旧金山是如何减少艾滋病感染的

亚博全站APP登录官网，亚博全站官网登录平台，亚博全站最新版app下载|It wasn’t his first broken condom, so Rafael didn’t worry. But three weeks later, the man he’d met in a bar called to say that he had “probably been exposed” to H.I.V.拉斐尔不是头一回遇上保险套斩了这种事，所以一点儿也没有放在心上。但三个礼拜后，他在酒吧遇上的那人打电话来说，他“有可能认识到了”艾滋病病毒。Rafael, a muscular, affable 43-year-old, went to a clinic and within 45 minutes learned he was infected. Although it was already closing time, a counselor saw him immediately and offered him a doctor’s appointment the next day.43岁的拉斐尔是为人友好的肌肉猛男。

他去了一家医院，过了45分钟获知自己显然被病毒感染了。尽管当时早已是下班时间，一名顾问立刻跟他碰头，并立刻为其购票了第二天的医生看诊。At Ward 86, the famous H.I.V. unit at San Francisco General Hospital, the doctor handed him pills for five days and a prescription for more. Because he was between jobs, she introduced him to a counselor who helped him file for public health insurance covering his $30,000-a-year treatment.在旧金山市综合医院(San Francisco General Hospital)知名的86号H.I.V.病区(Ward 86)，医生给了他五天的药量，又为他进了处方好让他可以购买更加多药。

因为他继续赋闲在家，这名大夫将他讲解给了一名顾问，后者协助他申请人了一份公共医疗保险，每年缺席3万美元的治疗费。“They were very reassuring and very helpful,” said Rafael, who, like several other men interviewed for this article, spoke on condition that only his first name be used to protect his privacy. “They gave me the beautiful opportunity to just concentrate on my health.”“他们很拜托，这让我深感宽慰，”拉斐尔说道。

出于隐私考量，他与本文其他几位拒绝接受专访的男性都坚决仅有以姓氏有别。“他们获取给我一个很好的机会，让我需要仅有心专心于自己的身体健康。”Despite bad luck in sex-with-strangers roulette, Rafael did have some good fortune: He lives in San Francisco, which is turning the tide against H.I.V. and serving as a model for other cities. The city that was once the epidemic’s ground zero now has only a few hundred new cases a year, the result of a raft of creative programs that have sent infection rates plummeting.尽管在一夜情的轮盘赌博中撞到上霉运，但拉斐尔也有幸运地之处：他住在旧金山，这是一座挽回了预防艾滋病颓势、至诚其他城市效仿的楷模城市。这里曾多次是艾滋病的重灾区，好在实行了一系列富裕创新的方案，感染率急遽减少，现在这里每年只有几百例新的病例。

“I love the San Francisco model,” said Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases. “If it keeps doing what it is doing, I have a strong feeling that they will be successful at ending the epidemic as we know it. Not every last case — we’ll never get there — but the overall epidemic. And then there’s no excuse for everyone not doing it.”“我大爱旧金山市的这个模式，”美国国家过敏症及传染病研究所(National Institute of Allergy and Infectious Diseases)所长安东尼·S·福西(Anthony S. Fauci)博士说道。“如果坚决目前的作法，我深信他们一定能顺利地落幕现在的疫情。我不是说道这样就能避免所有的病例——难道我们总有一天也做到将近这一点，但大体上歼灭疫情是几乎有可能做的。

没理由不这么做到。”Last week, the World Health Organization essentially agreed. Issuing new guidelines for the treatment and prevention of H.I.V., the agency called on the rest of the world to do much of what San Francisco is already doing: Every H.I.V. patient should start antiretroviral drugs as soon as they test positive rather than waiting for measures of immune system strength to drop, the agency said, and everyone at risk of infection should be offered preventive drugs. San Francisco adopted the first practice — “test and treat” — five years ago and the second in 2013. It has bolstered those efforts with others, like the rapid-doctor’s-appointment program that swept Rafael in, and another to track difficult patients.上周，世界卫生组织(World Health Organization, W.H.O.)对旧金山模式回应了基本的赞成。

