Ego

Happy Valentine's Day, gay men. Here's what we're getting this year: A brand-new reminder from the local health department that the crystal-meth users among us are still busy pumping out—and I do mean that quite literally—more reasons for the rest of us to worry.

This year the depressing news, announced by King County health officials last week, is that four local gay crystal users have come down with strikingly similar versions of HIV. Normally it's no surprise, and hardly news, when gay meth-heads become infected with the virus that causes AIDS. After all, gay crystal users are far more likely than the rest of the gay population to contract HIV, for the obvious reason that they tend to engage in marathon, meth-fueled sessions of unprotected sex, often in groups of people who aren't sharing their HIV status with one other (and, in many instances, aren't even sharing their names with one another).

But the fact that these four local gay crystal users have come down with HIV ended up being noteworthy for this reason: All of them contracted a particularly worrisome form of the virus, a version of HIV that is highly resistant to treatment with antiretroviral drugs. It's possible that the four men don't all have the exact same strain of drug-resistant HIV. But health officials believe it's likely that they do. All four of the men's viruses are resistant to two classes of HIV medication and partially resistant to a third. And genetic testing showed the men's viruses to be highly similar. Because of this, health officials fear the men represent the leading edge of a single, hard-to-treat strain of HIV that is now spreading in the local gay community.

"We wanted to get the message out— particularly to people who might be having risky sex in the gay community—that HIV is bad, but some HIV is worse," Dr. Bob Wood, the HIV/AIDS program director for the county's health department, told me on February 1.

On the bright side, the men's version of the virus doesn't appear to be progressing with unusual speed, nor does it seem to be more easily transmitted than regular HIV. In addition, when public-health officials went to track down the four men's sex partners, none of the men's partners—that is, none "who have been found"—turned out to be infected with this particular drug-resistant strain. On the less-bright side: The four men all reported having mostly anonymous sex, so a good number of their partners will be impossible to find.

The four men claimed not to have slept with each other. If true, then this is more bad news. It means there is likely someone out there in the gay community who gave the virus to these men, or, worse, multiple gay men who gave it separately to each of the four diagnosed men. Further, given the four men's sexual histories, it's probable that they themselves passed their drug-resistant strain of HIV on to other men before they were diagnosed (one of them was diagnosed in 2005 and the rest were diagnosed in 2006). Thus the recent identification of this four-person "cluster," as local health officials are calling it, is likely to be only the beginning of a new, meth-linked gay-health problem.

Sigh.

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This, by the way, is hardly the only health problem gay men have. Setting aside the grim and self-destructive world-within-a-world that is the gay meth scene, gay men as a whole still suffer from sexually transmitted infections—such as syphilis, gonorrhea, and chlamydia—at levels that are higher than those of any other group in the general population. In addition, despite the fact that the means of preventing HIV are no mystery, and despite the fact that condom use has been encouraged among gay men for more than two decades, the number of new HIV infections each year has remained stubbornly the same—about 400 annually in King County for at least the last decade, and about 40,000 annually nationwide since 1990.

I apologize for being the bearer of such unsexy news so close to Valentine's Day and, to be honest, I'd rather not be writing about this at all. Not just because it's disheartening, but because I'm quite sick of reporting on this topic. Writing about gay men's health is one of the most repetitive and least rewarding types of writing I do. It's repetitive because the fundamental dynamics affecting gay men's health have not changed since long before I ever started in on the subject. And it's unrewarding for the same reason: No matter what anyone writes, little seems to change.

But to review, as one always ends up doing in these stories: There are two major milestones in the gay community's 27-year-long reaction to, and processing of, HIV/AIDS. The first milestone is the emergence of the virus, in 1980, and the subsequent panic and protective behavioral changes it caused among gay men. From 1981 to 1995, rates of transmission of the virus, along with rates for all other common sexually transmitted infections, declined sharply among gay men in King County, and among gay men around the country. This was a time when people were dying of AIDS, or living with AIDS but looking dead, walking around skeletal and brittle and spotted with Kaposi's sarcoma lesions. As a result, gay men were scared, condom use proliferated, barebacking became potentially fatal, and having fewer partners started to seem like a better and better idea all the time. Then came the second major milestone: In 1995, the first effective antiretroviral drugs emerged for treating HIV and preventing it from progressing to AIDS, and this development ushered in an era of much less fear and much-increased risky behavior among some gay men. As HIV became more of a manageable chronic illness and less of an immediate death sentence, the rates of transmission for common STIs such as syphilis, gonorrhea, and chlamydia began to climb again in the gay community, ominously it seemed.

People here and elsewhere worried that this rise in STIs among gay men heralded a concomitant rise in HIV transmission, since many of the same behaviors that spread STIs also spread HIV. Everyone who cared about gay health was thus on the lookout for a resurgence of HIV in the gay community (and this required some creative looking out, since gradual rises in HIV infection rates can be hard to notice due to bad reporting standards, irregular testing among some gay men, and the variable dormancy of the virus from individual to individual). In June of 2003, King County health officials announced that HIV appeared "resurgent" among local gay men and that syphilis, gonorrhea, and chlamydia were at "extremely high levels" in the gay community—and rising. The officials said there had been a 40 percent increase in new HIV infections over a two-year period, and they warned of potential further increases in local HIV infection rates. The worst fears, it seemed, were coming true.

