June / July #8 : Second Wave, Second Thoughts - by David France

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Table of Contents

Down for the Count

Second Wave, Second Thoughts

AIDS' Next Frontier

Role Model

Banker's Hours

Pedigree Activism

Sex Positive

Hey! Watch the Teeth

A Boy and His Toy

Kitten Does Disability

Take Your Best Shot

ADA Upheld

Don't Regulate My Body

Those Darned Kids

Curb Your Dogma

S.O.S.

AIDS Sweeps Week

White Line Fever

Hot for Teacher

Diet and Exercise

New Test for HIV Itself



Most Popular Lessons

The HIV Life Cycle

Shingles

Herpes Simplex Virus

Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

Hepatitis & HIV


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June / July 1995

Second Wave, Second Thoughts

by David France

Prevention activism moves to the fore as safer sex is scrutinized

At the YMCA after a swim, Jonathan Capehart, naked, frequently lingers under the wallmounted driers and observes men beckoning from the adjacent toilet stall. "I assume something's happening," he says coyly. From the same vantage point, just a few feet from a sign banning "sexual activity of any kind," he can also gaze into the large shower room and the sauna, where furtive sex is not uncommon. But before last January 31, when he went to a gay bathhouse in Manhattan, the handsome and bright 27-year-old with a cautious smile says he'd never entered a sex club. He took his boyfriend.

And he wrote about the escapade -- less any reference to his own proclivities -- for New York City's Daily News, where he's the youngest member of the paper's editorial board. "They asked me to go there and file notes on my experiences," he explains sweetly over merlot one evening. "So I typed out a memo, which they then published."

Capehart reports seeing no sex of any sort at the club -- instead he describes condoms stacked everywhere and reams of literature extolling safer sex and threatening eviction for violators. "I did not see unsafe sex during my two-and-a-half hour visit," he penned, unequivocally.

Yet that does not keep him from drawing a baseless and distracting conclusion. "My intention," he writes, "was to confirm whether the club is, in fact, the latest and most extreme representation of a tragic phenomenon: A resurgence in unsafe sex among gays. I discovered, with almost complete certitude, that the answer is yes."

Amid the bilge and hyperbole that has shadowed the debate over HIV prevention, his piece on "factories of destruction" stands as one of the most falsely ominous, one of the least productive, one of the most rank and bigot-friendly contributions so far, though he doesn't quite understand why people would be upset. "I just wrote what I saw," he says softly.

"Walking the halls is an endurance test," he wrote. "The sound of water in the shower room draws men like a dinner bell on a dude ranch." He added, darkly: "An attendant opens the door, says, 'No sex in the sauna,' then goes on his way."

Tensions exploded when an "older paramour" eyeballed him in the hallway. "He touches my chest with his hand, and pushing the limits of my nerve, I touch him back," Capehart wrote. "He invites me to his room -- the same room to which he'd already brought a dark-haired young man after getting intimate with him in the hall. I decline. How many partners had he had before we arrived? How many more did he have after we left? Were his encounters safe? Did he care?"

Within weeks, the tabloid's crusade against sex clubs -- though not against HIV transmission -- was in full swing, an exact redux of the bathhouse controversies of last decade. New York City's gay community became locked in an angry debate over whether campaigning against the sex clubs is an appropriate tactic -- and more fundamentally, whether a "second wave" of transmission even exists. A new organization was formed to police the clubs, instigated by gay media powerhouses Gabriel Rotello and Michelangelo Signorile, along with a handful of other skilled propagandists. They took their hotbutton position all the way to 60 Minutes.

And by spring, the predictable results were in. New York City's inspectors had shuttered three openly gay romping establishments, including Capehart's bathhouse, but not his YMCA or any other locale that doesn't self-identify as gay. Meanwhile, the old preventive initiatives have not been rethought and few new ones have been proposed.

In the cloudy morass of AIDS prevention, the debate over permissible sex, replete with dishonest embellishments like Capehart's, has once again jump-started a heated discussion. For the first time in years, AIDS activism seems to be crackling with a lot of energy but few answers. HIV is still being spread in every community in America, at an unhindered rate of some 60,000 new seroconversions a year.