该机构印发了新的H.I.V.预防指南，敦促世界其他地区以旧金山为榜样：一旦H.I.V.检测呈阳性，患者就应当尽早开始服用外用逆转录病毒药物，而不是等到免疫系统功能指标衰落后再行化疗；此外，该机构还认为，应当向所有高危人群获取预防性药物。5年前，旧金山市早已首度实践中了上面的第一条——“检测即化疗”，2013年又实行了第二条。这又造就了其他的一些措施，比如购票医生的快速通道、追踪较为困难的患者等，拉斐尔正是获益于前者。The results have been striking. Last year, San Francisco had only 302 new H.I.V. diagnoses, the lowest recorded number. In 1992, at the epidemic’s peak, there were 2,332.这些措施效益难以置信。

去年，旧金山市仅有追加了302事例H.I.V.发病病历，创历史新高。而在疫情最相当严重的1992年，曾约2332事例。

In 1992, the city had 1,641 deaths from AIDS. Last year, just 177 San Franciscans with H.I.V. died, and most of them actually succumbed to heart disease, cancer or other old-age ills, said Dr. Susan Buchbinder, the head of H.I.V. prevention research for the city health department.1992年，该市有1641人杀于艾滋病。到了去年，只有177名艾滋病病毒感染者丧生，而且其中大多数实质上是病死心脏病、癌症或其他老年病，旧金山市卫生部H.I.V.防治研究的负责人苏珊·布赫宾德(Susan Buchbinder)博士如是说。By other measures, too, San Francisco is ahead. According to a 2012 estimate by the Centers for Disease Control and Prevention, only 39 percent of all infected Americans had seen an H.I.V. doctor, and only 30 percent were taking their pills consistently enough to be “virally suppressed,” meaning they were not infectious. By contrast, in San Francisco, 82 percent of residents with H.I.V. were in care, and 72 percent were suppressed. In Ward 86 — all of whose patients are uninsured or on public assistance — suppression has reached 84 percent.用其他指标取决于，旧金山市某种程度居住于领先地位。

美国疾病掌控和防治中心(Centers for Disease Control and Prevention, C.D.C.)2012年估算，在所有受到H.I.V.病毒感染的美国人中，只有39%曾到专科医生处就医，只有30%能坚决服药以后超过“病毒诱导”（此时他们仍然具备传染性）。相比之下，在旧金山的居民中，82%的H.I.V.感染者都拒绝接受了化疗，72%超过了“病毒诱导”状态。

86号病区中的患者要么没医疗保险，要么依赖公共救济过活，但他们中的抑制率也已超过了84%。San Francisco has some natural advantages: wealth, political leaders who consistently back the fight — in part because the gay vote is so big — and a close-knit medical community in which many of the top officials in the fight against H.I.V. have studied together, trained each other and done research projects together through the University of California, San Francisco.旧金山市不具备一些天然的优势：有钱人、一贯力挺抗H.I.V.斗争的政治领导人（他们这么做到的部分原因是因为同性恋者人群是众多票仓）、密切合作的医学界。

许多外用艾领域的高官都曾在加州大学旧金山分校(University of California, San Francisco)一起自学、培训，并共同完成研究项目。Because of the tech boom, City Hall’s budget grew from $5 billion to nearly $9 billion in 10 years. For patients not eligible for federal or state aid, the city has its own health insurance: Healthy San Francisco. And it has been able to counter every cut in federal AIDS funds.利用科技兴旺的东风，10年之内，市政厅的财政预算从50亿美元快速增长到了近90亿美元。对于无法取得联邦或州府医保救助的患者，该市获取了自己的医保计划：身体健康旧金山(Healthy San Francisco)计划。目前它已不足以应付联邦政府AIDS基金的缩减。

“One of my first budget questions is always, ‘Are they cutting our Ryan White money again?’ ” Mayor Edwin M. Lee said in an interview, referring to the 1990 law that pays for AIDS drugs. “Since 2011, we’ve backfilled more than $20 million — with very little debate.”“我面对的最重要的支出问题一直是：‘按照瑞安·怀特法案（Ryan White，瑞安·怀特是美国抗击艾滋病和避免艾滋病种族歧视的标志性人物，1990年他去世之后，美国国会通过了美国仅次于的针对艾滋病患者及携带者的免费化疗法案——学术著作）我们应当获得的经费是不是又被斧头了？’ ”市长李孟贤(Edwin M. Lee)在拒绝接受专访时说。“2011年以来，我们顶替了2000多万美元的资金遗缺——完全没引起什么争议。

