Starting a new ecosystem in the age of AIDS

By Jeff Walsh, Oasis Editor

In the opening shot of David Lynch's movie "Blue Velvet," an idyllic suburban home is descended upon by the camera. Warm, rich colors of green grass, a white picket fence and a happy Technicolor couple fill the screen. The camera never stops descending, though. As it continues down, it goes into the soil and thousands upon thousands of screeching bugs fill the screen, leaving the viewer with the sense that things are never as simple as they appear on the surface.

In a similar vein, HIV and AIDS have also been sanitized and shown in glorious Technicolor to mixed audiences who take away mixed messages. Many magazines feature articles on HIV-positive people jogging and living active, healthy lives. Protease inhibitors are not only giving some people a new lease on life, but some don't even test positive for HIV anymore. But these images and articles seem to ignore the fact that many people are still getting infected, many people are sick and many are still dying.

In his new book, "Sexual Ecology: AIDS and the Destiny of Gay Men," Gabriel Rotello says his research proves the AIDS epidemic is still growing. Rotello found that one HIV-infected person is, on average, infecting more than one other person.

His book challenges the gay community's value system toward monogamous relationships, what needs to change and why condoms as the only means of prevention isn't good enough if the community wants to rid itself of this epidemic.

Mixed messages

Rotello says it's natural for people to be hopeful about the epidemic drawing to a close because of the effectiveness of protease inhibitors. In some instances, this "drug cocktail" causes formerly infected people to test negative. Many people read that as an end to the "death sentence" of HIV and AIDS that we grew up hearing about.

"That is a logical conclusion to draw, even though, in my opinion, it is incorrect," Rotello says. "Not only incorrect, but potentially tragic, because if people get that message and feel that it means they can ease up on safer sex, that becomes a little less safe a little more often, the consequences of that probably will be not only an increase in the epidemic itself, but also an increase in the number of people who are infected with strains of the virus that are not treatable by the drugs that we have spent many years and billions of dollars developing."

But that message is out there. In a recent column in Out magazine, Michelangelo Signorile wrote an amazingly disturbing story about people who enjoy "bareback sex," which is anal sex without using a condom. Signorile found people who actually threw parties when they seroconverted because they no longer had to live with the fear of getting infected, and weren't concerned because they feel AIDS is now manageable.

Because of these developments, Rotello says society will become, and already is becoming, less sympathetic to people who are HIV-positive.

"One of the major arguments that the AIDS activist movement used for many, many years in order to prick the conscience of mainstream society as far as providing services and seeking a cure or vaccine was that the majority of those who were infected with HIV had become infected before anyone even knew that there was an epidemic afoot, much less before people knew how to avoid becoming infected. And we used that argument over and over again very efficiently and effectively," he says. "Even people who were prone not to be sympathetic to gay people, which is a very large portion of our society as you know, nonetheless many of them said 'I'm not sympathetic to gay people and I don't even like them all that much, but you have to hand it to them, it is true that the vast majority of these guys got infected with this disease before they even knew it was happening. And because of that, perhaps we should ease up on them a little bit.' And I do think that argument, rightly or wrongly, has begun to diminish over the past couple of years as people began to realize that younger people who are HIV-infected almost surely were infected after they knew how not to be infected."

Rotello doesn't think the backlash is valid, though.

"I personally don't think that is any reason why society in general should reduce its commitment to AIDS. After all, we have a gigantic commitment to taking care of people with lung cancer and of finding cures for lung cancer, even though most cases of that are causes by voluntary behavior that everybody knows is dangerous. And we spend tens of billions of dollars dealing with the medical problems of obesity, even though for most people that is a behavioral thing that's preventable," he says. "So, I don't think that just because that you can make the argument that contracting HIV at this point is something that people know how not to do that society in any way should turn its back on people with AIDS. Nonetheless, it's sad to say, but that is likely to happen more and more and it is already happening as we speak.

"And if you combine that with the idea that AIDS is becoming a manageable disease, that also lessens the support and urgency in mainstream society to care about people with AIDS or to do much of anything for them," he says.

Rotello says people get their AIDS information from a variety of sources, but young people tend to get their information from other young people, he says.

"And that is as it's always been, not just for the AIDS epidemic, but for everything for most of time. So, certainly, there's a lot of people talking amongst themselves and either spreading good information or bad information amongst themselves," Rotello says. "They also get information from society around them, their families, their schools and the media. And another major source, in this particular epidemic, is the gay community and AIDS prevention organizations. If anything, if people are really beginning to think today that they don't need to worry about the AIDS epidemic and they're getting that information from friends and from the larger society and, to an extent, from AIDS groups, the amount of misinformation is even worse now. And I think that that is the case."

