FIRST DEATHS FROM AIDS
Even as she spoke, the infectious agent Dr. Dritz feared was already spreading through the homosexual community. In 1979, doctors in New York were treating two homosexual men for Kaposi's sarcoma (KS). KS, a cancer which causes ugly purple lesions on the skin and lesions on the internal organs, had been considered a disease of elderly men of Mediterranean descent, who usually died of something else before the cancer killed them. But these were young men, and the disease was killing them. By February, 1981, six cases of KS were diagnosed in New York all homosexual men.
On June 5 Morbidity and Mortality Weekly Reports published the first report of five cases of Pneumocystis carinii pneumonia (PCP) among gay men. PCP is a rare form of pneumonia which becomes serious only if the patient suffers from a severe immune system failure. Some of the patients were also suffering from oral candidiasis (thrush), another disease normally seen in patients with immune system failure. Doctors began to speculate that there was a link between these cases. On July 4, 1981, MMWR published another report entitled "Kaposi's Sarcoma and Pneumocystis Pneumonia Among Homosexual Men New York City and California":
The occurrence of this number of KS cases  among young, homosexual men is considered highly unusual...That 10 new cases of Pneumocystis pneumonia have been identified in homosexual men suggests that the 5 previously reported cases were not an isolated phenomenon.(MMWR 1981)
Because the original cases occurred in homosexual men, the condition was first labeled Gay Related Immunodeficiency Disease Syndrome (GRIDS), but when the same syndrome was identified in other populations the name was changed to Acquired Immune Deficiency Syndrome - AIDS.
From the beginning, doctors realized they were dealing with a killer. A 1983 report noted that about one third of these Pneumocystis carinii pneumonia and Kaposi's sarcoma cases proved fatal.(Ketterer 1983) And it would only get worse. By January 1, 1990, 147,498 cases of AIDS in adults had been reported; as of January 1, 1997 almost 90% of these persons had died.("HIV" 1997)
In attempting to understand this new disease, epidemiologists looked at various common risk factors among the first victims. The prevalence of so many STDs within the homosexual community complicated the work of discovering the cause of AIDS. Some researchers considered the possibility that the total collapse of the immune system in homosexual men was related to repeated infection by and/or treatment for a series of infectious diseases. Other researchers suggested that the condition might be a reaction to drug use, in particular the use of nitrate inhalants.(Seage1992) Some researchers even considered the possibility that the disease was a reaction to semen in the bowel. When a study found that 96.3% of homosexual men attending STD clinics in Houston (vs. 42% of heterosexual men) had serum antibodies to human cytomegalovirus (HCMV) , the researchers considered a possible relationship between AIDS, Kaposi's sarcoma and HCMV infections since "HCMV-induced mononucleosis syndrome has been shown to be associated with transient immunosuppressions."(Greenberg 1984)
When, in 1983, the human immunodeficiency virus (HIV) was isolated and identified, the other theories were discarded and AIDS was recognized as the end stage of infection with HIV. It was also recognized that the period between infection and the diagnosis of AIDS could be as long as ten years.
HIV is a particularly nasty virus. Besides its long latency period, there is now some evidence that the HIV may create a viral tropism, activating other viruses. It is now believed that KS is caused by a virus transmitted through anal intercourse (which is why KS is found almost exclusively among homosexual men who engaged in this practice).This virus appears to become virulent only in the presence of the HIV.(McGrath 1995) In addition, the report of the rapid decline and death of a health care worker from hepatitis-C acquired by simultaneously with HIV suggests that HIV may increase the rate of progression of other viral infections.(Ridzon 1996) And new studies show that the presence of other sexually transmitted diseases such as amebiasis, giardia, and herpes simplex in HIV positive persons "are associated with a more rapid progression to AIDS."(Boyles 1995).