”Wealth also eases the burden in a harsher way: Soaring rents have driven out many poor residents. Two-thirds of San Francisco’s infected are white or Asian; nationally, 63 percent are black or Hispanic. Older, wealthier, openly gay white men are more likely to be insured and well-informed about risks than young black and Hispanic men, the epidemic’s fastest-growing subgroup.与此同时，金钱也在以一种更加残忍的方式减低该市的开销：攀升的房租令其许多贫穷居民被迫离开了此地。旧金山三分之二的H.I.V.感染者是白人或亚洲人。

而纵观整个美国，63%的感染者是黑人或西裔美国人。与年长黑人和西裔男性这个疫情快速增长最慢的人口亚群比起，年龄较小、更为富足、且早已出柜的白人同性恋者男性享有保险的可能性更高，对各种风险理解得也更为充份。But the city’s chief strength has been a willingness to go first, to rapidly adopt tactics that work in pilot projects or clinical trials, before they are endorsed by public health organizations like the C.D.C. and the W.H.O.但该市仅次于的优势之源是不愿先行一步，在C.D.C.和W.H.O.这样的公共卫生机构接纳之前，就很快应用于那些在试点项目或临床试验中有效地的策略。In 1983, the city opened the first dedicated AIDS ward. In 1987, it tested the first antiretroviral drug, AZT. In 1992, it began distributing clean needles to drug addicts.1983年，该市开办了第一个艾滋病专用病房。

1987年，它试用了第一种外用逆转录病毒药物AZT（砌氮胸苷）。1992年，它开始向瘾君子们发给洁净的针头。

In 2010, it adopted “test-and-treat” — antiretroviral drugs given as soon as a patient tested positive. In 2013, it started the preventive drug program, PrEP — pre-exposure prophylaxis with Truvada, a two-drug pill — at no charge to the uninsured. By some estimates, 15 percent of the city’s gay men are now taking Truvada.2010年，该市实行了“检测即化疗(test-and-treat)”策略，只要患者的检测呈阳性即尽早给与外用逆转录病毒药物化疗。2013年，它开始实行防治用药方案，即用于特鲁瓦约（Truvada，一种外用逆转录病毒药物，主要成分为恩去他滨和提诺福韦——学术著作）为无医保人群免费获取曝露前防治(PrEP)。

据估计，该市的男同性恋中有15%正在服用特鲁瓦约。Numerous recent studies have shown that people taking antiretroviral therapy every day not only live longer, but also have so little circulating virus that they are highly unlikely to infect others even through unprotected sex.近期的众多研究表明，每天拒绝接受外用逆转录病毒治疗者不仅寿命更长，其循环系统中的病毒也很少，即使再次发生了无维护的性行为，传染他人的可能性也较小。But the shift to immediate drug treatment was a struggle. Dr. Grant Colfax, who was then the city’s director of H.I.V. prevention, met resistance from doctors arguing that drug side effects were too harsh to begin immediately and that patients not yet motivated by brushes with death might take medicines carelessly and develop resistant strains.然而，将预防策略改变为立刻上药依然困难重重。

该市H.I.V.防治部门的负责人格兰特·科尔法克斯(Grant Colfax)博士遇上了来自医生们的阻力，他们赞成的理由是：药物的副作用过于得意，不合适实行找到后立刻化疗的原则；一部分并未深感死亡威胁的患者化疗的积极性不低，很有可能不只想服药，以致因此产生耐药性病毒株。Community groups were also angry. Many had lucrative city contracts to hand out condoms and advice, which the city rewrote to require they do tests and provide medical care.社区团体也不高兴。之前许多社团都跟市政签定了利润可观的合约，负责管理发给安全套和宣传外用艾指南。根据该市新的草拟的新指南，他们还必须帮助展开检测，并获取医疗服务。

“We were accused of ‘medicalizing H.I.V.,’ ” Dr. Colfax said. “Which I found ironic.” But the new-infection rate had not budged for 11 years. “We couldn’t keep doing the same old thing,” he said.“别人谴责我们‘对H.I.V.过度医疗化’，“科尔法克斯博士说道。“这让我觉得很有嘲讽意味。”新的放感染率11年未变过。

