The Second Wave Will Drown Us

TWO YEARS AGO, IN THESE pages, the US Centers for Disease Control and Prevention (CDC) forecast a resurgent HIV epidemic among US men who have sex with men (MSM). Nationwide surveillance data had not yet shown a higher rate of new infections, but congruent indicators from sexually transmitted disease registries and studies of self-reported risk behavior all suggested that the consistent practice of safer sex was eroding.1 Earlier this year, the CDC announced that the forecast already had come true: new HIV diagnoses increased by 14% among US MSM between 1999 and 2001.2 New York State and California—where the largest US MSM communities reside, although they are excluded from these data—provide consistent and equally alarming indicators: multiple behavioral measures coincide with unprecedented outbreaks of syphilis3 and increasing rates of rectal gonorrhea.4 The first wave of HIV gathered force and carried off thousands of MSM before the rising crest became evident. This time, there was ample warning. What is going wrong? Condom use, which is simple in principle, is difficult in practice. Changes in the milieus in which HIV spreads—cultural, attitudinal, technological—elude behavioral surveillance and outpace behavioral interventions. Development of biomedical interventions languishes through lack of resources, capacity, and strategy. Prevention and treatment research have been dichotomized instead of interwoven, to the detriment of both. Moralism—homophobia in particular—exacerbates rather than alleviates the threat.