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HIV Prevention Apathy, Methamphetamine
  AIDS Fighters Face a Resistant Form of Apathy
NY Times, Sunday April 3, 2005
Where have all the condoms gone?
Don't try looking at the Monster, the Hangar, Starlight or Barracuda. On a recent evening, these and more than a dozen other Manhattan gay bars were well stocked with free going-out guides, but not a scrap of literature about H.I.V. prevention or the perils of crystal meth. As for condoms, the frontline defense against sexually transmitted diseases, only one establishment stocked them - behind the bar.
As part of his graduate course work at New York University, Michael Marino set out last winter to compare the AIDS prevention efforts of New York and London. He was troubled by what he found. At most New York bars, and even at some bedrock gay and AIDS service institutions, educational pamphlets and free condoms were hard to find, if not impossible. In London, Mr. Marino found them easily.
"No wonder things are getting so out of control here," he said.
Condoms, which still can be found in vending machines at a handful of places, were once given away by the bucketful. While no one believes free condoms will completely halt the spread of H.I.V., their disappearance from bars, the equivalent of a town hall for some gay men, is a telling indicator of how much steam has been lost in the fight against AIDS.
Although the city health department's recent warning about a rare, possibly more virulent strain of H.I.V. has caused a stir among gay men, many AIDS activists hold out little hope the news will prompt substantial or lasting changes in behavior. They point to the continued popularity of methamphetamine, which has contributed to a rise in condomless intercourse, known as barebacking, and the widespread apathy in which H.I.V. is seen as a nuisance, not a potential killer.
Compounding this laissez-faire attitude, they complain, are drug company advertisements that gloss over the disease's effects by portraying patients as the picture of perfect health.
Locally, at least, the statistics paint a mixed picture. The number of new H.I.V. infections among men who have sex with men declined slightly from 2001 to 2003, according to the most recent figures available, although in much of the country that number has been rising. But AIDS service providers, pointing to a recent spike in syphilis cases and the rise of methamphetamine abuse among gay men, fear it is only a matter of time before New York faces a new surge in infections.
The challenge is far more complicated than handing bar patrons informational brochures and telling them to be good, prevention specialists say.
"Just because folks are well informed doesn't mean they'll necessarily make the wisest choices in terms of their health," said Dr. Ronald O. Valdiserri, who oversees AIDS prevention at the Centers for Disease Control and Prevention. "This is true of all humanity, not just gay men."
The reality that gay men continue to have unprotected sex has been vexing health experts for 20 years, although the struggle became even more daunting in the mid-1990's, when a new class of medications sharply reduced death rates and fed the misconception that AIDS is only about as troublesome as the flu.
And then there are those who disdain condoms. With the specter of imminent death gone, the idea of using condoms has become an annoyance for many. "Let's face it, sex with a condom is not as good," said Dr. Robert L. Klitzman, a psychiatrist and professor at Columbia University. "Sex is supposed to be an incredibly intimate moment, and it's not as intimate when there's a piece of plastic between you and your partner."
There is a growing sense that the traditional sloganeering about condoms and club drugs is about as effective as birth-control campaigns that rely on abstinence. The only hope for changing behavior, public health experts and psychologists say, is to recognize and address the underlying factors that propel men into risky situations. Loneliness, alienation and self-hatred, they say, are the real culprits that need to be addressed.
But others, describing such talk as na•ve, say it makes more sense to stress personal responsibility. Demonize crystal meth, stigmatize unprotected sex and remind people that living with H.I.V. can be grueling, or worse. An important first step, they say, would be to stop running pharmaceutical ads that portray people with AIDS as carefree and virile.
Other ideas include following the lead of the San Francisco health department, which is seeking strict limitations on the availability of erectile dysfunction drugs that counteract the impotence induced by crystal meth and encourage the spread of sexually transmitted diseases.
Many AIDS activists in New York, describing current public service campaigns as toothless and ineffective, say bus ads and billboards should remind people that AIDS is a devastating and entirely avoidable illness.