“我们无法再继续过去的作法了，”他说道。He persisted, and won.他坚决了下来，并获得了胜利。

To identify infected people, the city increased testing and created a program called Rapid, the one that helped Rafael: It guarantees a quick doctor’s visit, with cab fare to get there if necessary, and help finding insurance.为了筛选感染者，该市强化了检测力度，并创立了快速通道（Rapid program），保证不受感染者可以尽早获得医生的看诊（如有适当，甚至还缺席去医院的出租车费），并协助他们取得医疗保险。拉斐尔就是该方案的受益者之一。

The Magnet Clinic, where Rafael was diagnosed, did 9,600 H.I.V. tests last year. It lies in the heart of the Castro, the city’s rainbow-flag-bedecked gay mecca, and resembles a cheery cellphone store: The waiting room has couches, flowers, disco music and photographs of the Sisters of Perpetual Indulgence, a campy drag troupe. A mobile of smiling penis toys dangled over one examination table.为拉斐尔临床的磁铁医院(Magnet Clinic)去年展开了9600事例H.I.V.检测。这家医院坐落于在旧金山市贴满了彩虹旗的同性恋者圣地——卡斯特罗街区(Castro)的中心地带，外观就像一个流畅的手机店：候诊区里另设沙发、鲜花、迪斯科音乐和“无尽耽溺姐妹”（Sisters of Perpetual Indulgence，一个男扮女装的同性恋者剧团——学术著作）的照片。在检查台上方，还挂着一些具有微笑表情的阴茎玩具。“We didn’t want it to feel like a jail cell,” said the nursing director, Pierre-Cedric Crouch, wearing the clinic’s signature “No Blame/No Shame” T-shirt. “And we have no stigma. You can come in saying you just slept with 20 guys and don’t know what a condom is, and we don’t criticize you. We help you out.”“我们想让人实在这里看起来牢房，”护理部主任皮埃尔-里斯德里克·克劳奇(Pierre-Cedric Crouch)身穿医院标志性的“不责备/不后悔(No Blame/No Shame)”T恤说。

“我们这里不做到评判。你走出来说你跟20个男人读过床，而且从知道安全套为何物，我们也会责难你。我们只获取协助。”Magnet’s social workers will enroll patients in insurance or, if they have coverage, fight to make sure it covers what they need.磁铁医院的社工会动员患者参与保险，如果他们早已参保，则不会谋求保证它可以缺席他们的所需支出。

Jayne Gagliano, the benefits manager, said she regularly had to explain to out-of-state insurers that using Truvada to prevent infection was, in fact, F.D.A.-approved.福利经理杰恩·特利亚诺(Jayne Gagliano)说道自己常常必须向外州的保险公司说明用于特鲁瓦约防治H.I.V.病毒感染实质上早已经过了美国食品和药品监督管理局(Food and Drug Administration, F.D.A.)的审核。“The fragmented American insurance system is one of our biggest obstacles,” said Dr. Diane V. Havlir, the chief of the H.I.V. division at San Francisco General, who has seen patients stop taking their pills because of coverage lapses.“支离破碎的美国保险体制是我们仅次于的障碍之一，”旧金山市综合医院H.I.V.部门的负责人黛安娜·V·哈夫利尔(Diane V. Havlir)博士说，她曾亲眼目睹一些患者因为医保缺席问题而不得不戒断。East of the Castro is the Tenderloin — a grim neighborhood peppered with single-room-occupancy hotels, homeless shelters and liquor stores. More than a quarter of the city’s homeless are gay or transgender, and many are found here. Some trade sex for drugs or a place to sleep, and end up infected.卡斯特罗区的东面是田德隆，一个弥漫着单身公寓旅馆、无家可归者收容所和酒类专卖店的可怕街区。这个城市中多达四分之一的无家可归者是同性恋者或变性人，其中许多人都生活在这里。

有的人用性来互相交换毒品或迁来地，结果病毒感染了H.I.V.。Four years ago, San Francisco created Linkage into Care teams — Lincs for short — to track such patients.四年前，旧金山市创立了同步护理团队（Linkage into Care teams，全称Lincs）来跟踪这类患者。In 2012-13, Lincs “navigators” searched for 315 missing H.I.V. patients and enrolled 116 of them — the rest were not found, or were jailed, dead or refused help. Navigators call and text patients, visit them and even escort them to doctors.2012-13年间，Lincs的“领航员”对315名下落不明的H.I.V.患者进行了搜索，并将其中116人划入了医护项目，其余的人要么是没有寻找，要么是早已丧生或被关在了监狱，也有的拒绝接受协助。“领航员”们给患者们打电话、发短信、探望他们，甚至陪伴他们去看医生。

