We know in our bones what’s in store. Despite all our efforts to put ahuman face on AIDS, HIVers are in danger of becoming as demonized as inthe darkest days of the ’80s. With the ranks of Americans with HIV nowexceeding the one million milestone, the nation is growing impatientthrowing money at a preventable epidemic that no one can seem tohalt.“You should’ve known better” is the increasingly common response to newHIVers, many but a step  removed from prison, promiscuity anddrugs. Nothing illustrates this intolerance better than the media’snear-unanimous praise of a published “apology” by Jesse Helms, for manyyears the most powerful anti-PWA lawmaker in the land: “Until[befriending evangelist Franklin Graham and rocker Bono], it had beenmy feeling that AIDS was a disease largely spread by reckless…sexualand drug-abusing behavior and that it would probably be confined tothose in high-risk populations. I was wrong.”
Tragically,we stand at the brink of a potentially epic breakthrough in the scienceof prevention that could turn the American epidemic around. But thiscritical development comes at a time when what prevention needs is tofree itself from the irrationality and ideology that have long informedit—both the moralizing of  Christian conservatives and the moralrelativism of liberals—in favor of hard science. Instead, it remains atthe volatile center of the culture wars.

The little-publicizedresearch focusing on “sexual networks” is telling us to go right to theepidemic’s viral hot spots—and not simply test those high-risk peoplebut launch reality-based interventions that offer carrots rather thansticks (drug treatment, for example, not prison). But most leadingcivil rights and AIDS organizations lack the political will to riskbacking these measures in the face of a Bush administration that owesits reelection to the evangelicals, for whom abstinence funding ispayback.

Looking at the prevention through “sexual networks”reveals one immensely significant fact about the epidemic: that a tinyfraction of people with HIV—perhaps less than 5%—keep a particularcommunity’s viral wildfire burning. These hot spots are defined notonly by sexual connections but by personal problems like addiction andsocial ills like poverty that dramatically accelerate the spread ofHIV. As their staggering HIV infection rates attest, people of colorand men who have sex with men are up to five times as likely as theaverage Joe or Jane to shack up with one of these high-risk core-groupmembers—or, like the crystal meth–addicted gay New Yorker at the centerof the recent supervirus furor, get sucked up into the hot spotsthemselves. If community-based prevention—including condom andclean-needle distribution—can be said to be a failure, it is preciselybecause it has failed to adequately reach this crucial 5%. Butinterventions that expand our grass-roots prevention to includerational  public-health measures like partner notification stand achance—if only our community could embrace and implement them in ourown way.

Unfortunately, old fears have prevented us fromthinking clearly about such methods. Meantime, we are mired in anargument about whether to disown or protect these hard cases at theheart of the epidemic. Outside our community, a similar argument istaking place between our friends and enemies, one that increasinglycenters on the personal responsibility of all HIVers in sex—despite theevidence that the 95% of HIVers outside the viral hot spots have littleeffect on driving the epidemic. But when has reason ever trumpedemotion when it comes to AIDS?

Still, talk of “personalresponsibility,” however threatening to some HIVers, may be the openingto a new and necessary dialogue. People with HIV alone do have thepower to stop new infections—and not only through facing fears ofdisclosure and always protecting sex partners, as profoundly importantas those are. The personal responsibility that is increasingly focusedon all HIVers also offers the chance for our community to be leadersonce again in prevention.

Failingto do so, we risk beingscapegoated—lumped together by an AIDS-weary, moralistic nation asreckless infectors. Given the abstinence-pushing forces ranged againstus—from private groups, like Focus on the Family, to the highestgovernment officials—taking charge of, let alone reforming, preventioncould take a miracle. But HIVers have made miracles before. In 1983, afew desperate gay men invented “safe sex,” cutting new infections sorapidly that public-health experts hailed it as miraculous. That theydid so in the face of society’s stigma and persecution is even moremiraculous.

We can once more find the courage to confront our demonsand transform them into salvation. We can fight the urge to back awayfrom new HIVers and to deny that we too know the drug addictions andsexual compulsions of that hard core. Together, we can bite the bullet. 