But in the ghoulish mathematics of public health, that is not far from being an acceptable number. In a long-term study of gay male New Yorkers at Columbia University, investigator Laura Dean found the average number of unsafe sexual encounters dropped from 11 a year at the start of the epidemic to one a year by 1991. Only a small number of those contacts will result in infection, she says. The net result is that fewer people will be catching HIV than will be dying from it. She sees gay men as being on the threshold of the epidemic. "I don't want to have to say things like that," says Dean, "but as people die and they're not being replaced, well, the epidemic shrinks."

The question few are trying to answer is: Where do we go from here?

Walt Odets, a clinical psychologist and researcher in Berkeley, has one proposal and he's adamant about it: Give back oral sex, he says, and HIV transmission numbers will nosedive.

On its face, it seems as counterintuitive as distributing cigarettes to end cancer. It was nearly two years ago that fellatio was cut from the "possibly risky" column in safer sex literature and reclassified as "high-risk" based on two studies as well as the belief among many positive men that they contracted HIV by sucking a penis. My lover Doug Gould, for example, was 33 when he died in 1992, having been fucked only once, pre-epidemic; he was convinced a blow job killed him. At a recent national conference on women and HIV, a lesbian in attendance said she'd gotten HIV by going down on her positive girlfriend, an indictment of the safety of cunnilingus, which is only now being researched.

But for every anecdote attesting to oral transmission, there are countless others debunking it. Universally, gay men are taking the risk, despite what the literature says. In fact, researchers have been unable to study men who suck condoms -- because the sample population is too tiny. "I've been swallowing cum too often and staying negative too long for there to be anything wrong with it," says a friend. As a call-boy through the early '90s, he was having dozens of ingestions weekly; he continues the activity today, as recreation. "I've sucked off hundreds and hundreds of men and nothing's happened to me."

I have a similar hunch about my own so-far negative results: Many of the men whose cum I have swallowed have, it turns out, been HIV positive.

"The data is very clear," says Odets. "Oral sex is an extremely safe activity -- about half as dangerous as driving a car." He says almost all HIV transmission takes place through unprotected receptive anal sex. He cites the San Francisco cohort of gay men pulled together in the '70s for research on the hepatitis B vaccine. Of the original 6,704 men, most have seroconverted. "There were just two possible oral sex cases," Odets says. One of them had ongoing oral sex after oral surgery. "That's 3/10,000 of 1 percent."

Odets faults the authors of safer sex guidelines for not distinguishing between those levels of risk. In the end, he says, placing oral sex alongside anal-receptive sex has fueled a sense of hopelessness among gays. And that hopelessness leads to slip-ups -- with people feeling that if they've already capitulated on oral sex they might as well go all the way.

Incidentally, slip-ups seem to be on the increase since the 1992 International AIDS Conference where oral sex was first linked to transmission. Ron Stall, an associate professor of epidemiology and biostatistics at the University of California, San Francisco, has recently interviewed 2,604 men in gay bars in Portland and Tucson and found that one-third of them had unprotected anal intercourse in the previous six months. Half that group was anal receptive (though it's not broken down further to suggest how many are having sex to ejaculation, which could be an important distinction).

A study in Seattle found 29 percent engaging in unprotected anal intercourse in the two months prior to the survey. Ongoing research in Los Angeles, Baltimore, Dallas, Miami and several California counties has found 44 percent of men under 25 reporting unsafe anal penetration in the previous six months. "Of course," says Tom Coates, director of the Center for AIDS Prevention Studies at UCSF, "it depends on where you do it -- unprotected anal intercourse in New York City or San Francisco is pretty dangerous."

The numbers suggest that the successes Laura Dean has chronicled prior to 1991 may not be sustained. "We see slight increases since then," Dean reports (though, because of a funding drought, she doesn't know exact numbers). "I'm not saying anything rampant, like huge numbers of people having receptive anal intercourse with a huge number of partners."

Still, Dean and co-researcher Martina Morris have created a mathematical model to illustrate the dangers of slip-ups at this point. If gay men were to hold steady at just one unsafe encounter a year, by the year 2030 just five percent of gay men will have HIV. Today, the average infection rate among gay men is more than 40 percent in New York City and San Francisco. Among men of color, the numbers are considerably higher.

But if the unsafe encounters increase to just two a year, the formula shows the epidemic snowballing. In that scenario, by 2030 fully 65 percent of gay men will be HIV positive. "We're still under that threshold," Dean says. "But you can see it's not by far."

