology that views unfettered sex as the defining feature of gay identity. As a result, heading off the next AIDS epidemic will take a lot more than free condoms and stern lectures from well-meaning health officials.

In June, the Centers for Disease Control and Prevention (CDC) released preliminary data from a seven-year, seven-city study of 15- to 22-year-old gay men that showed an alarmingly high incidence of unprotected anal sex--41 percent of respondents. CDC researchers have also found disturbing increases in the percentage of men under 25 reporting multiple sex partners, and of men having unprotected sex with multiple partners who don't even know whether their partners are infected. Researchers estimate that the increase in unprotected sex among gay men is rising exponentially: 50 percent in the last two years.

The effects are already apparent. The estimated number of new adult-adolescent AIDS cases diagnosed in the United States sharply decreased between 1996 and 1998, thanks to a concerted public health effort. But those gains have almost ground to a halt. The estimated number of new AIDS cases decreased by only one percent between 1998 and 1999.

There's reason to believe that gay men, and not intravenous drug users or other high-risk groups, are driving this change. In 1999, San Francisco researchers reviewed the results from about 9,000 people who had been tested in area clinics. Among the most recent infections, not a single woman who was tested turned up positive, nor did any IV drug users--except those who were gay. Those with new infections were gay men, mostly white, and in their thirties.

Clearly, the fear mongering that was public health officials' primary weapon against HIV infection for most of the 1990s is no longer working. It's no surprise, really. After all, condoms may offer protection against disease, but they hardly protect against the other things that drive us toward risky behavior--like loneliness, a simple human emotion that gay men probably understand better than most, and the one thing that usually prompts my own lapses.

For most gay men, sex has never been safe and often still isn't. Condoms or no, in almost half the states, consensual sex between two men remains a criminal offense. Relationships? Because there are no societal sanctions, most gay male relationships are a joke and rarely monogamous. It's easier to snatch a bit of intimacy with someone you meet in a bar or via a phone line or Internet chat room and call it a day. Even among the most openly gay men, the strain of managing a normal life in the face of systemic and judicially validated social exclusion often induces drug and alcohol abuse, depression, and excessive promiscuity--all of which contribute to the risky behavior that can lead to HIV infection.

At the same time, condoms have been a poor substitute for what serves as a check on promiscuity among straight people: morality. With all gay sex deemed immoral, gay men have no language for defining what's acceptable sexual behavior and what isn't, and no social consequences for violating those norms to help shore up their willpower. Without recognizing these complicating factors in gay sexuality, public health officials' simple exhortations for safer sex will likely fail at a tremendous cost, both in human lives lost and in the public expense of caring for a new generation of HIV's victims.

Bathhouse Rules

At the turn of the 20th century, a German scientist discovered that healthy people could carry the typhoid bacteria for years, spreading it around and making other people sick without realizing it. As a result, during a subsequent outbreak of typhoid in New York City, an ambitious city public health official tracked the source of the infection to Mary Mallon, an Irish immigrant who worked as a professional cook. The health department incarcerated her on an island in the East River until she promised to find different work.

But under a pseudonym, Mallon sneaked back into a kitchen. When officials traced more infections back to her, and she refused to cooperate with their infection-control efforts, the health director sent her back to the island for the rest of her life, where she became the famous Typhoid Mary. While that might seem extreme by today's standards, similar efforts to track down, treat, and contain the infectious steadily reduced death rates. Had that practice been employed early on, the spread of HIV might have been checked.

But politics made such measures nearly impossible. Gay activists fought efforts to allow public officials access to the names of infected people for contact tracing. All testing was done anonymously. Their arguments were compelling enough: the stigma of AIDS was such that inadvertent disclosure could cost people their jobs, housing, and even result in family breakups, especially when the sick person was still closeted or married. Health officials feared mandatory testing would also drive underground the very men most at risk of testing positive. At the same time, gay men resisted such efforts as closing gay sex clubs (euphemistically known as bathhouses) and other venues where transmission of HIV flourished. Their argument: The government had no right to impinge on individual sexual freedoms. With the religious right generating hysteria and demanding that all gays be branded or quarantined, suggesting a "Typhoid Mary" strategy was out of the question lest it be taken to extremes.

Even in the face of such hurdles, the public health system rose to the occasion--supplemented by many private organizations--by focusing on public education with a message consistent with knowledge of the disease. The condom code (i.e. "Use a condom ... every time") was at the heart of that message, and for a number of years it worked. HIV infection rates among gay white males took a dramatic downward turn in the late 1980s.

