Like many in his generation, Bill Yakamura is building a career after a recent layoff. Dismissed from his corporate development job, he hunts for work during the week and on weekends helps his partner remodel the house they share. He has something else in common with other young men in his circle: Yakamura, at the tender age of 30, is HIV positive.

An AIDS educator in high school and chairperson of World AIDS Day in college, Yakamura (not his real name) thought he knew enough about HIV to make him invincible. And that's how he got the virus.

After he moved to San Francisco in 1997, his well-worn prescription for safer sex yielded to a stronger desire to play the odds. "I had multiple sex partners and multiple opportunities for infection," he says. "I was convincing myself that the way I was having sex wasn't risky. I had a basic understanding of biology, and I was pushing the envelope by telling myself I could have anal sex without a condom" under certain circumstances. "Of course, that's very naïve, assuming that accidents aren't going to happen."

Bolstering his sense of invulnerability, Yakamura twice tested HIV negative during that time. Then in October 2000, his test results came back positive.

"Of course I was shocked, but doing what I was doing I was always somehow expecting a positive result," he says.

Yakamura fits the profile of the young gay man everyone concerned with AIDS has been talking about since the Centers for Disease Control and Prevention (CDC) dropped this bombshell: Men in their 20s are now acquiring HIV at a rate rivaling the explosive first years of the epidemic.

In a study of nearly 3,000 gay and bisexual men ages 23 to 29, the CDC found that 4.4 percent acquire the virus each year, almost double the rate of a decade ago. And the most devastating trend is among young African-American gay and bisexual men -- 14.7 percent, or one in seven, become HIV positive each year. Those rates, the CDC says, are close to the current infection rates in South Africa, where about one in five adults has HIV.

"The worst part is the magnitude of the numbers, particularly among African-American men. They are the astounding numbers," says Tom Coates, former director of the AIDS Research Institute at the University of California at San Francisco. "This is what we've been warning about. We've been screaming about it, and nobody's taken notice."

Coates and others warned of the trend years ago, basing their prognostications on the HIV infection rate in San Francisco. In 2000, Coates predicted that San Francisco's wave of new infections -- which nearly tripled in two years, going from 1.3 percent to 3.7 -- was a harbinger for the rest of the nation.

In many ways those fighting AIDS are victims of their own success: The 1990s saw advances in treatments which help extend the lives of those with the disease. The drugs that have sustained life and relatively good health for people with HIV have made getting the virus seem not so bad. And in many ways it isn't, compared to the dark early days of the epidemic, when whole circles of friends perished horribly and people stuffed scrapbooks with their friends' and lovers' death notices. While these new treatments led to an 8 percent decrease in AIDS deaths from 2000 to 2004, they also saw AIDS diagnoses increase 11 percent from 2001 through 2005.

The epidemic officially began on June 5, 1981, when the CDC's Morbidity and Mortality Weekly Report detailed a rare and sometimes fatal lung disease that struck five young gay men living in Los Angeles. That was the first foreboding glimmer of the opportunistic infections associated with AIDS. Since then, more than 25 million people worldwide have died of AIDS, over 565,927 in the United States. More than 33 million people -- most in the Third World -- are infected with the virus. In the United States, 1,106,400 people are living with HIV.

While the death rate dropped precipitously in the United States in the mid-1990s after protease inhibitors were introduced, there are signs that people with HIV are living on borrowed time. For some, it takes dozens of pills a day to keep the virus at bay. Long exposures to the mix of antivirals and protease inhibitors known as "drug cocktails" can lead to debilitating bouts of diarrhea, nausea, fatigue, osteoporosis and depression.

Some people lose fat in their faces and limbs only to have it reappear in disfiguring amounts on their upper backs or stomachs, a condition known as lipodystrophy, or "protease paunch" and "buffalo hump." Along with lipodystrophy comes an increase in LDL cholesterol (the bad kind) and a decrease in HDL cholesterol (the good kind), leading to early heart disease for many young people on protease regimens.

Yet young men like Yakamura, who has never seen anyone sicken and die from AIDS, accept the disease as something that can be treated and managed, much like diabetes. He's taking drugs to slow the growth of the virus and has experienced no symptoms or side effects. "I've met a handful of people with HIV here in San Francisco," he says, "and they seem very healthy. Here I developed an attitude that AIDS is manageable, and I wasn't afraid of it. It's great that it's manageable for [my generation], although I don't want it, and I'd get rid of it if I could."

Theories abound about why a second generation of young men -- exposed to all the information that's available about how to stay safe -- is getting the virus at such an alarming rate. Most gay men know precisely what they need to know: use condoms during anal sex; oral sex is less risky, but HIV has been transmitted via unprotected oral sex. But many figure they can dodge the virus without using condoms every time, and as the lines blur in the safer-sex rule book, there's greater opportunity to make a mistake.

"People shouldn't assume that knowledge is enough," says Coates, who at 61 has been living with HIV since the early 1980s. "It's not enough to make people stop smoking, it's not enough to make them wear seat belts or lose weight. This is more complicated, because it has to do with the act of love."

And, as many other gay men note, constant vigilance is tiring. There's a "fatigue factor" that settles over many gay and bisexual men as they ponder having safe sex over a lifetime. "It's hard to maintain perfection. It takes one slip, and you've got it for life," says Coates.

Gay men know that HIV remains a serious and often deadly disease, notes Brian Byrnes prevention director of the San Francisco AIDS Foundation. "What happens over time is that the risk-benefit ratio shifts for guys, and they employ different strategies over time," Byrnes says. "They're trying to have their needs met -- emotional, psychological, physical -- and often they believe they're making the best decision at the time, and in retrospect, they weren't."

Byrnes says the new numbers are screaming the need for more prevention programs. "You have to match the epidemic of HIV with epidemic proportions of prevention work," he says. The CDC provides close to $500 million to state and local prevention and surveillance programs targeting the people at highest risk of HIV infection, but Coates said he's surprised the infection rate statistic for young African American men didn't convince the agency to declare a national emergency. "They're great at counting the bodies," Coates says, "but let's decide what we're going to do."

In the meantime, Yakamura is having a harder time finding a job in the corporate world than he is coping with having HIV. He's in an HIV support group, and unlike some in his group, he's not consumed by the virus. He's thrown himself into painting, remodeling, and doing home maintenance, he says -- not dwelling on HIV.

-- Elaine Herscher is a senior editor at Consumer Health Interactive and a former reporter covering gay and health issues at the San Francisco Chronicle.

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Last updated February 28, 2008
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