Human immunodeficiency virus is not particularly easy to transmit. HIV is not an airborne virus which can be spread by a sneeze in an enclosed room. It requires fluid to fluid contact. The problem is that an HIV infection has a long latency period during which the infected person remains outwardly in good health, but is capable of infecting others. It would be possible for HIV to exist in a society without creating an epidemic if sexual activity before or outside marriage were rare. An infected person might infect family members, but the infection would not spread beyond the family group. There would be no epidemic.
However, once one hyper-sexually active homosexual man became infected with HIV and visited a commercial sex establishment where men routinely had unprotected insertive and receptive anal intercourse with several partners in a single evening, the outcome was inevitable.
When an infectious disease is introduced into a susceptible population, the speed at which it spreads depends on the number of contacts between infected and uninfected persons. Epidemiologists trying to uncover the cause of AIDS conducted in-depth interviews with patients. They were shocked by the sheer number of sexual partners reported. They learned that homosexual men normally begin social relationships with other men by engaging in sexual activity; few have male friends with whom they have not had sexual relations.(Shilts p.96) Among the first homosexual AIDS cases, the mean number of sexual partners was over 1,000. One man, Gaeten Dugas, a Canadian airline steward, was sexually linked to 40 of the first 248 diagnosed homosexual AIDS cases.
A study conducted in the Baltimore STD clinic revealed how quickly HIV infection can spread through a community. In 1983, the HIV seroprevalence among homosexual men was 14%. One year later it had jumped to 58%.(Rompalo 1990)
Because an HIV infection was almost the equivalent of a death sentence, many people outside the homosexual community assumed that once homosexual men understood the risks involved in promiscuous sexual activity and, in particular, the risk of unprotected anal intercourse, they would change their behavior and the epidemic would be halted.
Massive educational campaigns targeted at homosexual men were initiated and a number of studies were undertaken to measure the effect of these efforts. Studies done in the mid 1980s showed a decline in risky practices. Dr. Ostrow, who had worried about the possibility of an epidemic of a new disease, conducted a study of homosexual men in the Chicago area. These men reported that they had reduced the number of sexual partners and high risk behavior.(Ostrow 1986) A study done in New York reported a decline in the mean number of partners per month from 6.8 before awareness of AIDS to 3.6 after.(Feldman 1986) Another study found a substantial decline in the number of men frequenting locations where anonymous risky sexual behavior was common, such as public bathrooms, bathhouses, and the back rooms of bars.(Martin 1987) A study of homosexual men in New Mexico found that 80% of them reported altering their sexual behavior.(Jones 1987)
However, the researchers also found that a substantial number of homosexual men had not changed their behaviors. In 1985, 30% of homosexual men surveyed in San Francisco admitted they were still participating in risky behavior.(Research and Decisions Corporation 1986) In a sample of New York City homosexual men, 49.6% reported they had not changed their behavior.(Feldman 1986) In another sample, 67% of homosexual men admitted engaging in anal intercourse without condoms during the previous year.(Jones 1987)
Furthermore, even those who had changed their behavior remained at risk because the number of infected persons within the homosexual community continued to rise. A study done in Los Angeles between April of 1984 and April of 1985 revealed the extent of the problem public health officials faced. Of the 1,637 homosexual men enrolled, 51% were HIV-positive on enrollment; 88% had engaged in receptive anal intercourse with some of their sexual partners; 90% had more than 50 lifetime sexual partners (51% had 50 to 499 and 39% had more than 500). None of the men in the study had been diagnosed with AIDS when they entered the study.(Kaslow 1987)
In 1985, Dr. Don Francis, a virologist from the CDC, tried to explain the problem to a predominantly homosexual audience in San Francisco. Francis used a drawing to help them visualize the problem. It showed two lines:
