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By the time Kevin Shancady walked into the Denver Department of Public Health to enroll in an HIV vaccine trial, he'd managed to put most of his fears behind him: fears of a government hostile to gay men, fears that researchers might inject volunteers with a dangerous vaccine. "So many people have died," he said, "and I feel an obligation to advance prevention research. I'm willing to take some risk. And if the vaccine works, then I'll have protection." It's that mix of optimism, altruism and hope for personal benefit that has made it possible for the National Institute of Allergy and Infectious Diseases (NIAID) to recruit over 4800 Americans into a cohort being readied for HIV vaccine trials. But what Kevin heard when he sat down with a study counselor shows why recruiting volunteers is just the first step on the long and difficult road of HIV vaccine testing. In the best tradition of public health, the study counselor warned him of the possible risks of trial participation. "He told me participants in this trial might not be able to join other vaccine trials," Kevin said, "and if a different vaccine is eventually developed later, it might not work as well in me as in people who had not been in one of these early vaccine studies. I felt blindsided, actually."

The Voluntary HIV-1 Counseling and Testing Efficacy Study was designed to measure the efficacy of HIV VCT in developing country and resource poor settings where access to antiretrovirals and other expensive medications is difficult or impossible.

There have been many reactions to the release of preliminary data suggesting a significant increase in HIV incidence in San Francisco. Many are alarmed, some are saddened, and more than a few have a great deal of anger. The one reaction nobody has had is surprise. While a few don’t like the numbers and will argue about the analysis of them, there has been little shock that there appears to be a range of 750 – 900 new infections this year. That the majority of these infections are occurring in men who have sex with men (MSM) is also not surprising to most observers of or members of the San Francisco gay community. The increase in numbers is based on several realities: The AIDS epidemic changed forever when new treatments were unveiled in Vancouver in 1996. The perception of AIDS as a death sentence, already suspect among many gay men, is gone. If people see HIV as a death sentence, they make certain choices about risk. We know that when the perception of HIV becomes one of a chronic, manageable illness, people make different choices. The perception of HIV has changed on the streets and in the minds of MSM. Most HIV prevention efforts have not caught up with that change. Prevention and health education efforts, which rely on death or danger-avoidance for motivation, may no longer resonate with gay men. Studies indicate that high risk sexual behavior is increasing among MSM in San Francisco. Another factor contributing to the higher estimate of HIV incidence is that the population of gay men in San Francisco is larger than was previously thought. Because of recently improved data collection, such as survey work done for the Gay Men’s Health Study and some groundbreaking work with homeless gay men in San Francisco, we now know that gay men comprise between 15-20% of the adult male population of San Francisco. This is a significant increase from the data available in 1997. In San Francisco, one can look at gay men’s communities as being divided into three distinct groups, all of whom need HIV prevention. The first group is those who have eliminated high-risk behavior from their lives. These people have a thorough knowledge of HIV transmission and risk reduction techniques. They have chosen to eliminate risk based on personal decisions about their risk and need. Despite many years of risk reduction education and media, a second group of people have engaged in high-risk behavior throughout the epidemic. This has not changed. For these men, decisions about perceived risk are outweighed by their needs for identity, intimacy, pleasure, or other considerations. They know about risk, have made choices, and engage in behavior at the level of risk that they believe to be appropriate. A third group of MSM has increased their risk behavior recently. This group makes situational decisions about risk behavior. These decisions are based on their knowledge 3 and understanding of HIV transmission, the perceived risk of the behavior in question, and the stated or presumed HIV status of their partner. For nearly 20 years, we have conducted HIV prevention and education based on several theories, including cognitive learning theory. However, there are many issues that mediate people’s risk assessment and behavior. The behaviors in questions are basic, often urgent, and engaged in without complex cognitive analysis. A brochure can be informative on Tuesday morning; in a moment of intense passion on Friday night, a different analysis occurs. Substance use before and during sex is also a factor. Additionally, for some individuals chronic loneliness, isolation, and alienation lead to remedies, which may include highrisk behavior. The pursuit of pleasure in a society where discrimination can make life painful can be another motivation for pre-cognitive, high-risk behavior. There are many complicated and compelling reasons why a person chooses his own acceptable level of risk. In the era of HAART (highly active anti-retroviral therapy), many men make an assessment based on their firm belief that living with HIV is an acceptable option. Others make a determination about the potential for transmission from a given partner based on information (or perception) about his HIV status or viral load. The fact is, there is an increase in risk behavior amongst MSM in San Francisco. The AIDS epidemic has entered a new and complex era. It is time for prevention efforts to be based on these new realities. In the next section, we will outline an 11-point Action Plan to revitalize the HIV prevention programs of the City and County of San Francisco. No increase in HIV infections is acceptable, regardless of the reason. This new plan will allow us to break this epidemic by realistically equipping MSM to take control of their health.