Around the time he turned 30, "Chris" lost interest in safe sex-a considerable course correction from his 20s when, he says, protection was non-negotiable.
"You wouldn't have gotten me to do anything without a condom," he said. He was bent-"ridiculously, insanely"-as he put it, on staying HIV-negative; then he simply gave up. He didn't want to be 50 years old, wondering whether, through some fluke in his safe-sex regimen, his next HIV test would turn up positive.
"You would think that as you get older, you get smarter about it," said the 34-year-old business owner. "Well, that's not the case because your ideas about things change; that's what happened to me-something changed."
For the next three years, "90 percent of the time, [sex] was unsafe," he said. "I never did crystal meth; I never did any drugs to speak of-nothing-or drink. A lot of guys do drugs and get infected, or they do crystal meth and they get infected. That was not my case.
"I did it because there were a lot of issues; there was being overwhelmed just with the issue," he said.
Last March, Chris tested positive. I asked him if he'd felt any sense of relief. "Absolutely," he replied. "The first thing I said to the person at the clinic that day... I looked at her and I said, "I'm sure you're a wonderful person, but I'm glad I'll never have to sit here and look you in the face again.'
"Would I say it's been wonderful and I'm glad it happened? No. But I will say this much: There are times when I'll be driving home and I will all the sudden be overcome with a feeling of relief that it's over with, that all those years of worry are over with. Sure, maybe I'll die of it, but we're all going to die."
Diane Pendragon, a clinical psychologist at the Anti-Viral Research Center at UCSD, who works with men recently diagnosed with HIV, put a name to what Chris was feeling: "prevention fatigue."
"We've been living with the epidemic for 20 years now and gay men have been using condoms and trying to stay negative," she said. "You have that conversation [about HIV status]. You insist on the condoms. You find ways to do it. It takes a lot of energy, and it can sort of take the fun out of it. So it becomes this thing of, "I've been HIV-negative for 10 years, I've watched all my friends die, I've worked hard to stay negative and now I'm exhausted and I just want to have fun; I just want to go out and break the rules or take a risk.'
"It's hard to keep it relevant, and it's hard to find the new motivation," she said. "And when people stop dying, [and people with HIV] are looking pretty good, it just kind of fades from the headlines. Then it gets even harder. Sort of the long struggle."
Like Chris, Paul gave up, too. In every other area of his life, the slim, attractive 31-year-old is meticulous, a self-described control freak. But when it came to safe sex, he slowly shifted the boundaries he'd set for himself to the point where they eventually disappeared altogether.
"There were definitely attempts at practicing safe sex," he said, "but over time, with everything, you always get more and more lax. You end up kind of making and forming your own rules about things.
"It started out as always [using protection]," he explained. If he "topped," he'd skip the condom-it's being on the receiving end during anal sex that puts a guy most at risk of contracting HIV.
"But if he tops, he has to wear a condom-there's no question about it," Paul continued. "And then that kind of segued into, "He says he's negative. OK, let's do it.' And then it kind of got to the point where you just stop asking."
Paul got tested every six months, even though it sometimes seemed pointless. "There was still always that window-"But, gee, I had sex last week; it won't show up if I get tested now'-so there was never really a time when I felt certain that I definitely did not have it."
He once read an essay in which the writer talked about that same testing anxiety.
"Then he finally tested positive and it was kind of just this relief: Thank God I don't have to struggle with this anxiety every six months. There was this, "Let me just get [HIV] already and get it over with.'"
Jerry Turner, a board member of SD Pozabilities, an HIV support group, has been HIV-positive, by his estimate, for 25 years. He didn't get tested until the HIV drug AZT became available in the mid-'80s. To knowlingly live with the disease prior to any promising medical treatment would have been too overwhelming, he said. The 61-year-old guesses "toughness" is the reason he's survived this long.
Turner lived in San Francisco from 1980 to 1998 before moving to San Diego. He remembers the weekly obituaries in a local gay newspaper, the Bay Area Reporter. "It was not unusual for there to be three or four or five pages of obituaries," at AIDS' worst point. "You might see six or eight obituaries on a page, so if you've got six obituaries and five pages, that's 30 people every week. And that was the tip of the iceberg in those days. That's not happening anymore," he said, "and with that comes a certain sense of complacency.
"In the early '80s, maybe as late as '88 and '89, HIV and AIDS was viewed as a crisis. There were lots of people who became activists, who never would have become activists had it not been for the epidemic. I don't see as much activism around HIV and AIDS as I have in the past from any age group," he said.
In the mid-'90s, the number of new AIDS diagnoses hit a high mark, with 69,151 new cases reported in 1996. That same year, roughly 50,000 people reportedly died from AIDS-related illnesses, more than in any previous year.