The line sloping downward represented the overall reduction in the number of sexual contacts that most gay men had accomplished as part of the dramatic sexual counterrevolution that had seized the gay community over the past two years. That development was hopeful. However, the upward slope of the second line, representing the dramatically increased prevalence of the virus among gay men, showed why this is not good enough to save homosexual men from biological obsolescence. Reducing sexual contacts by one-half, Francis explained, was not enough if the people with whom a gay man had sex were four times as likely to infect him with the AIDS virus. The person would still have twice the chance of getting infected that he had had two years before.(Shilts, p.548)
In 1984, 1,006 gay and bisexual Chicago men volunteered to participate in the Multicenter AIDS Cohort Study/Coping and Change Study (MACS/CCS). The study provided what was hoped would be optimal conditions for behavioral change:
All of the men in the cohort were sufficiently aware of the threat of AIDS to volunteer for participation in a highly demanding and intrusive set of studies in 1984, a time when the number of AIDS cases in Chicago was under 200 and large segments of the homosexually active male population did not view themselves as being at risk. . .Thereafter, they have returned for all or most of their semiannual MACS/CCS assessments visits and have received information about AIDS, the HIV-1 antibody test, and recommendations for safer sex through their study participation.(Ostrow 1994)
For 40% of the group prevention was too late. They were HIV positive when they joined the project. Although all were tested for HIV, the majority of participants did not ask to see their test results. From 1984 to 1991, the overall numbers showed a significant decrease in receptive anal sex (RAS); however, the researchers admitted that the aggregate numbers were misleading because the aggregate "obscures the high rates of lapse/relapse to unprotected RAS observed when individual patterns of RAS behavior change are examined." As a result of relapses to dangerous behavior, 14.3% of the men who were HIV-negative at the beginning of the study were HIV-positive at the end. The total infection rate was 54.3%.
Many homosexual men changed their behavior, but it soon became clear that these changes would not be sufficient to stop the epidemic. Donald Hoover and associates studied data from Baltimore, Chicago, Los Angeles, and Pittsburgh on men who were HIV negative in 1984. They found that despite the media coverage of the epidemic and AIDS education, by January 1990, 46% them had become HIV positive. They concluded that:
Given that this cohort consists of volunteers receiving extensive anti-HIV-1 transmission education, the future seroconversion rates of the general homosexual population may be even higher than those observed here. . .Most alarmingly, we must conclude that study-initiated counseling provided to relatively self-motivated and health-conscious MACS study participants is not sufficient to halt transmission of HIV-1 in this cohort.(Hoover 1991)
Early in the epidemic, Karolynn Siegel and associates conducted two interviews 6 months apart of 162 asymptomatic gay and bisexual men. They hoped to understand the patterns of change in sexual behavior among gay men in New York City. According to their report:
only 30% of our respondents reported having maintained completely or probably safe sexual practices during both reporting periods, which means that 70% of the men we surveyed had regularly engaged in sexual practices capable of exposing them to HIV infection.(Siegel 1988)
The study also revealed that converting homosexual men from risky to safe sex was not as straightforward as some had assumed. During the six month period between the two studies, 22% of the group shifted from risky to safe behavior, while 10% shifted from safe to risky. The authors commented on their findings:
It is sobering to note that the most common pattern was the persistence of risky sexual acts with multiple partners. However, one-third had chosen a compromise that preserved both an important dimension of their gay life-style as well as their health: They limited their sexual acts to those considered safe, often through the use of condoms, but had multiple (often anonymous) sexual partners.(Siegel 1988)
It is interesting to note that multiple, anonymous sexual partners were considered to be an important dimension of the homosexual lifestyle so important that these men continued engaging in this dimension even at the risk of their lives.