Some 73 percent of the Lincs patients stayed in care, and they were twice as likely to be virally suppressed as similar patients who were not in Lincs.在Lincs的患者中有大约73%坚决了化疗，且超过病毒诱导状态的可能性是出于类似于状况的非Lincs患者的两倍。Recently, Erin Antunez, a Lincs navigator, spent her day focused on three: a young man released from jail that morning, a drug injector living in a Market Street hotel, and a 36-year-old mother staying in a former AIDS hospice.不久前的一天，Lincs的一名“领航员”埃琳·安图内斯(Erin Antunez)在当天的工作主要环绕着三个人进行：一名当天上午刚刚从监狱释放出的年长男子，一个住在市场街旅馆里的瘾君子，还有一个是生活在曾多次的AIDS安养院的一位36岁母亲。The former prisoner “was not a big red flag,” she said. He usually took his pills and had a clinic appointment that afternoon.那个刑满释放人员“不是什么大问题”，安图内斯女士说道。

他常常发给药物，而且还购票在当天下午拒绝接受医疗。The drug user often disappeared. He recently had texted her: “Where can I get an abscess drained without all the red tape?” but then had not answered several messages.瘾君子常常玩游戏下落不明。前一阵子他还发短信回答她：“在哪儿做到脓肿竖井可以不必承受那些困难的繁文缛节？”她给他放了若干消息，但之后就杳无回音了。

“A lot of this work is ‘Where’s Waldo?’ ” Ms. Antunez said.安图内斯女士说道：“我的工作有很多时候都看起来在玩《沃尔多在哪里？》（‘Where’s Waldo?’，由英国插画家Martin Handford创作的一套儿童书籍，读者必须在人山人海的图片中找到沃尔多——学术著作）”Her first visit was to the Maitri Hospice, a haven on a residential block. Founded, according to its website, by a “drug-addled drag queen turned Zen master,” it has a Buddha and origami cranes for décor, and separate smoking porches for tobacco and medical marijuana.这一天，她首先前往某住宅区一家取名为Maitri 临终关怀中心(Maitri Hospice)的安养院。网站讲解其创办者“原本是个酗酒上瘾的男扮女装者，后来沦为禅宗大师”。安养院里装饰着佛像和纸鹤，还另设独立国家的吸烟者门廊以供吸烟者和医用大麻。

The young mother was not dying, although she had survived two types of AIDS-related pneumonia.她要探望的这位年长母亲并无性命之忧，不过之前熬过了两种有所不同的AIDS涉及肺炎。Rather, she “just needed a break,” Ms. Antunez said, from methamphetamine binges in her housing project, during which she slept on any free couch and neglected her pills.更加清楚地说道，她“只是必须从她住处的甲基苯丙胺狂欢节中逃脱，只想睡觉一下”，因为她不能随意去找张空沙发睡，几乎忽视了出院这件事。

Today, she was waiting in a turquoise tank top, floral shorts and a white Tilley hat, ready to ride a city bus to Ward 86.她今天穿上了绿松石色的背心和印花短裤，还戴着了一顶白色的Tilley帽子，于是以等着搭乘城市公交车前往86号病区。Ms. Antunez asked about her new tattoos. Deeply shy, the woman focused on her phone and mumbled childlike answers — until she mistakenly thought a reporter was a supervisor assessing Ms. Antunez, and leapt to her defense: “Erin is great! You can tell some people don’t want much to do with you, but she knocks on doors, she calls me, we play phone tag.”安图内斯女士问道她的新纹身。她很喜欢，仍然看著手机，喃喃地诉说着孩子般天知道答案，直到她误以为记者是来评估安图内斯女士工作的主管，一下子跳跃了一起，为她申辩道：“埃琳有趣！你看出有些人只不过并不心甘情愿想要跟你扯上关系。但她来敲打我的门，打电话给我，我们还一起玩游戏电话捉迷藏的游戏。

