Side Effects - New Yorker, May 2005

This week in the magazine and online, in "Higher Risk," Michael Specter writes about crystal methamphetamine and the rise of H.I.V. infections in the urban gay community. Here, with Daniel Cappello, he discusses the drug, its repercussions, and the recent "supervirus" scare.

DANIEL CAPPELLO: We have been hearing about crystal methamphetamine and its recreational use in certain gay populations since the nineteen-nineties. What is the crystal-meth problem, and is it worse now?

MICHAEL SPECTER: Crystal methamphetamine is a highly addictive stimulant, and it's a problem not only in the gay community but throughout the country. Its use is growing rapidly, in part because it is relatively easy to make and not nearly as expensive as cocaine. It's become a particular problem in some urban gay populations because it stimulates the libido while, at the same time, helping to reduce inhibitions. The result has been that many men who would never normally engage in unsafe sex do so when they are on crystal-and even if that happens only rarely, it greatly increases the potential spread of S.T.D.s like H.I.V. and aids and syphilis.

Do we know what biological effects the drug has on the human immunodeficiency virus, or its physiological impact on the immune system?
There are now several studies going on which attempt to answer that question. One thing seems to be clear: crystal use compromises the immune system, and for people with H.I.V. this is particularly dangerous. People who take the drug rarely eat while they are on it, which also has a negative impact on the immune system. And there is some evidence to suggest that it interferes with some people with H.I.V. keeping to the complicated schedule of pills that they need to take each day.

Is the correlation between the drug's use and increased instances of H.I.V. infection biological, then, or behavioral?

More behavioral. It clouds judgment, fuels the sex drive, and has been shown to make it less likely that people would use condoms or practice safe sex.
Crystal meth is thought of as a "gay drug" today, but was it always "gay"? What do you know of the history of its use in this country, from housewives to truck drivers, and how did it become "gay"?

No, it wasn't always gay, and it's not only gay now. During the Second World War, Air Force pilots (in the United States and Britain, but also Japanese kamikaze pilots) took the drug to stay alert, and it has often been said that Hitler was a speed addict. In America it was for a long time seen as a poor man's alternative to cocaine-a much cheaper stimulant. It became a gay party drug for obvious reasons: it keeps you up, gets you sexually excited, and often makes people feel good about themselves at first because it acts as an antidepressant. But it is also incredibly addictive.

You talked with several men who said they never had unprotected anal sex before starting crystal meth. Did they continue to engage in risky sex even after being off the drug, as a sort of side effect?

Yes, like a side effect. There are people who just don't practice safe sex; but most men I have spoken with do-or at least try to. The problem for many of them is that once in a while-maybe once a month or twice a year-they might take crystal, and that is when they aren't as cautious as usual. It may happen rarely, but when it does the chances of becoming infected with H.I.V. or syphilis or another S.T.D. are greatly increased.

How does crystal meth compare with other recreational drugs? What other drugs are popular among gay populations, and do they have similar effects on H.I.V. infection?

Well, there are many drugs that gay men-and everybody else, for that matter-use often. Cocaine, Ecstasy, and poppers are often used as "party drugs." No drug use is going to have a good effect on people who have compromised immune systems, which is the case with any H.I.V.-infected man or woman. But those that keep you up at great length and take away your drive to eat or drink seem to be especially dangerous. And, of those, crystal is the worst.

You report that recent surveys suggest that more than ten per cent of gay men in San Francisco and Los Angeles have used crystal meth in the past six months. In your interviews, did you get a sense from users that they understood the possible implications of the drug use?
Many do. Often they feel that they can do it once in a while-say, once a month or every few months. Kind of as a vacation from reality. And some do that, and have no problems. But because crystal is so addictive it's a dangerous game to play.

What about the Internet? What role is it playing in the increase in H.I.V. among gay men?

The Internet makes it easy for people to meet for sex, and men and women in every possible combination use it for that purpose. But when you combine crystal, which we know lowers inhibitions, with sex among men-at least some of whom are already infected with H.I.V. (including some who do not even know it)-the danger increases demonstrably.