Siegel and associates were pessimistic about the potential for change through safe sex education:
It appears, then, that some of the factors associated with the continued participation in high-risk sexual behavior are resistant to current educative intervention. Educational campaigns, however well executed and well intentioned, have been insufficient to stem the spread of HIV infections.(Siegel 1988)
The authors admitted that:
education of at-risk individuals about AIDS is not, by itself, adequate in a large proportion of cases for inducing the kinds of changes sufficient to protect against continuing spread of HIV infection.(Siegel 1988)
and that the problem was not ignorance:
Most of the men in our sample were highly educated, mature adults. All were well informed about the transmissibility of AIDS through sexual activity and could describe the specific measures necessary to protect against infection. Yet even under these relatively ideal conditions, the large majority of these informed men did not adopt and maintain behavior to the extent necessary to prevent HIV infection in themselves or others.(Siegel 1988)
The authors concluded:
The findings suggest that the mere transfer of information concerning safer sex practices is not sufficient to induce the desired behavior changes in a substantial proportion of gay men.(Siegel 1988)
They suggested that, rather than rely on "more of the same," the public health task required a "mass behavior change." They acknowledged this would be difficult because of the nature of the change involved, since, in order to stop the transmission of HIV, homosexuals must change sexual practices which "are culturally defined interpersonal acts that have deep psychological meaning."(Siegel 1988)
TRACKING THE EPIDEMIC
Jeffrey Kelly and associates published a large number of studies on the relationship between homosexual men's behavior and HIV transmission. They recognized that: "To slow the spread of AIDS and HIV infection, it is critical that persons at greatest risk for the disease quickly alter those behaviors that place them at risk." In a 1989 study of 104 homosexual men with a "history of frequent AIDS high-risk behavior," those who received education and behavioral training "greatly reduced their frequency of high-risk sexual practices." Kelly et al were optimistic: "Change was maintained at the 8-month follow-up."(Kelly 1989)
However, it soon became clear that their optimism was premature. In a study of HIV risk behavior patterns among homosexual men in small southern cities, they interviewed 355 men and found that of the men who were sexually active (83% of the total):
48 percent reported multiple sexual partners. . . 25 percent of all respondents reported engaging in unprotected insertive, and 23 percent unprotected receptive anal intercourse during the past two months. . .A proportionate calculation revealed that condoms were used by the insertive partner in only 51 percent of all anal intercourse occasions.(Kelly 1990a)
In 1990, Kelly and associates published a study of 526 patrons of gay bars in Seattle, Tampa and Mobile. Of these, 37% reported engaging in unprotected anal intercourse during the last 6 months.(Kelly 1990b)
Since it was clear that many of the homosexual men who had adopted safer behaviors were relapsing, Kelly and associates conducted a study into the situational factors associated with AIDS risk behavior lapses, and coping strategies used by homosexual men who avoided lapses. They recruited 470 men in gay bars and at social meetings of gay organizations in Memphis TN, Tampa FL, Mobile AL and Binghamton NY. Forty-five percent of the men had engaged in unprotected anal intercourse in the previous 6 months.
The authors expressed concern that risk reduction behavior changes were difficult to sustain. They cited studies which showed that: "One third of homosexual men in Chicago who successfully initiate risk reduction later resume high-risk practices. Cross-sectional studies indicate that 30% to 40% of gay men in other cities still report engaging in unprotected anal intercourse in a given 3-month period." And they warned:
Homosexual men who continue to engage in high-risk sex even occasionally are in great danger of contracting HIV infection. Gay men in large cities who have unprotected receptive anal intercourse with a single partner over 1 year are three times more likely to seroconvert than men who refrain from this activity and, with five partners, are 18 times more likely to develop HIV infections. While lapses are the rule rather than the exception following initiation of change in all health behaviors, we were aware of no other population or health area where there is such a small margin for error and where even infrequent lapses carry such potentially grave health consequences." (Kelly 1991a)
Kelly and associates concluded one of their studies with the following caveat:
In view of this combination of high current infection prevalence and transmission efficiency, even infrequent high-risk behavior lapses among homosexual men carry serious health repercussions. Kingsley et al  for example, found that urban gay men who have unprotected receptive anal intercourse with only one partner over 12 months are 300% more likely to develop HIV infection, and engaging in this practice with five partners produces an 18-fold increase in likelihood of HIV seroconversion.(Kelly 1991b)
CONDOM FAILURE RATES
Jeffrey Kelly and his associate, Janet St. Lawrence, also publicly questioned the reliance on condom education as the primary means for prevention of HIV infection. In a letter to the editor published in the prestigious British medical journal Lancet, they warned that "condoms have a substantial failure rate...13-15% of women whose male partners use condoms as the sole method of contraception become pregnant within one year, and condoms are generally regarded as unreliable." They suggested that: "Failure rates may be even higher during sexual activities between male homosexuals."