But from there, the number of AIDS diagnoses and AIDS-related deaths fell rapidly. People were getting tested regularly, and HIV, the virus that leads to AIDS, was kept at bay with new medication. There was also the safe-sex push: If you're old enough, you likely remember being handed a condom if you walked by one of those safe-sex street-level campaigns in places like L.A. and San Francisco.
But then, around 2000, the numbers stopped dropping and leveled off. A 1996 study in the Journal of Public Health had predicted a steady, continued decline of HIV diagnoses in gay men to the point where that group would account for only one-quarter of all new HIV cases. That never happened. According to the most recent stats put out by the Centers for Disease Control (CDC), between 2001 and 2004, half of all HIV diagnoses were gay males-double what the Journal of Public Health had predicted. The report also found that homosexual men were the only at-risk group whose rate of diagnosis had increased; for every other group the numbers had declined. One explanation was that more guys are getting tested, but CDC numbers hardly account for all HIV cases. When it compiled the most recent set of HIV stats, the CDC accepted data from only 33 states. It does not take data from states that allow anonymous HIV testing (as opposed to confidential testing). California remains one of nine states that allow anonymous testing, though state lawmakers are trying to change that.
Robert Lewis, director of HIV services for Family Health Centers of San Diego, has worked in the HIV/AIDS field since 1985. Like Turner, he attributes the rise in HIV cases to complacency. That, he said, "is the word that gets batted around in professional circles a lot. A lot of it has to do with the fact that treatments have gotten much better and there's a perception that having HIV is not a big deal. I think that there's many people in their 20s, 30s and older who believe that." Lewis said guys have told him it's "not a big deal" if they get HIV because there's a cure. Right now, no known cure exists.
"Manageable" is how Rafael Acevedo, the 30-year-old co-founder of the San Diego Young Positives HIV support group (SDYP), described the virus. Rafael tested positive in 2002-he remembers the date, Dec. 10. He contracted HIV from a partner who told him he was HIV-negative.
"I felt self-guilt for along time," he said. He'd started out as a pharmacology major at Rutgers and has a master's degree in counseling. He thought he had a good grasp on the disease. "The thing is that people lie; my partner lied to me. What can you do when someone gives you wrong information?"
Kaleb James is SDYP's other co-founder. He and Rafael have known each other for several years; it was Kaleb who Rafael turned to when he found out he was positive. The two recently started SDYP as a "supportive social group," Kaleb says, because San Diego lacked such a group for guys younger than 40. "It's a place where [HIV-positive] guys can feel normal," he said. "A lot of guys feel like they're walking around with a big plus sign on their face."
Kaleb, 24, says he too often finds himself engaged in lengthy online conversations with young men who think HIV will have no effect on their lives-one 26-year-old asked Kaleb to "give him the gift," in other words: infect him with HIV. Kaleb follows up Rafael's "manageable" comment: "Just because it's manageable doesn't mean you want it."
Last month, Kaleb appeared on the cover of the Gay and Lesbian Times for a feature story about young HIV-positive guys. In the photo, Kaleb, who's modeled professionally, is lounging on a park bench in a snug red T-shirt, well-fitting jeans and a slightly come-hither look on his face. His cover companions are equally easy on the eyes. That week, Kaleb says, he received nearly four-dozen phone calls after the issue hit the street. Most of the callers wanted more information about SDYP; about a quarter of the callers wondered how someone with HIV could look "so hot."
Kaleb was raised Mormon and left his small hometown in Utah shortly after high school, where he graduated from a class of 30. He headed west and ended up in San Diego, where he hooked up with a guy eight years his senior. Kaleb describes himself then as "needy," looking for emotional attention. And, given his upbringing, he knew little about safe sex. His partner told him he was HIV-negative, and Kaleb believed him. Only after Kaleb tested positive did he find out that the guy had been HIV-positive for seven years. "Without someone telling you, you don't know; you really don't," he said.
A couple of the men I talked to said that when it comes to disclosing one's status, San Diego is different from L.A. or San Francisco. "There, it's one of the first things they ask you. It's like asking, "What's your name,'" Kaleb said.
Paul's had the same experience. "It's always said matter-of-factly and casually, and I always answer honestly," he told me. "And sometimes they're like, "Yeah, me too.' And sometimes they say, "I'm not, so we'll use a condom.'"
I asked them both why San Diego's different. "I wish I knew the reasons," Kaleb said. "Everyone knows everyone here. In L.A., if you tell someone you're positive, you may never run into that person again."