”Ms. Antunez’s afternoon client was not in his room at the Donnelly Hotel although she knocked loudly in case he was in a stupor.然而，安图内斯女士下午要造访的客户却没待在唐纳利酒店(Donnelly Hotel)他的房间里。她大声地敲打他的房门，害怕他是昏过去了。

A manager said he had “shown everyone his abscess” and then left.酒店经理说道他“向所有人展出他身上的脓肿”，然后就回头了。Worried that he would lance his own abscess, she checked restricted databases that Lincs has access to, including all public clinic visitors and all H.I.V. tests ordered.安图内斯女士很担忧他不会自己去滚脓肿，于是她利用Lincs的权限采访了数个数据库，查阅了公共门诊的所有就诊者和已决定好的所有H.I.V.检测。They revealed that her ex-prisoner and the drug user had seen doctors that afternoon. “Yeah!” she cried, waving her fists and doing a dance in her chair. “That’s a good navigation day.”结果显示，她负责管理的那个刑满释放者和瘾君子在那天下午都拒绝接受过医生诊查。

“好极了！”她手持着拳头大喊，在椅子上手舞足蹈。“感叹成功的一天”。

In 2013, shortly after the Food and Drug Administration approved the use of Truvada to prevent H.I.V. infection San Francisco started offering it to everyone at risk. Some gay men called others “Truvada whores” for avoiding condoms.2013年，就在F.D.A.批准后用于特鲁瓦约防治H.I.V.病毒感染后旋即，旧金山市开始向整个高危人群获取这种药物。有些男同性恋者管服用了特鲁瓦约就不用于安全套的人叫“特鲁瓦约男娼(Truvada whores)”。

The backlash has mostly faded, said Dr. Bradley C. Hare, the director of H.I.V. for Kaiser, which also offered PrEP early. The first adopters, he said, “were the equivalent of the people who camp outside the Apple store for the latest iPhones.” Now a “second wave” has emerged, he said. “It’s people who needed a little more education but now say, ‘My friend is using it, and I’m doing the same things he’s doing, so ...’ ”凯萨医疗机构(Kaiser)也是最先获取防治药物的的组织之一，其H.I.V.部门的负责人布拉德利·C·黑尔(Bradley C. Hare)博士说道：抵触情绪基本早已消失了。他将首先尝试防治药物者“比作在苹果零售店外面半夜排队等着卖最新款iPhone手机的人”。

如今，“第二次浪潮”早已经常出现，他说道。“这些人必须更好的教育，现在他们再一意识到：‘我的朋友正在用于它，既然我们总是在做到某种程度的事情，那么……’ ”Dr. Lisa Capaldini, a popular doctor in the Castro, said she was “still ambivalent” about PrEP. Avoiding condoms, she said “makes it a Trojan horse for syphilis and gonorrhea, so if I had an 18-year-old gay son, I’d say, ‘I’d rather you used condoms.’ ”在卡斯特罗区颇受欢迎的医生莉莎·卡帕尔迪尼(Lisa Capaldini)博士说道自己对预防药的态度“仍摇摆不定”。因为很多人服用预防药后就不用于安全套了，她指出“这就像特洛伊木马一样给了梅毒和淋病可趁之机。所以如果我有一个18岁的同性恋者儿子，我会对他说道：‘我宁愿你用于安全套’。

”Dr. Buchbinder, of the health department, disagreed, saying, “Denying PrEP to patients because they might have unsafe sex makes about as much sense as our colleagues who treat high cholesterol denying statins to theirs because they might eat more ice cream.”卫生部的布赫宾德博士回应了有所不同意见，她说道：“因为担忧患者不会再次发生不安全性的性行为就拒绝接受对其应用于预防药，就像化疗低胆固醇症的同行因为害怕患者有了他汀类药物后不会抓起不吃冰淇淋而不愿给他们开药一样。”A recent study of the first 657 Kaiser patients on PrEP found that their condom use had indeed gone down and more had caught venereal diseases — but in two years, not one had caught H.I.V.最近的一项研究实地考察了Kaiser的前657名拒绝接受防治药物的患者，找到他们的安全套使用率确实上升，且更容易患上性病——但两年内这些人中无一病毒感染H.I.V.。Stephen, a slim, soft-spoken 24-year-old Chicago native, just got on Truvada. He delayed for a year, he said, until he found a job with health insurance. He had been on his parents’ policy and feared their seeing the prescription. They are conservative Roman Catholics who know he is gay but dislike it. “My father offered to buy me hookers,” he said, shaking his head.斯蒂芬(Stephen)是一个24岁的芝加哥小伙子，身型薄弱，说出轻声细语，他刚刚开始用特鲁瓦约。