That same week a long story I wrote for The Stranger appeared in the paper. "The Immoral Minority" looked at the way the sexual health of the gay community is disproportionately affected by a small subgroup of gay men—a "core group" that includes men who aren't talking about their HIV status, men who have unprotected anal sex with people whose HIV status they don't know, men who mix unsafe sex and multiple anonymous partners, and men who use meth. In addition, my story explored the way local gay-health leaders, in the name of being "sex positive" and "nonjudgmental," were using public funds to coddle this core group and even, in some instances, were outright encouraging some of the core group's worst impulses or recruiting potential new core-group members. In a follow-up story a few months later I wrote about an event put on by Seattle's Gay City Health Project. The event was designed to draw young "sex-club virgins" to a local sex club and was called, with unintended irony, "Murder in the Dark." It was ultimately canceled under pressure from the health department, which sees sex clubs and bathhouses as hubs of HIV and STI transmission, and the next month Gay City was cut off from county funding for two years.

"The Immoral Minority" won a local journalism award, but it was also very controversial in the gay community. For a long time, gay men have fought—correctly—to be free from shame for who we are sexually. But some gay men have gone further, conflating their morally neutral sexual identity with certain morally unjustifiable actions, and incorrectly asserting that they have a right to be free from shame no matter what sexual decisions they make as gay men, and no matter how adversely some of those decisions affect their own health or the health of their community. Woe to the writer who suggests that some gay men—particularly some "core-group" members—should have a little more shame about their actions (not their identity), or at least be a little more ashamed about the unhealthiness their actions are perpetuating.

In retrospect, however, one thing was wrong with my article. It relied on the local health department's warning that local HIV infection rates appeared to be on the rise and would likely continue to rise. That turned out not to be true. What seemed like an uptick of new HIV infections in 2003 now looks to have been a momentary fluctuation in a local HIV infection rate that, four years later, remains as static as ever: about 400 new infections every year.

Dr. Wood looks at the static HIV infection rates and the continued high levels of STIs in the gay community over the last few years and, revising his department's earlier warnings, suggests that perhaps the gay community has simply reached a post-antiretroviral-drugs plateau, a "steady state" of unacceptably high HIV and STI levels that is going to be hard to change in this era of less fear, an era when HIV is no longer so immediately lethal and syphilis, gonorrhea, and chlamydia all remain easily treatable (if caught in time).

Referring to last week's announcement about the possible drug-resistant strain of HIV, Dr. Wood told me: "That's a main reason I want to put this out into the community—to put a little more fear and concern in the community."

Once upon a time, back in the 1980s, fear worked. And since that fear faded in the mid-1990s with the advent of antiretroviral drugs, nothing else has worked. Six years ago, the Centers for Disease Control and Prevention announced a national goal of halving the country's annual number of new HIV infections, from 40,000 to 20,000. This aim was to be accomplished by 2005. A study released in 2005 found "no new evidence of movement toward that goal."

Dr. Wood described the stubborn HIV and STI rates as frustrating, but noted the same phenomenon exists "in every developed country in the world where there's a substantial gay population."

He concluded: "The bottom line is that we've not made an impact but we're still trying. I'm not giving up on it, because that's not our style. But I don't know that we have any more ammunition.... Everybody wants a magic bullet but there are no magic bullets."

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Actually, there is a magic bullet, but it is considered so unrealistic by health professionals, and perhaps so anathema to the continued funding desires of gay-health organizations, that no one really speaks of it: Gay men could take more responsibility for their own health. They could take the easy steps necessary for bringing down the number of new HIV infections. They could use condoms for anal sex with all partners outside of a committed, seroconcordant relationship; they could openly discuss their HIV status with new partners; they could get tested regularly, from once a year to once every three months depending on their sexual activity; and they could see gay crystal-meth users for what they tend to be: incubation chambers for disease.

"I think we should help people who use methamphetamine," Matt Golden, the director of King County's STD Control Program, told me last week. "But probably that help should not include having sex with them."

Of course, it would help if there were more federal funding for smart HIV-prevention programs that encourage safer behavior. Of course, on the other hand, some of the biggest changes in behavior among gay men occurred in the early to mid-1980s, when gay men were terrified of getting AIDS and before there was any federal or state funding for gay-health programs.

There are some positive signs. Tuning out years of well-meaning but counterproductive messages from gay-health groups telling gay men that being HIV-positive is, essentially, positive, gay men independently began serosorting in significant numbers—that is, negatives making it a point to have sex only with negatives, and positives making it a point to have sex only with positives. This type of sorting is now being encouraged quietly here, but it is being much more loudly and effectively encouraged in San Francisco, where serosorting is seen as a cause of that city's startling 10 percent decline in new HIV infections over a five-year period ending in 2006. And a new survey released this year by the Substance Abuse and Mental Health Services Administration found meth use declined in the general population between 2002 and 2005, although such self-reported surveys are notoriously unreliable and this particular survey did not look at the trend among gay men specifically.

In the end, it could be worse. Rather than the current "steady, unacceptable level of infection" that we're seeing locally, the pool of highly promiscuous and sexually unsafe gay men who hold up King County's "unacceptable" levels of already-known infections could be incubating a new type of infection, one previously unheard of and as scary as HIV when it first emerged from the same type of gay pool. We know it can happen not just because it's happened before, but because it's happening right now with this new, highly drug-resistant variation on the old theme of HIV, the variation brought to us by the four local gay meth users. Experts believe that if things don't change, it's only a matter of time before something worse emerges.

Again, happy Valentine's Day.