Condoms fail to prevent pregnancy and disease transmission if they break during use or if they are not used properly. Given the fact that many homosexual men are under the influence of drugs or alcohol during sex, the possibility of their failure to use condoms properly is certainly equal to that among heterosexuals. Kelly and St. Lawrence challenged the idea that using a condom could be considered safe sex:
The prevalence of HIV infection among sexually active homosexual males is 20-50% in many American cities and the likelihood that a homosexual's partner will be HIV infected is substantial. Given the failure rate of condoms in family planning, homosexuals who practice anal intercourse will still be at risk even if they use condoms. The use of condoms during anal intercourse between homosexual men or vaginal intercourse between heterosexual men partners if one of them is in an AIDS risk group may reduce the HIV transmission but only if the sheath remains intact. The possible consequences of condom failure when one partner is HIV infected are serious enough and the likelihood of failure sufficiently high that condom use by risk groups should not be described as "safe sex."(Kelly 1987)
Instead of recommending condom use they suggested that homosexuals avoid anal intercourse with or without condoms:
Encouraging non-penetrative sexual activities that do not afford HIV an entry to the bloodstream is more difficult than simply recommending the use of condoms. However, the seriousness of the AIDS crisis is such that sexually active AIDS risk group members should be urged to refrain from penetrative sexual activities, especially anal intercourse, with or without condoms.(Kelly 1987)
A recently published study of condom breakage, found that, in a group of 98 male students 18 - 29, 50% had experienced at least one condom break 368 breaks in all. According to the report "18.2% of the condom breakage episodes were never revealed to female partners." Men who failed to disclose breakage had more lifetime sexual partners and were less likely to use condoms consistently. Their reasons for not disclosing the breakage included an unwillingness to interrupt intercourse and a desire to minimize their partner's anxiety.(Warner 1997) While this study examined heterosexual behavior, there is no evidence that men engaging in homosexual activity are more responsible.
Ron Stall and associates reviewed articles, unpublished reports and papers given at major conferences on the relationship between behavior, transmission and education. They noted that "current organized efforts to prevent further HIV infection are restricted almost entirely to the communication of health education messages regarding the risks of certain behaviors of HIV infection." Yet it was clear from the studies that "neither attendance at a safe sex lecture, reading a safe sex brochure, receiving advice from a physician about AIDS, testing for HIV antibodies, nor counseling at an alternative test site was associated with participation in safe sex" and that "knowledge of HIV risks was consistently unrelated to risk behaviors." Stall and associates concluded:
The efficacy of health education interventions in reducing sexual risk for HIV infection has not been consistently demonstrated. More education, over long periods of time, cannot be assumed to be effective in inducing behavior changes among chronically high-risk men. (Stall 1988)
Factors related to continued risk taking included: combining drugs or alcohol with sexual activity; agreeing with the statement "safe sex cannot be satisfying"; believing that one is incapable of making necessary behavioral changes to reduce risk or improve health; sexual impulse difficulty; and the belief that biomedical technology will soon cure AIDS. This last finding may signal future problems, since announcement of successful treatment may well lead homosexual men, and particularly younger men, to abandon condom use and other "safe sex" precautions.
RISKY BEHAVIOR CONTINUES
Chart A compares the results from a number of studies. In some cases, percentages were calculated from data so that rates could be compared. The percentage of homosexual men self-reporting unsafe behavior varies depending on how the sample was selected and the number of months surveyed. When researchers considered behavior during a single month the results appeared hopeful; however, the longer the time period surveyed, the more likely the participants would relapse into unsafe behavior.
