Gary Smith* is a gay man who doesn't practice safe sex.
"I don't meet people for a sexual encounter; I meet people, and we may end up having sex," he said. "I'm simply not willing to be terrified of life and sex."
Smith has been lucky. He does not have AIDS or HIV. He is 35 years old, well educated and works in the health care industry.
He knows that 60 percent of new cases of HIV are among men who have sex with men.
He knows that 50 percent of men with another common sexually transmitted disease, chlamydia, show no symptoms.
He knows that men in his age category - 30 to 39 years old - are frequently diagnosed with syphilis.
And he knows that in Phoenix, the proportion of new cases of gonorrhea represented by gay or bisexual men increased from 5 percent in 1998 to nearly 15 percent in 2001.
Still, with two decades of health messages behind him, Smith is not persuaded to use a condom each time he has anal sex.
"That's just not something I see as reasonable," he said.
Growing up gay
Born on an Air Force base in Idaho and raised in conservative Virgnia, Smith had his first sexual experience at a young age. Unlike some of his friends who are gay, Smith felt comfortable with his sexual orientation even as a teenager.
Being gay and having gay sex came naturally to him. "I became (sexually) active when I was 13; I came out to my parents when I was 17," Smith recalled.
"Somewhere in there, I thought, 'Oh, yeah. That's what they call it.'"
Smith turned 13 in 1980; the next year, cases of a new disease called AIDS were first diagnosed. It was an era of alarm for most gay men. With an epidemic of deaths and terrifying prospects of an incurable disease, many gay men cut back on their number of sex partners and stopped having anal sex.
But Smith was unfazed.
"I was aware of AIDS out there," he said. "I was sexually active. (But) I was invincible. It wasn't going to affect me."
Meanwhile, health agencies bombarded the public with messages about safe sex, and the gay community also began to educate itself.
Celibacy, they concurred, was the surest way to avoid HIV and other sexually transmitted diseases, but a life without sex isn't a viable option for most gay men.
Another certain way to avoid sexually transmitted diseases is by maintaining a long-term relationship in which both partners are monogamous, tested and uninfected. But gay relationships, like heterosexual relationships, don't come with lifetime guarantees.
In the late-1990s, scientists gave health education a desperately needed partner: improved medications for treating AIDS and HIV.
With "cocktails" of various drugs, the number of people dying of AIDS dropped dramatically, as did the number of people who progressed from HIV to AIDS.
These medications allowed men who have sex with men a degree of relief. But with that relief, however, has come complacency, according to a report from the American Public Health Association.
The slump in AIDS-related deaths has led some gay and bisexual men, especially young men, to conclude that the HIV epidemic in the United States is over.
It is not. According to the Centers for Disease Control and Prevention (CDC), because fewer men are dying from AIDS, more are living with it.
Compared to just a decade ago, gay and bisexual men are less concerned about becoming infected with HIV because medications are so effective in fighting the virus, noted Dr. Kimberley Fox in the American Journal of Public Health. High-risk behaviors, especially anal sex without a condom, are becoming increasing popular among many men who have sex with men. Fox further reported that gay men are having more anal sex and more unprotected sex with more partners than ever before. This is true even for some men who have tested positive for HIV.
Health officials are concerned about an accompanying increase in other sexually transmitted diseases, especially gonorrhea, chlamydia and syphilis. These diseases may not kill, but they cause serious health problems nonetheless.
The rise of Gonorrhea
Smith's reaction to gonorrhea? "Been there, done that."
Although he has been tested numerous times for HIV, he has been less wary of other sexually transmitted diseases and hasn't bothered getting tested for them. He found out he had rectal gonorrhea after his partner was diagnosed with the disease.
"I (had it) and apparently did not know it because it was a long time between sexual experiences," he said. "Then my partner...got it so I had to get it taken care of (with antibiotics)."
His experience hasn't persuaded him to practice safe sex. "Condoms are an HIV issue. The greatest concern is with the greatest disease," he said.
Health officials say it's not that simple.
People who are vulnerable to HIV tend to be more vulnerable to other sexually transmitted diseases, and are more likely to pass on AIDS. In addition, the other sexually transmitted diseases, with their own sets of serious health risks, are rising at alarming rates, according to government health statistics.
The number of U. S. gonorrhea cases, for example, rose 9 percent in just two years - between 1997 and 1999 - following more than a decade of progress, during which gonorrhea rates were dropping by 10 percent a year, most likely due to an increase in condom use, according to the CDC. Scientists at the CDC speculate that young gay and bisexual men are largely responsible for the rise of the disease.
Because it is a bacterial disease spread through sexual contact, gonorrhea is probably underreported, said Phil Powers, an epidemiologist with the Arizona Department of Health Services.
In 2002, there were 3,784 reported cases of gonorrhea in Arizona, Powers said. About half of the cases involved men, most of who lived in metro Phoenix. Nationally, more than 350,000 cases of gonorrhea are reported each year, but the actual number of cases is probably double that amount, he said.
Among men, gonorrhea usually causes obvious symptoms, such as a burning sensation while urinating, prompting a visit to a physician. Sometimes, however, there are no symptoms, particularly if the rectum or throat is infected.
Left untreated, gonorrhea can cause the testicles to become painfully swollen; advanced cases can lead to infertility and to blocked urine flow. The disease also is linked to the spread of HIV, the CDC warns. Men who are infected with both HIV and gonorrhea are more likely to pass HIV to someone else than are men who are infected with HIV alone.
More common STDs
As a university-based physician, Dr. Gary Septon, chief of medical staff at ASU student health services, said he sees fewer than a half-dozen cases of gonorrhea a year. "At the university, we most frequently find other sexually transmitted diseases," he said.
More common among his student patients are genital warts, herpes and molluscum contagiosum, a viral skin infection that leads to pimple-like growths, often in the groin or buttocks.