That slim margin underscores Walt Odets' urgency. "We should just tell gay men: Do anything else -- just don't get fucked without a condom," he says. By "fucked," he means to ejaculation. This one-step rule to safer sex, he says, is likely to have gay men in more regular compliance.

"The transmission numbers would go down drastically," Odets argues. Because it's doable, "a realistic scope," he says. He says that by cultivating the longest possible list of banned behavior, what's been created instead is a puritanical glossary of shameful activities. "Nobody's using condoms for oral sex anyway -- we can't get anybody to do that."

Tony W., 40, an HIV negative African-American from Brooklyn, has never stopped giving head. Furthermore, he's adapted safer-sex guidelines dramatically to suit his desires. "I've never really given up unprotected anal intercourse," he says.

When he has broken the rules, it has been at home and seldomly negotiated verbally. He has simply expressed his desire to his partners and they have sometimes concurred. Tony's sex life excludes getting fucked, but nothing else.

In interviews with a dozen people, one behavioral truism buoys to the surface: People devise their own definition of safer sex. It's basically a compromise between what they want and what the literature allows, though sometimes it's bolstered by personal empirical evidence.

"There is a Russian roulette aspect about being sexual in New York City," says Tony. "And you know it. And you accept it. It's very hard to commit yourself to safer sex on a very long-term basis. And it's more than a decade now. At some point, it stops being a risk elimination issue and becomes a risk reduction issue."

Currently, he is a "non-contraceptor," as the Journal of Adolescent Health has called the condom-averse, in a long-term monogamous relationship. Similar approaches are being popularized by prevention activists in Australia and elsewhere. A recent British safer sex video actually exhorts viewers to enjoy unwrapped oral sex, in apparent conformity to the Walt Odets principle.

The Australian model promotes "negotiated risk," a complex paradigm for what was once known merely as monogamy. Experts there recommend HIV negative couples go for retreat testing for six months or more following their last outside sexual liaison. If they continue to score negative and if they commit themselves to having no unsafe sex outside their relationship (and maintain that commitment), their condoms can stay in a drawer.

There are many positive couples who operate on a similar principle, despite the risk of infection with a new strain of HIV or exposure to other contagions. For them, the notion of negotiated risk is weightier on the "risk" side, but they elect for the benefits. "I thank God every day to be blessed with a big, beautiful HIV positive boyfriend with lots and lots of T-cells," says Brett, a positive, handsome man who works for Positively Aware, a Chicago AIDS publication. "We have a cute little house, and we have a garden and a dog, and we have unsafe sex," he says. "And it's really nice."

Jon Fine is straight, white and 27 years old. And HIV negative. He has his own formulas for staying that way. "I generally perform oral sex on women, unsafely shall we say. But for any sort of slip-it-in sort of thing, I pull on the jimmy. I would not want to have straight-out penis/vagina boom-boom-boom sex without a condom. But I rationalize the cunnilingus: If the woman is not bleeding or doesn't have gaping open sores, I figure that the risk, while it's there, is minimal." For Lori King, a 24-year-old African-American who has unprotected sex with her long-term boyfriend, that rationalizing takes the form of relational mathematics. He was a virgin and she'd been with just one other partner. "No, we didn't get tested first, and yes, we should have. But I'm in love with the guy I'm with now and I wouldn't even think of straying."

Not surprising, it's among youth that HIV is being volleyed about most earnestly. If there is a crisis in HIV prevention, it is among this population. And the crisis is, they've never been targeted with effective preventive measures. "AIDS is fast becoming a disease of the young," says Fred Hellinger, a health economist who tracks HIV data for Congress.

Official figures tally a mere 18,540 people between age 13 and 24 as having AIDS, though that category is growing by 15 percent yearly. (This doesn't count people with AIDS who were infected as teenagers but who remain asymptomatic.) And that's only the tip of the iceberg. Scientists now believe that positive people under 20 go longer before developing any AIDS-defining symptoms than older people -- 12 years versus 9.9 for 30-year-olds. There's reason to believe, then, that fully 22 percent of all AIDS cases result from teenage exposures, according to Hellinger. "To be able to sustain this level of infection every year really indicates there's some very, very risky activity going on."