Condoms aren't enough

In his book, Rotello describes a view that differs from the sole prevention message espoused by most people.

"For most of the epidemic, people have fought and argued that condoms alone are a sufficient form of safer sex and that if we could simply get people to use condoms every time they had anal sex, then we would be able to prevent most new infections, certainly not all, but most," he says. "And we would certainly be able to prevent enough new infections to bring the epidemic down below what epidemiologists call the tipping point of the disease."

Tipping point is a figure of speech amongst epidemiologists which says that if the average infected person infects one other person, the epidemic will neither grow nor shrink. It will just stay in a steady state.

If they infect more than one person on average, even if they infect 1.1 other people, the epidemic will continue to grow because people are more than replacing themselves.

"One of the major points, to me, of safer sex is, in addition to keeping yourself uninfected, if you're negative, or infecting someone else if you're positive... from a collective point of view, the major point of safer sex is to bring the epidemic down below the tipping point, to get to the point where the average infected person is infecting less than one other person," says Rotello.

According to mathematical modelers, Rotello says the average infected person infected five other people in the early years of the epidemic. At present, it's slightly over one. It has never gone below one.

"We have done a tremendous job of bringing it down, but we haven't contained it. For a long time, we argued we could do that with condoms alone. If we simply got everybody to use a condom, every time they had anal sex, that alone would prevent so many new infections, it would bring the epidemic down below the tipping point and the epidemic would continue to go away," he says. "Now, it is clear, after 15 years, that has not worked. Even though we have promoted condoms and educated people, and provided condoms in an efficient way, and even though virtually every sexually-active gay person now from their teen years onward knows how HIV is transmitted, and knows that condoms can prevent it, we have still been able to bring the epidemic down below the tipping point with condoms. And the reason is, not everybody uses condoms every single time they have anal sex. So, not enough people use them often enough to bring things down below that point."

Rotello delved into why gay men don't use condoms consistently, and found the same patterns among straight couples, even when they knew one of them was infected.

"So, I don't buy the idea that gay men don't use condoms consistently because of some inherent problem in being gay. Sometimes you hear that gay men are suffering from survivor's guilt or a specific dysfunction... it seems more likely that any behavior change is difficult to accomplish, whether it's quitting smoking, losing weight, using condoms every time, whatever... and in human life, many people are imperfect and are not able to do these things perfectly all the time. And if you have a population as saturated with HIV as we are, for this strategy to work by itself, all alone, you would need virtually 100 percent compliance, and we don't have anything like that."

Rotello then looked to other avenues in which to intervene to bring down the infection rate. He is adamant that condom use is still crucial.

"I argue very strongly that condoms are crucially important, they always have been and always will be in containing HIV, but I wanted to see if there was something else we could do to go beyond that, that might provide us with room for error, so that when people don't use condoms perfectly, their failures will not lead to disaster as it can now."

Bringing down the contact rate

Rotello found that the likelihood of transmission among gay men was based on three factors: infectivity, prevalence and contact rate. Infectivity assesses how likely you are to become infected with HIV when you have sex with someone HIV+. Prevalence addresses the percentage of people in your pool of potential sexual partners who are already infected.

"Obviously, that plays a huge role, because if the pool of people you're having sex with only one in a million have HIV, then you can have an awful lot of unsafe sex. And virtually, if the pool is 50 percent is infected, you're faced with a much more difficult situation," he says.

The third factor is contact rate: the number of people with whom people have sex. This is the factor Rotello says the gay community needs to address, because condoms bring down the infectability and prevalence can't be controlled.

"The contact rate, the number of people that people have sex with, is something you can do something about, and that's the thing that we have not addressed so far in safer sex," he says. "We have basically said that if you simply argue that everybody should use a condom every time they have sex, it doesn't matter how many people they have sex with. Because if they're using a condom, they're not going to transmit anything and therefore it doesn't matter. But if you factor into that the fact that people don't use condoms every time they have sex, and despite everything we've done for 15 years, it looks like they're not going to, then the contact rate becomes very important.

"It becomes, in fact, the most important thing that you can still address. So, I basically argue that we need to continue to do everything that we are doing in terms of condoms. We cannot ever allow the message to go out that condoms are not the most important single thing you can do to protect yourself from HIV," he says. "But, we also have to send out additional messages and one of the most important ones has to do with reducing partners altogether."

Rotello realizes how deep the gay communities' attitudes are about sexual freedom, but his message is that we need to look validate and nurture attitudes about monogamy and relationships.