You talk about how the "growing medicalization of America"-that is, America's increasing reliance on drugs as a panacea for health problems without regard to their possible consequences-might be contributing to H.I.V. complacency in the gay community. Is this the case?

My point is just that we take it for granted now that medicine plays a central-and, usually, a positive-role in the lives of many of us. Drugs for depression, high cholesterol, erectile dysfunction, and diabetes, just to name a few, have saved or improved millions of lives. That is perhaps nowhere more clear than with the antiretrovirals that have changed aids from a death sentence to a controllable disease. Yet, once people begin to feel that H.I.V. is not that dangerous, they also naturally let their guard down on issues like safe sex from time to time. And that creates a problem.

You report that after many years of decline the number of new H.I.V. diagnoses among gay men increased every year between 2000 and 2003, while remaining stable in the rest of the population. By what degree did it increase among gay men, and how significant is that increase epidemiologically?

The degree is large because the pool is small; that is, if ten more people get infected out of a thousand, that is one per cent, which is a significant problem. When you have an infectious disease that is spread sexually and one that lies latent for years, a small group of sexually active people can fuel a serious epidemic.

What about groups other than gays who are especially affected by H.I.V. and aids? According to the Centers for Disease Control, nearly half of the newly infected men are black. And you write about how the number of aids cases has remained high among minority women. Do we know what accounts for higher numbers among these groups?

Well, it's complicated but very serious. Most public-health messages about aids are general: stay negative, protect your partner, etc. Many of these messages need to be tailored more specifically to certain groups. Many black men are simply not in the system that receives these warnings, and it's become a very, very serious problem.

The New York City Department of Health has been criticized for being alarmist about the so-called superstrain of H.I.V. recently detected in a New York gay man, who now has aids. Much has been made of a new "supervirus." Was this case mishandled, or did it serve as a sort of wake-up call?
Maybe a little of both. You can't win if you are a public-health official when it comes to this sort of thing. In the early days of the epidemic, many officials were accused of staying silent or complacent too long while the virus circulated widely in the gay community. So this time they decided to get the word out quickly. I think, yes, they jumped the gun. But perhaps a scare that is unnecessary is better than silence.

What surprised you about the man in question in the "supervirus" case was his age. You write that you could understand naïve youngsters engaging in unsafe sex, but not a man of forty who had lived through the eighties' aids epidemic. Should we expect today's youth to be naïve, or very well informed? Aren't young gay men today better equipped with knowledge about H.I.V. and aids than forty-plus gay men were at the same age?
Many young men are well educated about aids and well equipped to protect themselves; many, however, are not. But, in either case, most twenty-year-olds I have met consider themselves immortal. They can't possibly imagine what it is like to have entire communities of gay men dying for years-and that is what happened in the eighties in New York and San Francisco, among other cities.

You report on some people who point to other problems that may be contributing to the rise of H.I.V. among gays, such as sustained anti-gay attitudes in the country, and feelings of guilt among H.I.V.-negative gays who have to "closet" their negative status. Are these contributing to the problem?
Absolutely. One of the clear problems with crystal is that people take it to feel better. And gay people in this country have had a horrible time of it lately. The Bush Administration is openly anti-gay, and in November millions of Americans voted to deny gay men and lesbians the right to live legally as married couples. There is no way that can't contribute to a sense of despair.
You have written extensively about the worldwide aids epidemic. Last year you reported on the aids crisis in Russia. How is the United States faring in the battle against H.I.V. and aids, and what does your recent reporting on the rise of H.I.V. in the gay community bode for this country?

In general we are doing far better. Yet we need to remember that education can't just stop and that money needs to be invested not only in treatment but prevention. It's a lesson we, unfortunately, have to learn again and again.
It seems we are fighting different aids and H.I.V. battles in different countries, and even within different populations of any given country. Given your knowledge of the subject, what is your greatest hope?

My greatest hope is that humans are capable of adapting and learning. But it's not easy-it requires commitment and time and money. No scientist can solve that problem; it's one for all of us.