The de Wit study from the Netherlands must be considered a cause for alarm. The Netherlands was regarded as a model for HIV prevention. When de Wit et al. tracked men specifically identified as refraining from risky behavior for at least 12 months, they discovered that at the end of 88 months, 88% had relapsed into unsafe behavior.(de Wit 1994)
It was suggested that non-use of condoms by homosexual men might not be all that dangerous because the men doing so knew their partners' HIV status was the same as their own. To test this theory, a study was conducted on 677 English men who had sex with men. The researchers found that 79% did not know the HIV status of their sexual partners and 28% had participated in unsafe sex in the previous month. The report ended with the following statement:
It might be predicted that, as the risk of HIV infection becomes greater in the population, individuals will be more concerned to obtain evidence of sexual partners' HIV status. Indeed it appears that influenced by other considerations such as familiarity and trust, individuals frequently take what would appear epidemiologically to be substantial risk. Such perceptions and behaviors pose very considerable challenges to HIV prevention.(Dawson 1994)
Not surprisingly, continued high risk behavior resulted in HIV infections. A 1991 study published of 502 English men who had had sex with another man in the previous 5 years found: "Thirty one percent reported passive anal sex in the last month and 19% had had unprotected passive anal sex." The results were predictable:
Seroconversion to HIV has continued to occur amongst homosexually active men despite extensive changes in sexual behavior. An annual seroconversion rate of 3% has been estimated for homosexually active men who have been voluntarily tested.(Dawson 1991)
WATCHING THE EPIDEMIC
When public health officials are assigned the task of stopping an epidemic, they begin by identifying the source of infection. In the case of HIV, it would be crucial to know which persons were infected and capable of infecting others. The next step would be to prevent uninfected persons from coming in contact with the source of infection, namely the blood and semen of infected persons.
Epidemiologists Morris and Dean attempted to predict the possible course of the AIDS epidemic. They began their report recognizing the substantial behavioral changes made by homosexuals. They then calculated how much change would be required to reduce the rate of HIV transmission below the epidemic threshold. They concluded that if homosexual men had one unsafe contact per year, then the percentage of homosexual men infected would gradually drop to 5%. However:
With an average of about two partners per year...transmission would be above the threshold in all groups, and the disease would instead become epidemic, with seroprevalence levels of over 60 percent among the exposed population in the oldest group and about 25 percent among the youngest. (Morris 1994)
Would the changes observed so far be sufficient to stop the epidemic? Their conclusion: "Current analysis suggests that the answer is no." Although Morris and Dean admitted that their projection were based on assumptions, they pointed out:
Cohort studies continue to document annual seroconversion rates of 1-2 percent per year or higher in some groups... this leads to lifetime individual risks of seroconversion of over 50 percent, with the highest annual hazard (4.4 percent per year) occurring before age 25 years.(Morris 1994)
In 1978 no one knew that HIV was working its way through the homosexual bathhouses and bars, but a record of the epidemic's progress was being preserved. Homosexual men in New York and San Francisco had been recruited into a study of hepatitis-B infection (HBV) rates in preparation for a vaccine trial.(Hessol 1989) Blood was drawn from these men at regular intervals to measure the incidence of HBV infection. When a test for HIV became available in 1984, researchers were able to go back and test these preserved samples for the presence of HIV. Researchers were able to determined that in 1978, 4.5% of the homosexually active men in San Francisco were already HIV positive. By 1981, 35% were HIV positive. The infection rate climbed to 46% in 1982; 57% in 1983; 67.4% in 1984; and peaked at 73.1% in 1985.(Rotello p.74) Since new research suggests that a small percentage of the population is genetically immune to HIV(Waldholz 1997) and some homosexual men consistently refrain from behaviors which put them at risk, the 73.1% infection rates constitutes epidemiological saturation.