"You can't just tell people to reduce partners because people want to have sex. This is obviously an important, meaningful aspect of peoples' lives. The way most societies get their members to reduce partners is not just by standing over them like some strict old nun with a ruler in her hand saying reduce your partners, but rather by creating the conditions whereby people can be in relationships with one person at a time and have those relationships be workable things," he says. "And that is something I believe, at least in major cities, and this is different in smaller cities and towns. But in bigger cities, the gay community, at least the gay male community, has not done very much to promote the idea of relationships and monogamy within relationships. Certainly, as an AIDS prevention thing, we haven't done that at all.

"But beyond just AIDS prevention, from a cultural point of view, the culture of gay men in big cities tends to validate having multiple partners... going out to the bars, cruising, picking people up, tricking, all that kind of stuff... and when younger gay men come into places like New York and San Francisco they tend to be acculturated into a culture that says to them 'This is how we behave, this is how we act, so get with the program and I'll see you out at the bars.' And, it even frequently goes further than that, into the realm of commercial sex, sex clubs, bath houses, all that kind of thing. This is validated, encouraged, people are told that this is what it means to be gay, at least in big cities, to a very significant extent," he says.

For many gay men, sex gives them a feeling of belonging, closeness and community that they didn't get growing up feeling alone and confused about their sexual feelings, he says.

"I think most gay people want to belong and want to feel like they belong in a community. There are often people who were rejected by families and the communities we grew up in, so we are eager to fit in, to belong, and it's very enticing from a sexual point of view just to have a lot of partners, especially for men. Women seem less interested in that than men. So, people get pulled into this life which creates a culture of intrinsic risk. And that is where we are now, and that is what we have to look at and try to change."

Controversy follows

In e-mail discussions I've had, newsgroups I read and conversations I've heard, Rotello's book and its message have caused quite a stir. Some think he's an assimilationist trying to make us more proper for the straight world. Others think any attempt to stifle gay sexuality is homophobic. Rotello says most people who disagree with him have something in common.

"I don't think that most of the people saying that have read my book. What I have found when I engage people in those types of conversations is that they have not read the book," he says. "And what tends to happen is people say that until they read the book, and then when they read it, they say 'Oh my, God, I had no idea what you were talking about. You have completely convinced me. I think that you make an incredibly strong case.' So, while it's a little bit disturbing that you hear that kind of reaction, I'd be much more disturbed by it if it were from people who have actually read the book. Luckily, that's not happening very much."

Rotello is also well aware he is tipping some sacred cows in the gay community with his argument.

"Look, gay culture is built on a lot of these values that I was just describing. And if you come along and basically say to people that I have scientifically nailed down the fact that this lifestyle that we have been taught to think of as good is not only not good but is going to intrinsically going to keep mowing down generation after generation after generation of younger gay men until we change it, you of course, are going to get a very sharp reaction from a lot of people who have invested a huge amount, personally, psychologically and sexually, whatever, into that lifestyle. And they are going to be very angry about that," he says. "The only thing that I can encourage them to do is to read the book, because I find that when people do, they tend to change their minds."

He insists that most people tend to challenge his proposed remedies to the epidemic and not his findings.

"The central point, which you do not hear very often in those debates but which I feel I have nailed down pretty decisively, is that the AIDS epidemic will not be contained in the gay male population by condoms alone. That was a beautiful idea, which would have been lovely if it worked, but it has not worked and there is no evidence that it is going to work," he says. "So, we are now faced with a rather stark choice, which is to either change further aspects of gay sexual life in order to contain the AIDS epidemic, and change it in ways many people would not prefer to change it, or to decide not to change it and to accept a permanent continuation of the AIDS epidemic.

"And when most people read the book, and I'm not just talking about lay people, but also scientists and epidemiologists and mathematic modelers and so forth, when they see this material laid out in this fashion, agree that that is the case, whether you like it or not. If you're going to scream at me for laying out that rather stark fact, you're really just blaming the messenger, because I didn't just create that situation. I'm simply describing the way it is. Simply saying to people, this is the choice that we have before us."

Beyond agnostic

Rotello goes beyond journalistic reporting to add his voice, opinions and hopes for the future of the gay community in the book.

"In the course of the book, in the last few chapters, I say that my own personal druthers would be 'Yeah, we should survive as healthy people, and if in the process of surviving, we need to change major aspects of our sexual lives, that's what we ought to try to do,'" he says. "So, I do come down on that side. I'm not just an agnostic who puts this just out there and says, 'I don't care what anybody does, do what you want to do. Here are the facts, you decide.'