Fora reality check on how bad things are, consider the supervirus case.Last February, New York City’s health commissioner, Thomas Frieden, MD,announced that researchers had diagnosed a strain of  HIV soaggressive and drug-resistant as to seem untreatable. At a newsconference on the steps of City Hall, he declared an officialemergency, alerting the public to a dangerous new phase of theepidemic.

As AIDS leaders called for a renewed attack on thescourge of crystal meth among gay men, and public-health experts fannedout to labs nationwide looking for similar infections, the mediafocused intensively on one particular sexual network, New York’sfast-track gays and their meth-fueled unsafe-sex parties. Anti-PWArhetoric spewed from HIV negative gay journalists, such as CharlesKaiser, who told The New York Times, “A person who is HIV positive hasno more right to unprotected intercourse than he has the right to put abullet through another person’s head.”

Equating HIVers withmurderers, Kaiser’s “bullet” was the pitch-perfect sound bite, and thepress declared open season on risk-taking HIVers. Hearing  hatespeech from so close to home stunned many HIVers. In June, Canadian gaycolumnist Richard Burnett added: “If you want to play God, spread HIVand ruin other lives in the process—then do us all a goddamn favor andput a fucking bullet through your head instead.”

That thesupervirus had been downgraded in the media to a false alarm—no secondcase was discovered, “Patient Zero” was on treatment and back atwork—barely registered. Righteous wrath at irresponsible  HIVerswas the beat. Veteran journalist Andrew Sullivan says, “Ever since Icame out as positive, the hatred has been far more intense from a smallcadre of gay activists and journalists than from the religious right.Sometimes I wonder what separates the two with respect to attitudestoward people with HIV.”

Ifonly Sullivan were right. In fact, the name-calling of gay journalistswas so much spilled milk (and ink) compared to the blitzkrieg oncondom-based prevention unleashed in recent years by allies of the Bushadministration. HIVers and their advocates could, until Election 2000,boast of hard-won places at federal AIDS tables, including the Centersfor Disease Control and Prevention (CDC), which funds most of thenation’s prevention research. But in the Bush White House, HIVprevention at the CDC became a battleground on which the faith-basedmovement simply overpowered our AIDS service organizations. Demotedfrom trusted adviser to outside observer at the CDC, community groupsabandoned an emerging critique of our own failing prevention to mount adefense of condoms and frank talk of sex, the two cheapest, mosttrusted tools of sound prevention policy.

Then, in 2004, the CDCunveiled its Prevention for Positives Initiative, an implicitacknowledgement that the millions of federal dollars spent on adecade-plus of education for low-risk suburban teens and “a condomevery time” prevention was a bust—a view the rising new infection ratesconfirm. But shifting the burden for prevention from the HIV negativeto the HIV positive raised red flags for many advocates and experts.Julie Davids, head of the Community HIV and AIDS Mobilization Project(CHAMP), sees this shift as the beleaguered CDC’s strategy to keep bothconservatives and community activists off its back, but ultimatelyfeels that “what underlies all of this is what happens when you have agovernment that…doesn’t actually believe you can end AIDS.”

TheCDC’s justification sounds benign, contending that since most HIVers dothe right thing regarding safe sex—and studies support this safe-sexassumption—the key to controlling infections lies in testing the250,000 Americans who don’t know they are positive. The feds may toutthis as a radical new public-health focus, but these measures areneither new nor radical: HIV testing as a “routine” part of medicalcare and notifying sex partners for those who test positive are decadesold. The word condom, however, is suspiciously missing in the CDC’sproposal, so in practice, Prevention for Positives often begins—andends—with testing. As for counseling, care and treatment, the CDCmerely “recommends” these services, leaving it an open question wherethe money for the psychological and physical health of a quarter of amillion newly diagnosed Americans with HIV will come from.

AnaOliveira, executive director of Gay Men’s Health Crisis (GMHC),dismisses the new focus on positives as “simple-minded thinking on HIVtesting and names reporting…that you just need to ‘test and track’ andthe epidemic would take care of itself,” adding that  “HIVprevention [has been driven] into the arms of those who would ‘just sayno’ to sex and drugs.”