Many prevention advocates agree that only a creative, ever-changing arsenal of tactics can reduce the number of new H.I.V. infections. They point out that it has taken years and millions of dollars to change public attitudes about tobacco and seat belts, and even now reasonable people lapse into old ways.
"Everyone knows smoking is bad for you, but we still print those health warnings on cigarette packs," said Kwame M. Banks, a consultant specializing in prevention work. "People need to hear these messages 100 times a day. That's the way these things work."
Still, when it comes to H.I.V. and AIDS, some wonder whether it is time for a new strategy. Perry Halkitis, a psychologist at New York University who studies the relationship between drug use and sex, believes that many gay men who engage in risky behavior are grappling with profound mental health issues.
"People are not taking risks because they're stupid, or because they wake up one day and say, 'I'm going to take a risk today,' " Dr. Halkitis said. "They do it because the sexual risk fulfills a need, or somehow makes them feel better about themselves."
He and others say any successful fight against H.I.V. must deal with depression, substance abuse and low self-esteem, problems that studies have shown affect gay men at disproportionately higher rates.
"Many people might argue that as a community, we suffer from post-traumatic stress disorder because we're so ostracized by society," Dr. Halkitis said. "Being rejected by family, by our churches, and these days by our government most certainly has an impact."
That emotional fragility has been compounded by the trauma of the 1980's and early 90's, when sickness and death permeated the lives of so many. Peter Staley, a veteran AIDS activist, said it was no coincidence that some of the first people in New York to pick up crystal meth habits have been men 35 to 45 years old.
"We are the long-term survivors who watched friends die, who never thought we'd live to have a midlife crisis," said Mr. Staley, who is H.I.V.-positive and himself a recovering meth addict. "Then the new medications came along, and suddenly everyone returned to their old lives and people moved on to other issues, like gays in the military and gay marriage. Where was the communal processing of the emotional hell we had just gone through? I think as a result we're a deeply scarred group."
While such scars can lead to substance abuse, psychologists say the internalized homophobia and deep-seated feelings of low self-worth are just as powerful. That is where the allure of crystal meth kicks in. Those who have used the drug say it tends to blot out feelings of vulnerability, boosts self-confidence and imbues them with a false sense of connection to strangers.
Then there are the "bug chasers," H.I.V.-negative men who actively seek infection. Although such men are thought to be few in number, mental health experts say the phenomenon reflects the intense alienation that many gay men feel. Louis Pansulla, a psychoanalyst who runs gay therapy groups in New York, said younger men, in the generation that missed the darkest days of the AIDS crisis, believe that infection will win them membership into a clique, albeit one coping with a dreaded disease.
"It's almost a longing to belong, even though it's a completely unconscious thing," he said.
Michelangelo Signorile, the host of a gay-themed talk show on Sirius Satellite Radio, takes a less nuanced view: "If everyone in your group is beautiful, taking steroids, barebacking and H.I.V. positive, having the virus doesn't seem like such a bad thing."
It is for that reason that Michael Weinstein, president of the AIDS Healthcare Foundation, believes the disease is due for an image makeover. He cites a hard-to-miss ad in last month's Out magazine that is embedded with a tiny audio chip and features two robust men on a beach. Opening the magazine sets off the trill of a ringing phone and a man's voice essentially saying he is having too much fun to worry about his chronic illness. Mr. Weinstein has asked the ad's sponsor, Bristol-Myers Squibb, to stop using the ad for the drug, Reyataz. A spokeswoman said the company was re-examining its advertising campaigns.
"People are in such denial about how serious H.I.V. is," Mr. Weinstein said. "Unfortunately, the best prevention is seeing people die."
Of course, frontline prevention workers hope to avoid a new wave of deaths. At Gay Men's Health Crisis, prevention workers are planning a series of events that seek to promote "connectedness and community."
Others are creating antidrug messages that masquerade as packets of meth that can be dropped on dance floors. A series of subway ads unveiled by the state for the first time shifts responsibility to those who are already infected.
