Viewpoint: AIDS at 20

AIDS will turn 20 this week — at least, our awareness of it will, since it was June 5, 1981, when the Centers for Disease Control and Prevention first published a report about five gay men in Los Angeles with a strange illness. Last week the CDC drew attention to a new study, and many reporters focused on its most shocking, depressing finding — that nearly 15% of young black gay men are contracting HIV every year. One-third of black gays ages 23 to 29 are already infected in the six cities where the study was conducted. If these rates of infection continue, they could gobble up an entire community in a matter of years.

But to focus only on the tragedy stalking black gay men is to miss the larger story. Many young gays of all races have become complacent about HIV. The CDC survey showed that 4.4% of gay men in their 20s are being infected each year--about twice the incidence of infection in gay men overall as measured by other studies. These figures aren't perfectly reliable; so many gay men hide their sexual orientation that finding a representative pool is basically impossible.

But you don't need a degree in epidemiology to sense the change in gay culture. No, the corner bathhouse hasn't reopened, but gay men often chat--online and in bars--about unprotected sex. More fantasize about having it than have it, but we've been talking about it so much we had to appropriate a pithy catchphrase a few years ago: "barebacking." You can find a barebacking partner in most cities without much trouble on the Internet.

It's not just HIV that we could be spreading. National rates of syphilis transmission are at their lowest in 60 years. But in February the CDC released a report documenting 130 syphilis cases in Southern California, up from 100 the year before. Sixty-six of the new cases occurred in men who had had sex with another man at least once (presumably most of the 66 are gay). And only 20% of those men reported using a condom the last time they had sex.

There are many reasons young gay men are having unprotected sex, but I think the most pertinent is that we've never had to visit a friend in the hospital disfigured by Kaposi's sarcoma. Like many other gay men around my age (30), I have never known anyone who was ill with AIDS. The last time I was in the hospital was when I had my tonsils out. If I had been born 10 years earlier, I probably would know the names of the admitting nurses at New York City's St. Vincent's hospital.

It's also worth noting that gays are coming out so much younger. Openly gay boys can be found in high schools across the U.S.; they are bound to be as reckless as any other horny teenager. Why not? They have grown up in a time when pharmaceutical firms seem to have no shortage of HIV wonder drugs, when Bill Gates is spending $100 million to find a cure, when a Republican President names an openly gay man to run the White House Office of National AIDS Policy. Getting HIV seems not so much a death sentence as an annoying pill-taking regimen. The gay press is filled with delightful ads for HIV medications that depict healthy, happy-looking guys who seem too busy racing the Iditarod to be sick. Last month the fda actually had to order drugmakers to tone down the upbeat ads for HIV drugs--and remind readers that, oh, yeah, HIV is lethal.

Young gay men should take more responsibility for their health, but until this week, the government wasn't doing much to sound the alarm. Congress allocates more than $7 billion a year for AIDS treatment. But HIV-prevention efforts have never been sufficient. It took until this year--20 years into the epidemic--for the CDC to come up with its first comprehensive plan to change sexual behavior, through education and counseling, among those already infected. AIDS activists estimate that it would cost $1.3 billion to implement that plan, while the current budget for prevention is only $844 million. That money is often distributed to local officials who refuse to spend it on ads explicit enough to be effective.

Last week it seemed tempting to see AIDS as a pathology we could confine to the inner city. We can't. To be sure, HIV-prevention strategies must be culturally targeted, and the CDC must find a way to get through to black men who don't see themselves as part of the gay community. But the CDC may also have to start anew with gay America as a whole, since some of us weren't around the first time HIV started killing us.