But the arrival in the mid-'90s of antiretroviral drugs and other effective HIV treatments created new problems for public health officials. By 1999, no longer were huge numbers of men dying of "AIDS complications." And advertising aimed at gay men, depicting healthy, hunky models (black and white) engaged in strenuous activities, further minimized the risks of HIV. To young men coming into the world of gay sex then (and now), HIV and AIDS were things old guys got. It didn't affect them. Without the fear of imminent death hanging over them, men let their guard down, relaxed their vigilance in complying with the old condom code.

HAART (highly active antiretroviral therapy) also created another problem for public health officials: Normally, even without public health interventions, most disease epidemics eventually burn themselves out (at great human cost, of course), either by killing off most of those who might spread the disease, or leaving enough people with immunity that the bug loses its potency. Thanks to the advent of new drugs, HIV is one of the rare, fatal infectious diseases that can now exist in people who are largely healthy, potentially creating thousands of Typhoid Marys to keep the virus alive and kicking in new victims.

The dangers of this situation shouldn't be underestimated. HIV is an amazingly clever virus, capable of mutating to escape the new drugs. As the virus mutates, it limits the treatment options, leaving open the possibility of successive waves of untreatable illness. Even the 50 percent of HIV-positive people who respond to the new drugs run the risk of acquiring one of these drug-resistant strains if they continue to eschew condoms, as many apparently are. Already the costs are mounting: Treating drug-resistant HIV can cost $60,000 per year, per person, and it is only a matter of time before the death toll begins to mount once more as the drugs fail to save us.

Boys Will Be Boys

Clearly, medical advances can only go so far in saving lives from HIV. That means that gay men are going to have to change their behavior if they are going to avoid another replay of the funeral-a-day '80s and early '90s. So far, though, few people--gay or otherwise--are calling for such change.

While some individual conservatives may be developing a quiet tolerance of gays (see Dick Cheney), the conservative movement makes gays feel unwelcome and even hated in a thousand ways, including supporting political and religious leaders who are openly bigoted. Its pattern of reaction is unlikely to bring about gay men's necessary behavioral modification. And liberals turn deferential, adopting a boys-will-be-boys attitude when told of various gay male sexual practices. Both camps, it seems, believe that when a man has consensual sex with another man and gets infected, it's his own damn fault. (I admit I lean in this direction, and have long accepted that if I were to become infected, it would be no one's responsibility but my own.) But it's too facile to say the disease is its own punishment, and that society at large bears no responsibility for its social consequences.

Compare the way we treat gay men who spread HIV with the public reaction to Nushawn Williams, the 20-year-old black man in upstate New York who was prosecuted for infecting 10 young women. Rightly or wrongly, state officials decided that Williams was a public health hazard, and took an aggressive approach to preventing him from spreading the disease any further. They tracked down all of his sexual partners (there were 48), tested and treated them. They put his name, photo, and HIV status on posters all over town to warn potential intimates; CNN and other national news outlets got in on the story. And prosecutors brought enough assault charges against him to potentially put him away for life. (He got four to 12 years.)

Yet what Williams did seems almost mild in comparison to what goes on in gay culture, which features sex parties at which condoms and talk of HIV are prohibited. True, Williams's partners were willing (or willfully ignorant of his HIV status). But state officials decided that the lives of his potential female partners were worth protecting from any lapses in judgment. Gay men who engage in unprotected anal intercourse, though, are on their own. The laws making the willful transmission of HIV a crime have almost solely been applied to straight men who infected women.

That we don't sanction gay men who behave irresponsibly is a sign--one of many--that for all the progress made in gay rights in the past decade, straight people still don't see gays as part of respectable society. Of course, mainstream society has legally set gay people apart as a class at least since the end of World War II, if not longer. The government has persecuted gays, kicked them out of government jobs during the red scares of the '50s, deported legal gay immigrants, thrown them out of the military, and allowed blatant discrimination in housing and employment. (I, myself, was fired in 1984 from a job as an intelligence analyst at the National Security Agency.) In states that still have laws against consensual sodomy, the courts have even ruled that men can legally be arrested for asking another man out for a date! And that list doesn't even include the private abuse, the familial rejection, and risk of physical violence which gay people live under.

Because mainstream society has set them apart (morally, philosophically, culturally, physically), gay people have developed their own vaguely defined morality and ethics. This alternative, sometimes-perverse morality, I believe, underlies the current barebacking trend. And because that alternative morality (or amorality) was created in response to ostracism from mainstream society, society as a whole--conservatives and liberals alike--bear some responsibility for the rise in unsafe sex.