Jinny Hinks Reynolds, director of the adolescent HIV program of Advocates for Youth in Washington, D.C., says the "vast majority of teenagers know the basic facts about HIV transmission -- where they get confused is about how to prevent it." While the recent National Adolescent Student Health Survey found that 86 percent of eighth and tenth graders understood the importance of condoms, a similar study found that 12 percent of high school students thought birth control pills conferred some protection. And 23 percent thought they could eyeball their sexual partner and pronounce him or her risk-free.

"MTV spends money every week to do polling of young people for programming," says Mario Cooper, the HIV positive board chair of AIDS Action Council. "It's going to take those kinds of efforts to create messages and thematics that resonate. The tragic failure to invest, develop and promote strong prevention messages means that by the year 2000, more people will have died of AIDS than all American deaths in all wars in history. If the radical right in Congress and statehouses moves aggressively to halt frank prevention programs, the blood of all future PWAs will be on their hands."

HIV prevalence among young men who have sex with men (called MSMs by epidemiologists because they may not identify as gay or bisexual) can be as high as 9 percent in samples of men younger than 24, and 17 percent for men younger than 30. This has always been true about them, most of whom are men of color. Men older than 30 are much less likely to contract HIV and the probability drops with every additional year. Still, older men are converting. "I have two friends who just tested positive within a month apart," reports Spencer Cox, a member of Treatment Action Group. "Both are definitely involved -- one works for an AIDS group, one does gay and lesbian work." Similar stories are shared in the least expected forums, such as ACT UP meetings.

Naturally, alarm bells have been sounded. Some have deemed the ongoing infections a second wave of HIV transmission and have used that data to indict the entire preventive effort. "Very few people would say we're not having a serious problem," says Benjamin Schatz, head of the Gay and Lesbian Medical Association. "People may quibble about numbers: Are we talking about one-third or 50 percent or 60 percent of gay men that will seroconvert in their lifetime? But we're talking about large numbers, very frighteningly large numbers. I can't understand how anybody would think it isn't a crisis."

Still, many more think we're just in the middle of a long and endless epidemic -- one that will be cured by science, not by prevention.

I want our project to win the war," says Dan Wohlfeiler, the director of education at Stop AIDS in San Francisco. "I want us to close shop and reopen as Stop Crabs. Wouldn't that be nice? Of course, we did that already once."

In 1987, news of remarkable behavioral changes among gays was first published. Data from the first behavioral cohorts showed that once the word was out on HIV transmission, people stopped having risky sex. Rectal gonorrhea statistics, a key indicator, had withered from a high in Seattle of 955 cases in 1982, for example, to just 33 in 1988. HIV transmissions in San Francisco, which were at 8,000 a year at the height of the epidemic, had dropped down to a few hundred. It was believed the "crisis" part of the epidemic had passed.

In 1987, Stop AIDS declared victory and closed its doors. "We stayed shut until 1990," says Wohlfeiler, "when it was clear that the war was certainly not won, that new men continue to get infected and will continue to get infected."

"Success in this effort won't be the end of HIV," says Robin Miller, who evaluates prevention programs for Gay Men's Health Crisis (GMHC). She cites campaigns against drunk driving, which lowered the number of fatalities involving alcohol from 57 percent to 45 percent over a period of 10 years. "The question is: What level of transmission is acceptable, what's a realistic goal? I think there's nothing wrong with wanting only what's real. But we don't have any idea what that is yet. It doesn't mean we're bad or stupid. It just means we're not finished."

Sometimes, though, it seems we haven't gotten far from the starting line.

Michael Callen was the first to address the issue of prevention, in 1983, and he did it in his characteristically public way. He coauthored the pamphlet which coined the phrase safe sex, titled, How to Have Sex in an Epidemic: One Approach. Though it was written before the discovery of HIV, Callen supposed that "a highly contagious new AIDS agent" was on the loose and, to prevent its spread, he proposed a top-to-bottom rethinking of sex. Condoms were on top of his list. But it took an additional 40 pages to spell out all of his suggestions, which ranged from rules for safer water sports ("aim below the neck") to tips on creating a "closed circle of fuck buddies."

"Our challenge," Callen wrote prophetically , "is to figure out how we can have gay, life-affirming sex, satisfy our emotional needs and stay alive."

It must have seemed so possible, just a dozen years ago.




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