At the beginning of the epidemic, 100% of sexually active homosexual men were at risk. Once 50% were infected, only 50% would still be vulnerable. Even if these men were to become HIV-positive at the same yearly rate, there would be only 1/2 as many new infections per year. However, a man who was uninfected at this point in the epidemic would not have a pattern of behavior which included multiple unsafe acts with multiple partners. It was, therefore, predictable that, once the infection rate reached 50%, the number of new cases would fall sharply with new infections occurring primarily among those who entered the at-risk population after the beginning of the epidemic:
The all-time high-water mark of HIV prevalence in the gay population was measured in a San Francisco cohort in 1985 that suffered a cumulative total infection level of 73.1 percent. No other cohort of gay men attained such astronomic levels, but many saw cumulative prevalence rise to between 40 and 60 percent by the mid-eighties at which point new infections slowed dramatically.(Rotello, p.129)
When, after the initial mass infections within the homosexual community, the rate of new infections slowed, those who had been promoting safe-sex as the best way to stop the epidemic claimed credit. They insisted that homosexual men had responded to the threat, and the epidemic was under control. What probably happened was that most of those who were most susceptible were already infected, ill or dead. Rotello insists:
There was fairly straightforward evidence that saturation was more responsible for the decline in new infections than safer sex. There was practical and theoretical evidence that new waves of infection were inevitable once new groups of susceptible young gay men entered the gay life.(Rotello, p.134)
DENIAL AND DRUGS
Homosexual men who are engaging in behaviors that put them at risk often deny the reality of their situation. In a study of the sexual practices of 823 gay or bisexual men seeking primary health care, Lawrence Linn and associates found that:
in the previous 2 months, 64% [N=520] had engaged in at least one sexual behavior considered unsafe. These patients compared with those having safer sex, were younger, of lower socioeconomic status, and from a racial minority, especially Latin. The unsafe group also had more sexual partners, engaged in sexual acts more often, felt less control over their sexual behavior, used recreational drugs more frequently, and were less likely to talk about safe sex with partners.(Linn 1989)
What was most troubling to Linn and associates was that the "unsafe group" felt "safer from the risk of acquired immunodeficiency syndrome even when engaging in unsafe sex."(Linn 1989)
The study found that 51% of those who had tested positive for HIV had recently engaged in unsafe sex. This was not because they did not know how to use a condom. At some time in the past 42% had used a condom during anal intercourse. Their behavior could not, therefore, be blamed on a lack of education about condom use or lack of experience in their use. The authors concluded:
It appears that many gay and bisexual men may be faced with multiple addiction problems related to sex, drugs, and alcohol. Further changes in sexual behavior are not likely to occur unless the compulsive nature of their sexual behavior and polydrug use are dealt with more directly.(Linn 1989)
Ted Myers and associates conducted one of the most comprehensive studies of homosexual behaviors. In the initial phase of the research, they interviewed 612 homosexual Canadian men and found that drug use among them was high. Furthermore, those who used drugs in conjunction with sex were significantly more likely to have a greater number of sexual partners. Those who were HIV-positive were more likely to use drugs.(Myers 1992b)
Results of the completed survey of more than 4,600 men in 35 Canadian cities confirmed these findings:
men who reported use of alcohol prior to sex were more likely to report unprotected anal intercourse than those who didn't (23.4% vs. 14.9%)
men who reported using nitrites prior to sexual activity were more likely to report unprotected anal intercourse than those who didn't (28.3% vs. 18.3%).(Myers 1993).