And then there are people like Daniel Carlson, a former marketing executive who became so disgusted by the number of men soliciting unprotected sex online that he and a friend started a group to combat the prevailing ethos about sex and drugs. In the past two years, the group, H.I.V. Forum, has organized a half-dozen town hall meetings on crystal meth and unprotected sex that have drawn packed houses.
"I know it sounds touchy-feely, but if we could just emphasize a little bit more community and brotherhood," Mr. Carlson said. "We have to decide whether we're going to be selfish or whether we're going to care about one another."
Gays Mobilize Against Meth Addiction
By DAVID CRARY The Associated Press
NEW YORK (AP) - It's a Friday evening, traditional kickoff time for the party scene in New York's gay community, but the 75 men packed into a small room at a gay health center aren't in a partying mood. Through a humbling 12-step program modeled after Alcoholics Anonymous, they are battling to kick their addiction to methamphetamine, and in doing so escape an epidemic that is roiling urban gay communities nationwide with disease, despair, embarrassment and anger.
Meth is an equal-opportunity menace - many thousands of men and women, gay and straight, have fallen prey to it in rural villages, placid suburbs and city slums. But gay leaders in New York, California and elsewhere bluntly acknowledge that their communities have distinctive problems with the drug, and an unavoidable responsibility to combat it.
"Years from now we'll look back, as gay men, and be pretty despondent that we popularized and glamorized this drug," said Dan Carlson, an ex-addict who has become one of New York's leading anti-meth campaigners.
"I'm not anti-partying or anti-sex," he said. "But how can we fight for our rights as a sexual minority if we don't establish what's right and wrong in our community, and look out for each other."
Crystal meth - which can be snorted, smoked or injected - has been a popular gay party drug on the West Coast for more than a decade, and in New York since the late 1990s. In many cities, however, gay activists and health officials were not quick to confront the fact that the drug, by curbing inhibitions and boosting energy, encourages unsafe multi-partner sex and thus increases the risk of HIV transmission.
In New York, alarm over meth intensified in February, when health officials reported a rare strain of highly resistant, rapidly progressing HIV in a gay man who regularly engaged in meth-fueled sex parties. But the tide began turning against the drug a year earlier, when gay activists held the first of several forums on the epidemic and an ex-addict named Peter Staley circulated posters with an eye-catching message: "Buy Crystal. Get HIV Free."
Staley, a bond trader-turned-AIDS activist, is guardedly optimistic that the forums and ad campaigns are helping stigmatize the drug.
"A year and a half ago, this was a whispered-about epidemic," he said. "If it came up, it was someone bragging about their wild weekend on meth, and no one had the courage to say, 'What the hell are you laughing about?'
"That's completely changed," Staley said. "When gay men ask a friend about it now, they're as likely to hear, 'That stuff destroys lives,' as they are to hear, 'Oh, you should try this; it's amazing."'
One indicator that the anti-meth message is spreading is a surge of addicts seeking help at Crystal Meth Anonymous and other recovery programs.
Meth Anonymous started in New York six years ago with one weekly meeting, attended by a half-dozen men. It now offers 24 meetings a week, attended by anywhere from a dozen to more than 100 people.
Some of the men at the recent Friday meeting, clearly on edge, were just beginning their attempt to quit; others had been off meth for two years, yet still embraced the intensive group support in trying to stay sober.
The evening's speaker, a former flight attendant celebrating one year off meth, riveted the audience with a wrenching account of his unhappy youth, his descent into prolonged addiction, his years as a hustler getting paid for sex even as he contracted HIV and other diseases. "Darkness" was how he described his life at the nadir.
The spiritual, abstinence-only philosophy of Meth Anonymous works for some men, but repels others. Some counselors espouse an alternative known as "harm reduction," cautioning users about meth's risks while encouraging addicts who can't quit to avoid overdoses, take care of their health and - to the extent possible - engage in safe sex even while high.
Jean Malpas, a gay psychotherapist in New York, has been handling meth-related cases for four years. He won't condemn harm reduction, but says he has yet to encounter anyone who can use meth recreationally without developing an addiction.
"At some point, when Friday night comes along, they don't know what else to do," he said.