Zack the Knife

While researching this subject, I spent over 20 hours interviewing men (both HIV positive and negative) who admitted to regular barebacking. Because they were afraid of the stigma and legal consequences their behaviors engender, many refused to meet in person or even talk on the phone. As a result, I interviewed them all in real time via private Internet chat rooms. Almost none had ever thought about the moral ramifications of his acts. In almost all cases, these men (ranging in age from 19 to 53) seemed to feel no sense of responsibility for their actions toward others.

One of these men said he preferred his partners to be HIV negative because of the psychic thrill he got from knowing he might infect them. In addition, he said, he prefers that his sexual partner not know he is HIV positive; he gets a kick out of possibly infecting someone who doesn't know he's getting infected. "I think it's a power thing," 19-year-old Zach told me. "Normally, I like to be the one who is totally dominated, but when I'm topping a guy I like to know that what I'm doing is changing his life, especially if he doesn't want it to be."

There's not much difference between Zach and any other run-of-the-mill killer. He knows full well what he's doing, Yet many gay men (if my interviews are representative) would do nothing to stop men like Zack from infecting others.

These attitudes reflect the growth of an extremely vocal minority within the homosexual culture. It holds that sexual license (which its members call sexual liberation) is the defining characteristic of homosexuality. People like Michael Warner (an English professor at Rutgers) and Judith Butler (professor of rhetoric and comparative literature at Berkeley) recoil in horror at the merest suggestion by many prominent gay activists and writers--including Michelangelo Signorile, Gabriel Rotello, Larry Kramer, and Andrew Sullivan--that gay men should rein in their sexual appetites and adopt the heterosexual paradigm of coupled monogamy, if for no other reason than to curb the spread of STDs. They see any such talk as tantamount to forcing gay people to become pale imitations of straights. To them, being gay is being a sexual libertine--damn the consequences. They've even formed a group, Sex Panic, to promote their viewpoint.

As conservative gadfly David Horowitz observed in Salon.com, "Any acknowledgment of `normality' [by Warner, et. al] would suggest that the promotion of promiscuous sex in the midst of the AIDS epidemic is perverse at best and accessory to murder at worst. If heterosexuals were defending gay sex clubs in the face of the AIDS epidemic, their motives would be properly suspect. Still, their silence ... lends a quiet support to this intellectual fascism and sexual fanaticism that diminishes the prospects of survival for America's gay men."

Tough Love

Any new efforts to slow the spread of HIV, particularly among gay men, must be multifaceted and nuanced, taking into account the unique characteristics of gay culture. While the condom code was based on individual fear and safer sex, these new strategies must emphasize responsible sex and demand that gay men consider the effect of their actions on the well-being of larger society, not just on themselves. Dr. Jeffrey Klausner, director of Sexually Transmitted Disease Prevention and Control Services in San Francisco, has suggested a number of measures, some coercive, which he thinks would slow the increase of new HIV infections among gay men. Among them: closing sex clubs and adult bookstores, enforcing no-sex ordinances in bars and clubs; enforcing no-drug policies in bars and clubs; and Internet-based outreach and education, particularly in chat rooms where many gay men meet new sexual partners.

Putting aside political realities when brainstorming on this subject, Klausner also raised the possibility of quarantining those who cannot control their infectivity--e.g., those barebackers who've infected 20 different people and still refuse to use condoms. Many of these measures would probably be infeasible in the current political climate. Still, this doesn't mean they shouldn't be discussed. After all, in an environment where there are no consequences for actions that threaten the public health, it may be necessary to create some.

I believe, too, that a balance could be struck between effective public health measures and civil rights. And nearly 20 years into the epidemic, the gay rights movement might just have matured enough to make a reasonable discussion of such measures possible. After all, we've long accepted the need in certain circumstances for quarantining tuberculosis patients and recently began forcing some recalcitrant tuberculosis-infected individuals to take their medications under supervision. Likewise, contact reporting and tracing has long been the means of limiting the damage (to individuals and the public at large) from other sexually transmitted diseases. And if this is a public health issue-why, in the 17 states where willful transmission of HIV is a crime, is informing the uninfected partner ahead of time usually a defense against conviction?

Ultimately, though, HIV prevention efforts will not take root until mainstream society welcomes gays into the fold. After all, how can we ask gay men to respect the well-being of larger society if we don't ask mainstream society to respect the health of gay men? Legalization of same-sex marriage, domestic partnership benefits, and other measures that would allow gays to have culturally supported, monogamous relationships, would go a long way towards curtailing excessive promiscuity, not to mention protecting the public health. At the same time, homosexuals must be held to the same legal, moral, and cultural standards applied to heterosexuals both in and out of committed relationships. Given that the direct and indirect costs of not dealing with rising infection rates will be huge, what choice is there?

ANDREW WEBB is freelance writer in San Diego.