Surrounded on three sides by water, the island-like city of San Francisco is often swathed in fog until late-morning.
But geography and weather are not the only thing that cut this Californian city off from mainland America. While religious conservatism has become mainstream in the four years of George W Bush’s rule, freedom of sexual expression is one of the city’s trademarks.
Almost a third of the city’s 790 000 residents are estimated to be gay or lesbian, and there is even a gay and lesbian chamber of commerce.
City historians say the gay community’s biggest boost came after the Second World War. Thousands of gay soldiers, many dishonourably discharged for homosexuality, rather than face disgrace in small town America chose to settle in the city already renowned for a relaxed attitude towards sex.

By the early 1950s, the first gay and lesbian rights organisations had been formed and have been a powerful force every since.
This is recognised by city officials. One of the first things mayor Gavin Newsom did after being sworn into office in January was to order city officials to start allowing gay couples to marry.
This was against the advice of key party officials, who feared that Newsom, the city’s youngest ever mayor and a rising Democrat star, might dent his image.
By the time California Governor Arnold Schwarzenegger muscled in and stopped them, city officials had married 3 955 couples in a few months.
The Castro district is gay central and on a Saturday night, crowds throng the streets, some stereotypical half naked leathermen, bearded “bears”, identically styled lesbian couples. Souvenir shops sell products adorned with pink triangles and rainbow flags. Bar stools spill over on to the pavements.
The following afternoon, the annual “leather festival” is held in the downtown area known as south of the market (Soma).
Parading in the warm autumn sun, the thousands of leather-clad devotees of sado-masochist sex – the vast majority gay men – joke and strike explicit poses. Even the public displays of (mainly heterosexual) couples whipping one another seems more amusing, even tame, than aggressive.

But the city’s open-minded approach to sexuality has been through some tough times. Almost 20 000 people have died of AIDS there since the early 1980s, and the fear and panic caused by the epidemic resulted in a massive anti-gay backlash.
This focused on the gay bathhouses and sex clubs, deemed by the city to be a “social menace to the public”. Many closed after a court ruled in 1984 that they could only remain open if monitored for unsafe sexual activities every 10 minutes.
Gay physician Dr John Stansell believes that the official response to AIDS was “highly emotional and largely based upon preconception and prejudice about gay men’s sexual lives”.
“The prevention messages were basically aimed at frightening gay men into not having
sex at all,” says Stansell, who heads what was Ward 86 at San Francisco General Hospital, one of the first AIDS clinics in the world, and today is known as the Positive Health Clinic.
“In the 1970s, the Castro was a vibrant, active place. But by 1982, it was empty. A mass depression settled over the gay community. There was huge fear of engaging in any kind of sexual activity,” says Stansell.
About 20 000 people are living with HIV/AIDS in the city itself and a further 9 000 in the Bay area surrounding the city. Their profile remains virtually unchanged since the first four AIDS cases were documented in 1980.
The vast majority are male (92%), gay (73%) and white (68%). An estimated 28% of the gay population is living with HIV.
Since 2002, reporting HIV infection (without using names) became a requirement in California, which enables accurate data.
New HIV infections peaked at almost 5000 in 1990, and two years later about 1 800 people were dying each year.
But 1997 was a watershed year. Access to triple therapy ‘€“ three antiretroviral drugs used in combination — had become more widespread, and the death rate plunged by two-thirds. Last year, 206 people died of AIDS-related illnesses, the lowest in 20 years.
Today the challenges are different. About 76% of the city’s HIV positive are on antiretroviral treatment, and many have been for a number of years.
“People tire of taking their medication,” says Stansell of his long-term patients. “I need constant engagement with my patients. I need to tell them how well they are.”
Long term patients also have other health problems, such as elevated cholesterol, liver and kidney problems and heart disease.
Two other problems dog Stansell’s patients. Many are co-infected with Hepatitis C and over a quarter regularly use the recreational drug, speed (methamphetamine).
“The danger of speed is that it removes sexual inhibitions and makes people want to have sex,” explains Jeff Sheehy, who has been living with HIV for more than a decade and is the mayor’s special advisor on HIV/AIDS.
Further complicating the epidemic of methamphetamine use is the fact that speed users are more likely to engage in unsafe sex. Speed use is a major risk factor for HIV sero-conversion in San Francisco at this time.