But Ronald Valdiserri, MD, the deputydirector of the CDC’s National Center for HIV, STD and TB Prevention,defends shifting the responsibility for prevention to HIVers bypointing out that treatment advances are allowing people with HIV tolive  longer, have more sex and therefore transmit more HIV. Healso disputes the claims of right-wing pressure, saying, “I’ve beeninvolved with [the new initiative] since day one, and I’m not aware ofany influence at all.” Prevention for Positives may indeed uncoverthousands of new HIVers, but with no commitment to other supports—fromcondoms to HIV meds—the campaign may also backfire, producing thousandsof newly positive who are desperate, confused, angry, hardly the idealmind-set for taking personal responsibility in sex.

And doesPrevention for Positives address that crucial 5% driving the epidemic?Valdiserri claims that his agency not only endorses the science ofsexual networks but invented it. “The CDC, especially the STD program,has been aware of sexual networks before the theory even had a name,”he says. In fact, the CDC has funded and implemented a number of suchstudies over the years, but the new initiative uses it only to find newHIVers, not to enlist them in interventions.
“I don’t understand whythis is just coming to people’s attention right now,” says MaureenMiller, MD, a pioneering Columbia University researcher. “It shouldhave been on the agenda 15 years ago.”

Thedry, almost mathematical details of sexual-network science have alwaysbothered HIVers and other advocates (see “Hot-Spot Science,” page 29).They seem to reduce humanity, psychology, morality to statistics, data,a dot on a map. Back in the ’80s, it also led some scientists andpoliticians to a simplistic and punitive solution: The best way to stopHIV was to cut the sexual connections—by promoting abstinence ormonogamy. For those of us who can’t or won’t comply, condoms were anunfortunate last resort. A = Abstinence. B = Be Faithful. C=Condoms.Sound familiar?

Some Republicans in Congress proposed a moredraconian “solution”: Isolate the people with multiple connectionsthrough quarantine. A public-health emergency, they claimed, justifiedthe violation of civil liberties.

This willingness tosacrifice the few to save the many was heard often in the early days,and the revelation of how hated HIVers were has traumatized our community. Our prevention leaders wanted nothing to do with thisdehumanizing public-health numbers game.

Well, the scientistsand numbers people are back with their charts, graphs and a powerfulmessage—one that explains why even our most well-intentioned preventionhas failed to stop AIDS. Sexual-network experts describe the epidemicas clusters of people making choices about who to partner with, whatdegree of risk to take and how they and their partner are connected tothe larger network. Most HIV negative people have a low risk, and mostHIV positive people pose a low risk, as long as they always use condomsor partner exclusively with others whose status they can be sure of.But whether a person has a lot or a little sex, when they do havecondom-free sex with a new partner, everything rides on who that personis. If they’re directly connected to a cluster at the center of thenetwork—those who have high-risk sex with many partners, negative andpositive—the chance for transmission grows astronomically. At the sametime, the closer a person is to the core, the less likely thattraditional prevention  will reach them. A crystal-meth addict isunlikely to stop for condoms between parties and scoring. A young blackwoman who needs to keep her man is not likely to demand that he put ona rubber.
Columbia University’s Maureen Miller knows alltoo well how hard it is to change the behavior of people in a sexualnetwork. “The reality for the women I work with in Brooklyn is thatthere are 40% more women than men, largely because so many men areincarcerated,” she says. “This puts women at a disadvantage innegotiating safer sex, as they know that their partner can easilychoose to be with another woman.”

There’s a good chance that thisother woman will have a history of crack or heroin use and exchangingsex for drugs or money—and  therefore a risk of HIV. In the sexualnetworks Miller studies, most women have a much higher HIV risk, eventhose who have never used drugs and are monogamous.

Notall theresearch is grim, however. Many novel interventions are either in theworks or already up and running (see “Hard Core,” page 30). None is themiraculous answer to HIV that was once believed to be coming in “just10 years” in the form of a vaccine. But they are programs thatrealistically address the epidemic as we live it today. Though smallfirst steps, they offer hope precisely because they are grounded in theactual risks people take—not the ones that prevention activists orevangelical Christians think they should take.

