AIDS: The Perils of Progress

"...[San Francisco]... has a distinctive problem regarding AIDS. In an epidemic, the primary public health task is to protect the uninfected. However, that is becoming harder here because of gay men's confidence in the ability of... protease inhibitors... to enable HIV-positive people to lead normal, and longer, lives.

"Sex, says [city health director Mitchell] Katz, is a powerful motivator, but so is fear. Fifteen years ago 'to have unsafe sex was to die.' ...Now, says Katz, gay men who are frequently in settings involving unsafe sex 'say to themselves, "So, now I'm going to have to take medicine. I'm 35 and I'll live to 65 instead of 75."

"...Worldwide, 16,000 persons are infected with HIV daily, most by heterosexual contact. ...AIDS can be largely contained in America by avoidance of risky behavior by two groups. Two-thirds of new infections result from sexual contacts between gay men and the sharing of needles by intravenous drug users.

"Katz says that one reason no baby has been born with HIV in San Francisco in more than two years is that the city has distributed 2 million clean needles to drug users. ...Nationwide, the current rate of infection has been reduced from 100,000 people a year to 40,000 largely because of safer sex habits and needle exchange programs. But in San Francisco, at least, fear and safe habits are declining in tandem.

"...The behavioral changes of the late 1980s are not being sustained. Gay men are having two to three times more unsafe sex partners. The decline of fear produces fatalism about the inevitability of unsafe sex. Katz says that just as a person with high cholesterol is not going to live life entirely without French fries and doughnuts, a gay man, in the context of today's medicines, is more complacent about saying, 'I can't be safe for the rest of my life.'

"So the public health message, aside from 'there are problems with the medicines -- you could still die,' becomes, for example, the encouragement of 'assortative mixing' (encouraging HIV-positive people who are averse to condoms to have sex only with other positives.) But Katz recognizes that such messages are of limited -- very limited -- utility when gay sex is fueled by substance abuse and Viagra.

"Still, the good news is very good indeed: In this city AIDS is no longer, as it was from 1990 to 1996, the leading cause of death as measured by expected years of life lost."

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