Septon said he is also concerned about chlamydia, the most frequently reported infectious disease in the United States, with an estimated three million new cases each year, although only one in six is reported.
"We have about 100 students come in each year with chlamydia," Septon said.
Between 1984 and 1997, reported rates of chlamydia increased 90-fold due to improved screening efforts and recognition that infections don't always have symptoms.
Women are five times as likely as men to be diagnosed with chlamydia because of better screening processes, but according to Powers, "Men don't get tested for chlamydia; they get tested for gonorrhea. If that test comes out negative, their doctor will treat the infection as chlamydia."
Chlamydia's symptoms are similar to those of gonorrhea but aren't as painful or colorful, so infected individuals aren't as likely to seek therapy. According to the CDC, men who don't seek treatment may be left with severe urinary tract infections and swollen testicles.
Of the most common sexually transmitted diseases, doctors and the government tend to take syphilis the most seriously, especially in Maricopa County, which is one of the top 30 counties nationally for high rates of syphilis.
Although the county's rates fall below those of Los Angeles, San Francisco or New York City, syphilis is prevalent enough to garner additional funding for screening from the federal government.
Called "the great imitator" because its symptoms mimic those of many other diseases, syphilis is passed from person to person through contact with a syphilis sore - a painless, round sore that develops at the site where the bacteria enters the body. The sores usually appear on the genital, anus or rectum, but can also show up on the lips or in the mouth according to CDC physicians. Unattended syphilis can cause major problems and in few cases end in death.
Health officials say they're making headway against syphilis.
"We're on an upswing," Powers said. "Usually, 5 percent of cases of syphilis were men who have sex with men, but in December 2002, 20 percent of those reported were among men who have sex with men." Rates in the following months dropped back to 5 percent again.
Partnering together
Philip Wright, an outreach specialist with Body Positive in Phoenix, spends his days encouraging gay and bisexual men to get tested for sexually transmitted diseases. It has not made him optimistic that sexually transmitted diseases will be eradicated in the United States anytime soon.
"When I go out, I don't meet many men my age. Most of them are dead or dying," said Wright, 42, who is gay.
"HIV is a lost cause in the United States. The government doesn't want to deal with it. Communities don't want to deal with it."
Wright uses President Bush's recent State of the Union address as an example.
"The President promised to spend billions of dollars to reduce the spread of HIV in Africa. AIDS in Africa is not a gay person's disease," he said. "Bush would rather help straight people in Africa than the queers in the United States."
As a health educator, Wright is as frustrated with the government as he is with the way infected people behave.
"When people find out they have a (sexually transmitted disease), they go into slut mode and talk themselves into believing they're not infectious," he said.
"After they know (they're infected), they still don't practice safe sex," Wright said. "Their approach to life is to deal with consequences later."
Powers said he is convinced that the best answer is to provide quality screening programs and follow up with appropriate medications.
"We are less concerned with health education and with behavioral change because of time and budget constraints," he said.
"Before AIDS, 80 percent of syphilis cases were among men who have sex with men," he said. "Now, the rate is usually around 5 percent (because of screening and medicines)."
"I tell people that when they go to see their doctor, they should communicate what disease they may have been exposed to and what concerns they have. Otherwise, the doctor may just test for HIV, come up with a negative result, and give the person a clean bill of health," he said.
Medications, however, don't always provide a ready answer.
With the increase in the number of cases of gonorrhea, doctors are also seeing an increase in the number of cases that cannot be treated by the usual course of antibiotics, Powers said. Penicillin can no longer prescribed as a treatment because one out of five cases now resists this traditional treatment. Newer, more powerful drugs to treat gonorrhea are available, but resistance to these medications has been increasing during the past five years.
Powers also said Arizona doctors are concerned that Wyeth Pharmaceuticals stopped producing Suprax(r), the only CDC-recommended oral antibiotic to which syphilis has not developed significant resistance.
A careful man
Smith is in the midst of renovating his home in central Phoenix, a project involving a large amount of grout, paint and tile.
He has draped cloths over furniture and floors and taped the edges of the walls. He has laid out authentic saltillo tiles in a precise grid.
Every step is carefully planned and executed.
But when it comes to his personal life, Smith said he would rather rely on his instincts. As he approaches his 36th birthday, he no longer thinks he's invincible. But he's willing to take some risks in order to preserve the spontaneity of sex. He tries to screen men, he said, before deciding whether or not to use a condom.
"I talk to them and watch their body language. I attempt to discern whether I can believe what they say by speaking on a wide variety of topics," he said. "I determine if I can trust them to be honest with me. Then I ask them flat out if they are positive for HIV."
He knows that gay and bisexual men are not always honest about whether they have a sexually transmitted disease because if they admit it, it reduces their chances of having sex.
"I'm very aware every single time that this person could be lying to me, but I've done what I can," Smith said. "I have had several people tell me that they have lied to have someone touch them and to hold them and to meet their skin hunger kinds of needs. But I'm not taking a blood test in the screening process."
That attitude makes doctors shudder.
They fear that HIV will become a worse problem as the long-term effects of anti-viral medications become known. They worry that HIV may become resistant to the drugs that are now used to treat it.
Physicians now battling drug-resistant strains of gonorrhea wonder how long it will take before chlamydia follows suit. They wonder if an epidemic of syphilis among men who have sex with men is just around the corner.
At the moment, though, Smith can't ponder such fearsome questions. He has remodeling to do.
As the minutes of good sunlight tick away, he points out a single tile featuring a coyote paw print. It's a special tile he bought to lay amongst the rest on his new dining room floor. "It brings good luck," he said.
Reach the reporter at jeffery.hampl@asu.edu.
* The name has been changed to protect the individual's identity.