They also found that younger men were more likely to have unprotected anal sex. Reasons given for not using a condom during the last episode of unprotected anal intercourse included: "He was my regular partner," "The sex was so exciting," "It makes me lose my hard-on," "I am HIV-negative," "I pulled out before cumming," "I was using alcohol," "He did not want to use one," "We did not have condom," "He said he was HIV- negative," "I was using drugs," "I never use condoms," and most frighteningly "I am already HIV-positive."(Myers 1993)
Evidence of the relationship between drugs and alcohol abuse and unsafe sex was documented in a number of the other studies. The San Francisco Men's Health Study found that homosexual men, particularly those aged 24 to 34, were more likely than single heterosexual men in the same age group to use marijuana, nitrites, psychedelics, barbiturates, and amphetamines on a weekly basis and those who did were more likely to engage in unsafe sex.(Stall 1988)
While the use of nitrite inhalants is almost unknown in the heterosexual community, nitrites had become the drug of choice among homosexual men. Nitrites not only produce a "high," they also cause the anal sphincter to relax thus facilitating anal intercourse. A survey of 323 homosexual men in Alaska found that use of nitrite inhalants was an important predictor of high risk sexual behavior.(Fisher 1992) Since anal intercourse is the most efficient means of acquiring an HIV infection, users of amyl or butyl nitrite were more likely to be HIV-positive.(Haverkos 1988) In addition, those treating AIDS victims noticed that Kaposi's sarcoma was found almost exclusively among homosexual males:
The use of nitrites has repeatedly been associated with Kaposi's sarcoma (KS) in patients with HIV infection...three fourths of a sample of HIV/KS patients reported using nitrites an average of seven times a month for 5 years.(Fisher 1992)
Fisher and associates studied drug use among homosexual men in Alaska and concluded that: "substance use, especially use of nitrite inhalants may represent an important factor in noncompliance with risk-reduction guidelines." The researchers compared those who considered themselves at high-risk of contracting HIV and those who considered themselves at low risk:
The perceived-risk group averaged slightly more than twice as many reported partners in the previous year. However, the men who did not perceive themselves to be at risk had a mean of six sex partners in the previous 12 months. As one of our anonymous reviews pointed out, there seems to be a certain degree of denial in that men who had had this many sex partners in the previous 12 months did not feel that they were at risk for AIDS. (Fisher 1992)
In spite of 15 years of intensive HIV/AIDS education, in the '90s the situation deteriorated. During 1997, an estimated 100,000 homosexual men attended at least one of the more than 50 circuit parties, organized to raise funds for AIDS and other causes. According to several reports, circuit parties are venues for drug abuse and unsafe sex. An article appearing in the June, 1997 issue of the homosexual magazine The Advocate documented the party phenomenon:
The party's everywhere in nightclubs and sex clubs from Los Angeles to Miami and in private homes from Chicago to Atlanta. And as on Fire Island in the '70s, sex and drugs are on the invite list.(Heitz 1997)
On the circuit, the range of available pharmaceuticals has been expanded to include: GHB (gamma-hydroxybutyrate), a sedative with unpredictable side effects that causes some revelers to require medical attention; Ecstasy, a cocaine/amphetamine derivative which, acting as a stimulant and a hallucinogen, gives users a sense of well-being and sensory distortion; Crystal Meth, a form of the powerful stimulant methamphetamine, which is used to intensify the sexual experience; and Special K, the animal tranquilizer, ketamine. Crystal meth appears to be the new drug of choice because it is cheap and can keep a user high for 48 to 72 hours at a time. In The Advocate article one homosexual man saw drug usage as directly related to sex:
I think the comment we're hearing from people is, there's an increase in drug use and disinhibition when it comes down to sex unsafe sex.(Heitz 1997)
For AIDS expert Ron Stall, there is a direct connection between the use of crystal meth by homosexual men and HIV infection:
Every single study that I can find shows that gay men who use more drugs, and who have a higher frequency of drug use, are much more likely to become HIV positive than gay men who hardly use drugs or don't use drugs at all.(Signorile 1997)
The fact that the parties are AIDS fund raisers and that the participants know the risks appears to have little effect. The Advocate article reported that a "high-ranking official in one of the country's largest AIDS service organization" engaged in unsafe sex while high on cocaine.(Heitz 1997)
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