Chris has kept his status a secret from one of his closest friends, concerned that if his friend sees that Chris doesn't look sick or feel sick, he'll assume HIV is harmless. "If he sees that I'm not necessarily ill and not struggling with it, he might be more prone to do things that will put him at risk: "He's doing OK; why shouldn't I let my guard down?'"
In the '90s, Chris said, guys didn't talk about whether or not they should practice safe sex. Bare sex-intercourse without a condom-was a fringe activity, he said, "so far out there, it was non-negotiable."
Ten years later, guys still aren't talking-but unlike the '90s, safe sex isn't always the default option. Last year Family Health Centers of San Diego launched a campaign, putting up billboards and placing ads in the local gay newspapers, urging men to talk to their partners before sex.
"People across age groups don't necessarily disclose to their partners," said Family Health Centers' Lewis. "People frequently make assumptions, and this is where communication can break down. Someone who is positive may make the assumption that the person [he's] with isn't talking about HIV so [he] must be positive, too, whereas the person who's negative may assume, "Oh, they're not mentioning HIV or safe sex so they must be negative.'"
UCSD's Pendragon said young people, especially gay men, aren't always socialized to know how to talk about sex. "The way that people handle HIV, where do we get our skills to talk about it? Even in general, if you think about people learning to talk about sex and negotiate sexual boundaries, in our country we're sort of ambivalent about sex ed. It's mostly abstinence education, which is not going to help someone learn how to say no or negotiate condom use or talk about what behaviors are OK," she said.
"Sometimes," she added, "it's easier to have sex with a total stranger than sit with a total stranger and say, "What's your sexual history? Do you have any STDs? Are you HIV positive?' We don't like to talk about sex, but we like to do it, so we're at a loss."
Sex ed for women has made some strides, Pendragon said-it's gay teens who are completely left out when it comes to learning relationship basics.
Perhaps to avoid awkward conversations, a lot of men turn to the Internet, joining online chat groups designed to facilitate quick, anonymous hook-ups.
"People will tell you it's to make friends and meet other people, but when it comes down to it, it's for sex," one guy told me.
I asked him why these random hook-ups are so prevalent in the gay community. It's gender dynamics and the male sex drive, I'm told. The latter is a given. As for the former, guys who admit to frequent hook-ups don't risk the social stigma that would be attached to a woman should she do the same.
"Men and women think differently, and it's hard for them to get to an understanding," he said. "It's OK for men to have anonymous, meaningless sex as much as they want. There's no stigma associated with that; it's just convenience."
In their online profiles, some guys will include their status; others won't. Paul's profile, for instance, says he's positive. "It avoids awkward disclosure," he said. He prefers having sex with other positive guys. There's been a couple times, though, when he's not revealed his status to a sex partner. "I've never lied about it, but I haven't disclosed and I've always felt really uncomfortable about that."
"Troy," a 32-year-old architect, admits he's not really into the online hook-up scene, "but if I do get online, all my profiles already say I'm positive." He says he doesn't want to be put in the position of having the option of not telling someone or likewise telling someone once they meet up and then possibly getting rejected-a painful thing, a couple guys told me, even if the reason for the rejection makes sense.
"I want to be straight up," Troy said. "I don't want to have that connection with somebody unless they're going to be able to accept it. Part of me wants to believe that once they get to know me, they'll be OK with it, but that's not necessarily the right way to go. It's like shopping for a house and you don't have the approval for a loan yet. You just get your hopes up."
Brian Hayes' online profile says nothing about his status. "Usually that's a sign to people that you're positive." But, he adds, if someone expresses an interest, he makes no promise of sex. "I'll meet with people and always say it could lead to sex, but before it ever does get to that point, I will make sure I reveal what my status is."
Brian has been HIV-positive only for a few months. When I met with him in late December, he was still working to gain back the 25 pounds he'd lost in the last couple of months.
Being HIV-positive has put him in a strange place, since he's worked in HIV prevention and education since college, most recently with "Connect to Protect," a UCSD outreach program targeting young gay men of color.
Last fall, he got sick and ended up in the emergency room. A battery of tests revealed nothing. "Then I got a call three weeks later saying, "The doctor wants you to come back in and talk to him about your results.'" Brian didn't think it could be HIV. "It's the field I work in," he said. "I know which risks I don't take and how little exposure I had." He doesn't say much about how he got it. "I have an idea," he said. "There were so few people that I actually put myself at risk with. I knew my risks, so I was willing to take those. I minimized any kind of exposure I could, but, obviously, any kind of sexual activity is some risk."
Though he's worked in HIV counseling and run a testing center in Massachusetts, Brian admits he's having a hard time adjusting to being HIV-positive. "It's almost like I can't follow my own advice," he said. When he goes to the health clinic, he averts his eyes. A self-described extrovert with a degree in education, he says it's been a struggle to go from helping others cope to helping himself cope.
