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 HIV, the virus that causes AIDS.
Mr. Watkins, 24, is an HIV prevention educator and counselor in San Francisco. He knows how HIV 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 HIV," 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, HIV negative and HIV 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' HIV 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 HIV 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 HIV infection rates are increasing among young gay men.
"I think the promiscuity of the 1970's is back," said Dr. Virginia Cafaro, an HIV 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 HIV 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 HIV 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 HIV positive. John spoke on condition that his last name be withheld for fear it would cause difficulty on his job.
"Now I've got HIV 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 HIV positive. "If people want to use condoms they can. I didn't go out and purposely get HIV 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 HIV positive, most go to great lengths to avoid transmitting the virus.
"I would sooner cut off my arm than expose my lover to HIV," 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 HIV 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 HIV-infected men, already stigmatized, should not be further burdened.
"There is a huge continuum of sentiment about whether HIV-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, HIV 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 HIV prevention branch at the Centers for Disease Control and Prevention, which convened the National HIV 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 HIV."
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 HIV 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 HIV 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 HIV 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 HIV for two decades, any rationale for unprotected sex is incomprehensible.
"I can't imagine someone being HIV 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 HIV 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 HIV, 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 HIV, 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 HIV In some animal studies, such prompt treatment has been shown to prevent infection. And in health workers exposed to HIV, such preventive treatment has been found to reduce infection by 81 percent. Both men remain HIV 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 HIV 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 HIV 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 HIV.
"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 HIV 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 HIV 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."