Theugly truth is that our epidemic is still driven by sexual promiscuityand drug addiction. As this news gets louder and more public, youneedn’t be psychic or paranoid to predict Jerry Falwell and JamesDobson giving impassioned speeches, run hourly on Fox News, tocriminalize gay sex in the interests of national security. Fiscalconservatives will argue that it is no longer fair to ask the rest ofAmerica to cover expensive HIV meds for people whose deviant behaviormade them sick.

Will HIVers then divide into ugly oppositions:the “innocent” infected vs. the “you should’ve known better,” negativesvs. positives,  hetero vs. homo? It will be harder than ever forHIVers to speak openly about the complexity of their lives before theywere infected. But such honesty is the only corrective to thestereotypes exploited by the morally righteous to justify thescapegoating of HIVers.

Given our nation’s growing intolerance,the ability to respect painful differences and speak shameful truthswill take courage. But do so we must. Failing to reach—and reach outto—the most despised and irresponsible among us will lead toretribution against all HIVers. After all, so many HIVers wereonce desperate souls who know what it is to putanother person at risk, and with each passing month, a larger majorityof newly positive people will be, too. Who better, who else to lead theway?

Hot-Spot Science

Thescience of sexual networks explores how people are related throughsex—and the risk of HIV. While radically reducing our rich humanity todots on a chart—connected by lines to other dots—the method’s power isto offer a bird’s-eye view of who is infecting who.

“Ithas long been known that some contribute much more to the spread of HIVthan others. Ignoring that fact hampers our ability to slow HIV/STDtransmission,” write Dan Wohlfeiler and John Potterat, two researchpioneers. This throws light not only on why untargeted, “a condom everytime” prevention misses the mark but on the very people and places wemust reach—that core 5%—to stop HIV.

Hotspots—whether a sex-worker strip, a needle-shooting gallery, a gaybathhouse, a prison or the ’hood where women outnumber men—share fivefeatures:
1. Size: The more people, the faster HIV spreads.
2. Sex: The more sexual links, the faster HIV spreads.
3. The Core : The more people with more  partners, the faster HIV spreads.
4. Partner Sharing: The more people with more sex partners at one time, the faster HIV spreads.
5.The Periphery: Sex between people on the periphery, with fewerpartners, and those in the core, with many, define the  scope ofHIV.

Studyinghot spots in tandem with such social ills as segregation, stigma, drugsand poverty explains why HIV still rages in the communities of peopleof color and gay men. Science has advanced us a long way from the oldnotion that everyone is equally at risk and responsible, but preventionhas yet to catch up.

Hard Core

Thesethree interventions offer new ways to access sexual hot spots. None isearth-shattering, but each uses self-interest as an incentive forhigh-risk, hard-to-reach HIVers—and they work.

1. Kinder, Gentler Partner Notification
Universityof North Carolina’s Adaora Adimora, MD, launched a partner-notificationprogram—a standard public-health measure long resisted by the HIVcommunity—but with a twist. Rather than subject a person who has justtested positive to the sexual third degree, Adimorapays these black women to recruit others for testing. Her programproved nearly five times better at finding undiagnosed HIVers than theCDC.

2. Get Cash to Get Clean
Similarly,UCLA’s Steven Shoptaw, PhD, has found that paying meth-addicted gay menincrementally larger stipends for staying clean over time not onlyworks better as a drug treatment than standard approaches but also dramatically reduces unprotected anal sex. Money talks—especially tofolks who have hit bottom. (For more on kicking crystal, see Resources,page 44.)

3. A Risk-Reduction pill
Scientistsrecently confirmed that herpes-2 astronomically increases the risk ofgiving or getting HIV. So researchers at the University of Washingtonin Seattle are studying whether blanketing gay communities on the WestCoast and HIV hot spots in Africa with acyclovir, a cheap herpes med,will reduce new HIV infections.