Increased publicity about the gay meth epidemic comes at an awkward time for the national gay-rights movement as it pushes for same-sex marriage rights.
"There is anger at the opportunity this phenomenon is giving the rest of the world to associate the gay identity with promiscuous sex, with out-of-control behavior," Malpas said. "We don't need additional opportunities to be perceived negatively."
Kathleen Watt, who runs the Van Ness addiction-recovery center in Los Angeles, believes some major gay advocacy groups have tried to play down the epidemic.
"They're afraid people are going to say, 'Why should we put money into HIV treatment when these guys are knowingly going out and having sex and infecting other people?"' she said.
Matt Foreman, executive director of the National Gay and Lesbian Task Force, said some accounts of the gay meth problem had been "salacious" and "overjudgmental" - highlighting the role of promiscuous sex while underplaying the destructive addictiveness of meth for any user, gay or straight. He praised gay activists for taking the lead in fighting the epidemic.
Foreman and other gay-rights leaders also note that even in the hardest-hit communities, most gay men don't use meth. Estimates have ranged from 10 percent or 20 percent of all gay men, and as high as 40 percent in San Francisco - by any measure a problem that can't be wished away.
Perry Halkitis, a New York University psychologist specializing in the study of HIV/AIDS and drugs, says the root cause of meth addiction for many gays is not sex or partying, but deeper problems of isolation and low self-esteem, particularly if they are HIV positive.
"Users are often experiencing mental health problems," he said. "You have this really vicious cycle - HIV, meth, depression."
Experts say many men in this category are experiencing "safe-sex fatigue" - they are tired of using condoms, believe medication can contain their HIV, and are emboldened by meth to forget their difficulties and engage in unprotected sex. "Meth was the drug that would turn your head off and allow you to have the sex you thought you were missing out on," Kathleen Watt said.
At the Callen-Lorde health center, which serves New York's gay community, the staff wrestles constantly with cases involving meth and unsafe sex.
"Safer sex is not everybody's idea of a good time," said Callen-Lorde's executive director, Jay Laudato. "When you're high, you decide not to make the healthy choice - you think, 'Why should I?"'
The resulting addictions are often disastrous, Laudato said - men lose their jobs, their friends and, because of one alarming side effect, even their teeth.
The current prevention campaigning tries to promote the concept of healthy, meth-free sex. Peter Staley's latest ads, for example, feature posters of buff male models, accompanied by the slogan, "Crystal Free and Sexy."
New York City's health department contributed $300,000 last year to support the activists' education campaigns. More money is coming this year.
"When gay men saw their peers' lives destroyed, it was like another HIV/AIDS plague," said Brett Larson, director of the city's office of lesbian and gay health. "This was something they weren't going to tolerate. The community has done an incredible job getting the word out."
One of the celebrities who enlisted in the campaign is John Cameron Mitchell, director and star of the hit film "Hedwig and the Angry Inch."
"I've seen a lot of friends wasting away - they start to look like a ghost and can't even see it," he said. "What we need are intelligent scare tactics, to convince people the drug is uncool."
Such messages may not sway hard-core users, Mitchell said, but should be targeted at gays who might be tempted to sample meth, particularly newcomers to big cities.
"You have a lot of young gay men coming into the city - they were the nerds in high school, the wallflower, the ugly kid," he said. "They feel the city is the place to be sexy, to be a star, and they get a false burst of confidence with a drug like this."
Internet gay sex sites are a particular concern to anti-meth activists. Staley said at least one major site has been cooperative, displaying health messages amid the dating profiles. Other sites have been slow to help, and personal ads hinting at sex-and-meth parties still appear, though less often than a year ago, he said.
In California, West Hollywood Mayor John Duran has been discussing anti-meth strategies with players in the gay sex industry including pornographic filmmakers and sex club operators.
"We didn't come through the AIDS epidemic, and the battles over gays in the military and gay marriage, to end up here, a community filled with drug addicts," said Duran, who is gay and HIV-positive. "We've fought too long and too hard to let this drug take us down."
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