So, how are we doing? The short answer is that we get a B-plus for our work with IDUs and heterosexuals but an F in regard to the effort among gay men. Overall, we get a D.

According to the report-whose findings are preliminary and subject to revision by a larger group of experts who will meet this autumn- the annual incidence of new HIV infection among heterosexual IDUs declined from 1.0% in 1997 to 0.6% in 2000. The actual number of IDUs infected in 2000 was estimated at 68, down from 117 in 1997. Among non-IDU heterosexuals, HIV contagion has nearly vanished, with 45 new infections in 1997 and only 6 in 2000. But for men who have sex with men (a.k.a. MSM or gay/bisexual men), the annual incidence rose from 1.1% to 1.7% in those three years. In terms of actual men infected per year, the estimated count more than doubled, from 283 to 573; partly this was due to the increased incidence but partly also to an upward revision in the number of gay men thought to be living in San Francisco. For MSMs with a history of injection drug use (mostly of speed) the estimated rise was even steeper: from 2.0% to 4.6% annual incidence.

Programs which applied for HIV prevention funding from the AIDS Office in the past three years have been instructed to phrase their goal- their only goal- as follows: "To eliminate new HIV infections in San Francisco". For the collectivity of programs which worked toward that goal among gay men, the judgment three years on is apparently, "you're failing".

Prevention for IDUs: What's Going Right, and Why Isn't It Enough?

The City's HIV prevention work among IDUs justly deserves a B+ grade. The estimated annual seroconversion of only 0.6% means that the HIV+ prevalence among IDUs is unlikely to change much from the current 11% level, because the addition of new HIV+ people is roughly balanced by the dying-off of previously-infected people. (The dying-off also slowed down in the late 1990s, mostly because of enrollment of HIV+ IDUs into antiviral therapy.)

The reduced HIV incidence is the fruit of several sorts of prevention work:

•   Testing and counseling. More and more HIV+ IDUs are now aware of their infection, and are willing to take steps to protect their shooting buddies and/or sexual partners.
•   Needle exchange. Every year since 1988, more needles have been exchanged in San Francisco, and there is an ever more friendly "climate" for IDUs at the exchanges.
•   Outreach work. On an average day in San Francisco, something like 20 CHOWs are out on the streets, looking for new and old clients, giving out materials, teaching, reminding, cajoling...

This city's work is a model for the world, and we can indeed be proud that, apparently, we've stopped a potential "HIV IDU epidemic" dead in its tracks. However, this is not enough; there is another virus out there, and this sentence expresses our problem:

"HCV is far less forgiving of slips than is HIV, therefore there can be high HCV incidence where there's low HIV incidence"

Put another way, the hepatitis-C virus is much more likely to be transmitted by a single unsafe act ("slip") and a far higher proportion of the IDU population is already infected. Another essay, "Forgiving or Punishing Slips", presents a simple model that relates incidence to the rate of "slips". Making these assumptions for the model:

•	HIV-negative IDUs select sharing partners at random among the IDU population,
•	the IDU population is 11% HIV+ (i.e., there's a 1-in-9 chance of selecting an HIV+ sharing partner at random), and
•	each act of sharing with an HIV+ partner has a .0067 (1 in 150) likelihood of infecting an HIV- partner,

we can calculate that an average rate of 8 "slips" per year is consistent with a 0.6% seroconversion rate among uninfected IDUs.

The baseline numbers for HCV, however, are much more ominous, namely a background HCV+ rate of at least 50%, and a per-act risk of infection of about .05 (1 in 20). A population of IDUs, each of whom has 9 "slips" per year and hence a 0.6% HIV incidence rate, would have a 18% HCV incidence rate among its uninfected people.

The mathematical approach used here is crude and depends upon a number of simplifying assumptions. We know, for example, that most of the "slips" occur among a small percentage of the at-risk population (see "The Real Locus of HIV Risk"). Reality may be more like this among the 89% of IDUs who are HIV-negative: one tenth of them have 50-plus "slips" per year, one tenth have between 10 and 49 "slips", three tenths have 1 to 9 "slips", and half have no "slips" at all. This would mean that the relatively few HIV seroconversions would be among the highest-risk one-tenth. As for hepatitis-C, it could easily be that most of those who have any significant number of "slips" are already HCV+; and most of those who have no "slips" are HCV-negative and will stay that way. If this model is a reasonable approximation of reality, we should expect HCV prevalence among cohorts of San Francisco IDUs rise to about 60%-70% and stop there, because of the large minority of users who never "slip".

Prevention for Gay Men: What Aren't We Doing?

In its simplest form, HIV prevention for gay men is summarized thus:

"If you want to live a long life, you should negotiate safer sex practices, especially condom use, with each new partner, because HIV is still out there and there is no cure."

This exhortation consists of four separate parts, for each of which we can make a rough judgment of how well we're doing in San Francisco:

•   "If you want to live a long life..." Forty years ago this was a big issue for gay men. Happiness was seen as entirely dependent upon youthful desirability, which- explicitly in such dramas as Boys in the Band- was expected to end in pathos at age 30. Why plan for a long life if youth and beauty were the only things of value? Thankfully, that way of thinking is long gone in San Francisco, as much so as anywhere in the world. Because of the many decades during which gay life has flourished here, there are ample exemplars of gay men thriving into middle age and beyond.

•   "...you should negotiate safer sex practices...with each new partner..." Of course this has been the centerpiece of HIV prevention here as in every other gay community. But still gay men have many "slips", after which one or both partners thinks to himself, "I really, really didn't want to do that!" My main criticism is that safer sex education has been like a driver's education course that's all classroom learning and no supervised driving practice. What's needed is a kind of supervised fucking practice- a voice saying to tops, "this is the moment to gasp out, 'lemme put on a condom, OK?'" or to bottoms, "now is the time to say, 'hey, big fella, get a condom on!'" It comes down to the language, moves and manners of safer sex, not that different from the moves and manners of safe driving. One method would be to hire attractive sex workers to demonstrate these manners to high-risk men (see "A Modest Proposal"). A more feasible (and politically acceptable) method is to facilitate small groups of men to imaginatively mimic a sex act, rehearsing what they would say and do, and when.

•  "...especially condoms..." Condoms are still far from pleasant, especially for tops. The ideal condom is one that you can remove from its packaging with one hand in the dark, that's well lubricated, that smells nice, that's already unrolled, and that will fit not too tight and not too loose because it's the right size (think thickness, not length). I believe condom technology has focused too much on the cheap and abundant and not enough on the costly and exquisite. Why shouldn't a top pay several dollars for a fine condom for that special time with that cute hot guy, in an evening where a beer costs $3 and dinner $30?

•   "...because HIV is still out there and there is no cure." Everyone knows that HIV-positive gay men have died in fewer numbers than they did before 1996. But some are still dying, and it remains a major hassle and inconvenience to live with HIV; and the truth of this has been seriously underplayed here and everywhere else in the gay world.

In my view, then, we need to do a far better job at three aspects of HIV prevention for gay San Franciscans: make it clear that life will be much nicer if they stay HIV-negative, provide condoms that are truly fun to use, and give them practice in the simple etiquette of using those condoms. But maybe what we really need are some focus groups of recently seroconverted gay men, who would address the question, "Why did this happen to me, and what could have prevented it?"

(MidCity Numbers, April 2000)