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"No matter how badly we try to make safe sex fun, it's not," says Thomas Adams, executive director of the AIDS Foundation of St. Louis. "You're in the moment of passion, you want to go and break out the condoms? There are hundreds of tapes that have been filmed throughout the ages trying to make safe sex fun. They've all failed."
But health workers must confront another, more insidious problem. With the advent in the mid-'90s of effective anti-AIDS medicines such as protease inhibitors, researchers soon began finding that the public was increasingly regarding HIV as a manageable disease on the order of diabetes, rather than a death sentence.
"People aren't dying the way they used to," says Adams. "You don't see the people who weigh 97 pounds. You don't see the open lesions all over the face."
Like many AIDS activists, Adams places part of the blame for the shift in public perception on the companies that initially marketed the drug regimens.
"Sex permeates the gay community. It's in our videos. It's in our bars. If you look at the early pharmaceutical advertising for HIV medications, the guys were gorgeous. They were hunky muscular gym bunnies. The message? 'I take this pill and I'll look like that,'" he says. "A friend of mine called them G.O.D.S.: Gays On Disability and Steroids."
Whatever the cocktail of causes, researchers are finding that gay men are increasingly engaging in high-risk sexual activity. And as the January syphilis outbreak demonstrated, many of those having unprotected sex know they're HIV positive.
"It's a real mixture: Fear of HIV has declined. Behavioral studies are showing that gay men are practicing more and more unsafe sex and reporting more and more sexual partners," says the CDC's Fenton. "We have not seen as much of an increase in HIV in some of these big cities. We think what is happening is that positive men are having sex with positive men, and therefore the STD-transmission risk is high but HIV-transmission risk is lower."
Any epidemic is like smoldering coals," says Hilda Chaski Adams, epidemiologist for the City of St. Louis Department of Health. "There's always a baseline level of disease, but then a behavior, or an event, or a practice changes. It can be like throwing gasoline on the coals."
In the case of syphilis among the nation's gays, researchers point to two key environmental shifts: widespread use of the Internet and the rise of methamphetamines.
Point your browser toward the "Men Seeking Men" section of St. Louis' page of the popular Web site Craigslist.com and you'll find the following offer: "Monthly All Male Hotel Sex Party." The poster, who does not reveal his name, adds the following incentive: "LOCATION: DOWNTOWN ST. LOUIS HOTEL. All guys are welcome. No one is discriminated against."
There are dozens of similar sites: Gay.com, Men4SexNow.com and ManMatch.com, to name just a few. One of state epidemiologist Frank Lydon's favorites is GayUniverse.com, which among its many services reviews cruising spots across the U.S.
"I go here to try to get a feel for what's going on," says Lydon, opening GayUniverse.com. The state monitors its employees' Internet use, so Lydon must make note of the date and time. "Someone who doesn't know what I do for a living might think that this was a nonwork-related Web site," he says, navigating his browser to the site's Missouri section. "It gets pretty graphic."
Today's hunt nets an anonymous poster who recounts a racy encounter with an assistant manager for an area Wal-Mart. Apparently the latter works nights and has a taste for fellatio near the "tire and lube area."
"You've got to question some of this stuff," says Lydon. "Is someone just posting to get a reaction out of people? Are they a frustrated author? But you've also got to worry about whether it's true."
Lydon is all but convinced that the Internet fueled January's spate of infection. Unlike previous outbreaks, the rash of syphilis didn't emanate from an adult bookstore, bar or bathhouse. Whereas epidemiologists used to be able to look at a map and find a locus -- a particular neighborhood, business or social circle -- this outbreak was characterized by its diffusion: Those infected live all over the metro area.
"It used to be that when people would come up positive for HIV or STDs, health workers would ask the names of who they've been with," says AIDS Foundation director Adams. "Now I'm hearing reports that people can't tell them their [partners'] names but they can tell them their screen names. It's anonymous sex taken one step way further."
As with earlier syphilis epidemics, St. Louis still dawdles a few years behind the national trend. But if the past few years are any indication, the city is primed for a massive syphilis outbreak in the homosexual community.
In 1999 the national syphilis rate was at its lowest level since 1941, the first year the CDC began collecting infection-rate data. That year researchers saw an 88 percent decrease in syphilis rates from their 1990 peak. Nearly 75 percent of those cases occurred in only 9 percent of the nation's counties, prompting then-U.S. Surgeon General David Satcher to become the latest in a long line of public health officials to dream of eradicating the disease.