Interestingly enough, while San Francisco has one of the highest prevalences of heroin use in the U.S., the incidence of HIV seroconversion among opiate injection drug users is flat. Further, unlike speed users, narcotic drug users are no less adherent to their treatment than non-drug users.
“Heroin users know how to take drugs,” laughs Stansell.
As the threat of AIDS deaths has receded, San Francisco has started to regain its shine as the gay and lesbian capital of the US.

“There has been a reblooming of gay identity and community spirit. The new generation of young gay men who did not see their friends dying. They see HIV/AIDS is a manageable disease that can be treated,” says Sheehy.
But the removal of the fear factor also brought dangers. In 1999 and 2000, HIV infection started to rise sharply among young gay men precisely because they believed the virus was under control.
But, says James Loyce, who heads the city’s AIDS Office, this was a short-lived trend as the city and gay organisations managed to mobilise prevention efforts. Now new infections tend to occur disproportionately among African American and Latino men.
“What we have learnt over time is that the melting pot approach to HIV doesn’t work. Prevention strategies have to be specific to different communities,” says Loyce, a founder of the Black Coalition on AIDS back in the days when black communities assumed they were immune from the “gay white” disease.
“There is denial in the African American community about HIV and AIDS. There
is denial that people in our community are gay, denial that needles are used [for intravenous drugs], denial about unsafe sex. Previous prevention messages were never aimed at us,” says Loyce.
African Americans tend to distrust “white” hospitals and doctors, he says.
“In a recent survey, 43% of African American patients in San Francisco General Hospital believed they were given lesser treatment and experimented on by hospital staff, while only 9% of staff, probably African Americans, believed this was so,” says Loyce.
This distrust means that African Americans with HIV usually only seek treatment when they are very sick. This makes it more difficult to treat their HIV, and their life expectancy is lowest of all those living with the virus.
“We have to keep going back to different communities, identifying their leaders and trying to recruit them for the HIV prevention work we are doing,” says Loyce.
Stansell remains critical of prevention messages.

“The abstinence and condom use every time messages have failed. For a variety of reasons my patients largely don’t use condoms. Reasons include the belief that HIV is now a benign disease, mistaken beliefs about serostatus of partners and plain old ‘€˜responsibility fatigue’€™. Most reach a level of sexual risk taking that they feel comfortable with.’€
“But the federal government’s public health agencies are run by ideologues who cannot overcome their bigotry and homophobia,” says Stansell.
“What we need are explicit messages that list harm-reducing sexual activity such as: there is likely little risk to a positive person from engaging in unprotected sex with another HIV positive person, that oral sex poses less of a risk of transmission, that people with treated HIV and undetectable viral loads are probably less likely to spread disease and that strategic sexual positioning is likely to reduce transmission. Similarly, treatment for sexually transmitted infections reduces risk.’€
Although facing state and federal constraints, the city has managed to develop a sophisticated approach based not on the Centers for Disease Control and Prevention’s Abstain, Be Faithful and Condomise but on their own more complex ABC.
The city’s focus is on Adults and youth who are sexually active, Behavioural interventions and addressing Co-factors that affect HIV risk, including substance abuse, homelessness and mental health.
The spread of HIV via needles shared by intravenous drug users is now greatly reduced, thanks to needle exchange programmes throughout the city including in the basement garage of the city health department’s own offices.
The last record of the birth of an HIV positive baby was two years ago. There is no epidemic in non-drug using heterosexuals – the group where the virus is spreading fastest in the rest of the US. And early indications point to the rate of new infections stabilising in the gay community.

Loyce is also proud of the fact that no one is ever denied AIDS treatment.
“A person without health insurance may have to wait up to three weeks to see a doctor, but there is no waiting list in the city for access to treatment.”
But he is far from complacent. There are about 1 000 new infections each year, something the city aims to halve by 2008.

“We need to go where the people are, find out what they want and address all
the other factors that encourage the spread of HIV,” says Loyce.