"I say, 'Here are the facts, you decide, but here's my decision personally and this is how we ought to go about doing that.' Ultimately, it doesn't matter what I do or what I say," he says. "Ultimately, it matters what gay men collectively by the thousands, tens of thousands and hundreds of thousands decide to do. And that's not something that anybody can or should control. That's something for each person to decide based on the best possible evidence, which is why I urge people to read the book because that's where the evidence is. People need to make up their own minds, and I have no doubt that some people will decide that sexual freedom, an absolute sexual license, is so important and so meaningful to them, if that means gay men have to continue to die at these medieval levels of mortality, that's acceptable to them. I don't think it is, so it's just a personal opinion.

Looking for love

In five years of talking to gay youth online, and 19 months of publishing Oasis, I have seen hundreds of people accept their sexuality online. With ages ranging from 13 to 24, I have talked to people and help them sort through their feelings. Each person I've talked to initially had the same hope for their future as a gay man. They wanted to find someone special, fall in love and be in a long-term relationship. So, I told Rotello I thought gay youth were a good audience for his message, since it is what they already say they want, despite hearing messages to the contrary from the larger, older gay community. Rotello agreed, but says the larger gay community hasn't agreed with him on this count.

"When I say that, in some of these public debates, people hoot at me," he says. "What they say is, 'Well, that may be, but that's only because these kids have been indoctrinated by heterosexist models from their family and they've been brainwashed into thinking that's what they want. But the minute they taste the sexual freedom of the bars and sex clubs, that's really what they want.'

"But I tend to agree with you. I think most people would prefer a loving relationship with a single other person whom they were monogamous with and that person is monogamous with them," he says. "That's what most people would want. But we don't support that in the gay world very much, and Lord knows, society doesn't support it."

Rotello says heterosexual society is constructed to support monogamous relationships.

"Look at the lengths to which the heterosexual world goes in order to try to create the conditions in which straight people can live that kind of life. They have all these institutions, like marriage, for example, an engagement, going steady and starting from the time you're in junior high school, you are trained by society to think of relationships and sexual relationships at least in terms of one person at a time," he says. "And you are shored up in this, you are supported in this, encouraged to act this way. When you don't act that way, you are scolded by society and told you're being selfish and self-indulgent. And over the years, this does not make for the Garden of Eden in terms of social perfection for people, but it does create a climate where it becomes relatively easy to form and maintain relationships with one person for an extended period of time."

It's a situation that is nowhere near as institutionalized within the gay community.

"We really don't have that very much in the gay male world, at least in large cities. There is not anything like same-sex marriage. We don't come from a tradition where we were dating other boys, or lesbians were dating other girls when we were in high school. That is beginning to change a little bit and it's fantastic," he says. "At least for people in the older generation, in their 20s, 30s and 40s, they did not have that. There was very little social support for that."

So, how does Rotello think this change will happen, if it does, in the gay community?

"That kind of change happens just because we want it to happen, and I don't think it happens because we print up brochures that say that part of safe sex is to be with one person at a time. It happens because the culture encourages it on a daily basis," he says. "That is what we need to begin doing, and I'm very encouraged by what I see with kids in high schools and colleges today, who look like they are beginning to do that. You have the option now, in some cases, to do that. You can come out while you're still in high school, and certainly while you are in college, if you're at any sort of enlightened college, and begin to date other people of your same sex and form relationships at that early age, when people learn how to form relationships. And I think if that continues, the kinds of changes I am talking about will really begin to happen much more for what is now the younger generation. As they grow older, they will find it easier to form and find these kinds of relationships."

Rotello says many people start out wanting the house with the white picket fence, but their gay peers steer them away from that vision.

"A lot of kids tell me they came to a city, they were interested in romance. They were interested in having a boyfriend. And they very often end up with friends a few years older who are already fully acculturated into the culture of promiscuity. And those people tend to steer them in that direction," he says. "They'll say, 'Oh, Mary, you don't want that. Come out with us tonight.' And as time goes on, it doesn't take long and they realize they are now fully engaged in that lifestyle. I think this happens less in smaller towns.

"Michelangelo Signorile's new book describes a generation of people coming out of the closet in small towns and doing something the older generation never did, which is to come out of the closet and then to stay at home. Not to move to the city, but to stay at home and live as an out lesbian or gay man and remain, to a significant extent, still integrated into the life you grow up in, instead of cutting yourself off," he says. "I think a lot of people from older generations, for better or worse, and quite often for worse, cut themselves off from their families and the friends that they grew up with and moved away to a big city to live in the gay neighborhood and live a completely gay life with all gay friends, mostly gay jobs, eating in gay restaurants, shopping in gay stores and cutting themselves off from the rest of the world.

"That's certainly what I did."

Gabriel Rotello can be reached online at Gabo3@aol.com

Oasis editor Jeff Walsh would love to hear your feedback at jeff@oasismag.com