他被迫延期一年用药是因为他必须再行寻找一份带上医疗保险的工作。之前，他的保险附带在他父母的保单上，他生怕他们不会找到特鲁瓦约的处方。

他的父母都是激进的天主教徒，告诉他是同性恋者后十分反感。“我的父亲甚至给我钱让我去招妓，”他摇着头说道。Stephen first heard of the drug through a gay student group at his Catholic college. “But my friend said it means you’re super-slutty, that it’s for people who bareback, or go into dark rooms for sex,” he said. “I didn’t want to associate with it.”斯蒂芬第一次听闻这种药是在他所在的天主教学院的同性恋者学生社团里。

“我的朋友说道，这种药是给那些超级放纵、调情不戴着套或者一有机会就钻入小黑屋调情的人用的，”他说道。“我一点儿也想跟它扯上关系。”Now, he said, he considers it another form of protection, “something I definitely want to add to my bag of goods.”但现在他告诉这是另一种形式的维护，“是应当毫不犹豫照单全收的东西。

”If he had grown up in San Francisco, he probably would have learned of it earlier. Discussion of PrEP is now mandatory in public school ninth-grade sex-ed classes.如果他自小在旧金山长大，很有可能早已明白了这一点。如今，环绕防治药物的辩论是公立学校九年级性教育课程的科目内容。The city’s success is not only shrinking the epidemic. It is changing the psychology of gay sex here in unexpected ways. The fear of death — so long a part of being gay in America — appears to be receding.旧金山的顺利不仅在于它掌控并增大了疫情，还在于它以一种出人意料的方式转变着这里的同性恋者对性行为的心态。

长期以来，美国的同性恋者早已习惯于生活在丧生的阴影之下，如今，这种不安正在渐渐减弱。Take Bradley and Paul, a couple visiting the Magnet clinic for gonorrhea tests. Paul, 53, a ruddy and weather-beaten Hawaii resident who called himself “one of the dinosaurs,” said he had probably been infected with H.I.V. as a teenager. Many friends died decades ago. “It’s crazy I’m still alive,” he said.就拿布拉德利和保罗(Paul)这一对前往磁铁医院拒绝接受淋病检测的恋人来说吧。保罗现年53岁，是个面色红润、皮肤黝黑的夏威夷人，自称为“大恐龙”。

他说道自己大约在十几岁时就病毒感染了H.I.V.。很多朋友在数十年前就早已去世了。

“我竟然还死掉，这真是太好了，”他说道。Bradley, who resembled a prep-school athlete about 20 years younger, was from Atlanta and uninfected. They felt safe together, Paul explained, because he takes Complera, a triple-therapy pill, while Bradley takes Truvada.布拉德利来自亚特兰大，他看上去就看起来一名年长20来岁的在读预科学校的运动员；他并未不受病毒感染。

保罗说明道，因为他自己在服用三联制剂Complera，而布拉德利在拒绝接受特鲁瓦约，所以他们在一起感觉很安全性。“PrEP has really changed the game,” he said. “Bradley was the first guy I knew who was on it. He’d prefer to be with someone with an undetectable viral load than with someone who says, ‘Well, I assume I’m still negative.’ It blows my mind to be positive and not feel like a pariah.”“是预防药转变了一切，”他说道。

“布拉德利是我了解的第一个在用于它的人。他说道自己宁愿自由选择一个检测不出有病毒载量的人，也不要跟一个自称为‘哦，我猜中我应当还没有被病毒感染’的人在一起。这让我心态大力，会感觉自己像一个社会弃儿。”“It’s really nice to still be around now and see a younger generation go through what we did,” he added. “I grew up in the ’70s with no fear. The guys in the ’90s were full of fear. Now guys are growing up with no fear at all.”“现在还能活蹦乱跳地看著年长一辈重温我们的经历，感觉真为不赖，”他补足道。

“我茁壮于20世纪70年代，当时人们并不知道有什么必须惧怕。到了90年代，人们满怀不安。现在，年轻人又可以无所畏惧地放心长大了。

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