"I let the rest of the world down because I'm supposed to be preventing this, and here I got it myself."
Still, he acknowledges he's in a unique position to help other HIV-positive men. I asked him what an ideal prevention and outreach program would look like if he could design it.
"I think about this all the time," he said, "and what I've found is that because of the work I'm in and because of my lifestyle, there's a lot of overlap. When I'm talking to people [online] and I meet someone who is negative, we talk about their risks and stuff like that, just a casual conversation. It's much more effective than me going to a bar and saying, "Hey, would you like to talk about safer sex?' It's a much more effective way to communicate with somebody-to have those intimate discussions at that level."
He admits this idea wouldn't fly as an outreach campaign in the traditional sense. "But I think the best way to send the message is to make sure people are having those conversations and saying, "Look, you know better now, so next time you're with a sex partner, talk about it.'
"People don't talk about it because of the stigma," he said. "People are ashamed about it because of the stigma. There are all these weird perceptions that aren't true."
A friend of his recently grilled him on HIV transmission. "He didn't know you couldn't get it from saliva," he said. "Certain schools don't have a health program, or you have a PE teacher who's not talking about it, who's afraid. There's a lack of education there."
He blames the government's abstinence-only stance on sex ed. In the work he does, he's seen how CDC censorship has diluted HIV education, limiting what educators can say and what images they can show. "The CDC has gotten really restrictive with what you can and can't do," he said. "I think it's really making [educators'] message less effective. We need to talk in peoples' language; we need to put it out there, not make it pretty."
Perhaps the ugliest reality about the spread of HIV is the fact that so much of it is attributable to drug use, most often crystal meth. Like any other urban area with a large gay population, San Diego has a visible PNP-"party and play"-scene. "It's almost weird if you don't PNP," Kaleb said. "People aren't ashamed to admit they do."
Troy, a former Navy enlistee who was stationed in Hawaii when he tested positive six years ago-the Navy regularly tests and anyone found to have HIV must leave the ship-found himself at a PNP hotel, or a "gentlemen's hotel" in Palm Springs New Year's weekend.
He did a little meth, he said, mostly because he wanted to stay awake and check out the parties going on around the hotel.
He remembers walking past a room filled with guys in leather, the walls rigged with leather restraints. "So I watched people get in the leather; I watched them get strapped to the walls," he said. There was porn on the TV and sex toys littered around the room. They invited Troy in to watch. "I told them why I was there; I wanted to get out of my shell; I'd never seen this kind of thing before." But he quickly became disgusted. "They weren't using condoms, just fucking. They didn't know each other.... It's like people are fucking stupid; they're high on drugs. I was high on drugs, but I knew better."
"Drugs and HIV go hand-in-hand," Brian says. "People are taking drugs for a reason. They're taking them to forget, or relax; they're abandoning their ability to be responsible. You're having such a great time, you're invincible. You're having porn-star sex.... It's easy to have confidence when you're using drugs, but people don't realize how much they're addicted until they try to stop and they can't."
Paul knows what that's like. Meth, he said, started out as something he'd do at parties and art openings. "It was once a month, then it was once a week, and before long it was out of control.
"If you had meth, then my standards were whatever," he said. "I'd have sex with whoever had crystal." Most of the time he'd hit local bathhouses because he knew that's where he'd find both meth and sex. He's pretty sure he picked up HIV at a bathhouse, but he can't be totally certain.
Paul was in a long-term relationship when he tested positive. His partner was oblivious to Paul's free-for-all sexual habits, but he was willing to stick it out and help Paul through a rehab program. But it was too much for Paul to handle. "Our relationship ended, mostly because I couldn't deal with him being negative," he said. These days, the sex-and-meth addiction still nags at him and at times he gives in. But now he's set limits he knows he needs to abide by.
Near the end of my interview with Chris, I ask him why men who are HIV-positive don't always disclose their status and why guys who are negative don't always ask. He gives me a rundown of various scenarios, assumptions, self-esteem issues and the sheer frustration that, for a lot of gay men, the basic human desire for sexual gratification always has the threat of HIV hanging over it.
"It's complicated," he said. "To the vast majority of people who read this article, if they're straight, they won't understand. They'll think, "Why do they do this? Why do they continue to do this to each other?'
"It's much more complicated than you could ever put in an article.... And I think there are people out there who think, "If they don't know any better, they deserve it.'"
When Chris found out he was positive, one of the first people he told was his brother.
"If the worst thing you did was have sex," his brother told him, "you don't deserve to die for that."