舊金山是如何減少艾滋病感染的

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.

拉斐爾不是頭一回碰上保險套破了這種事，所以一點兒也沒放在心上。但三個禮拜後，他在酒吧遇到的那人打電話來說，他“可能接觸到了”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歲的拉斐爾是爲人友善的肌肉猛男。他去了一家診所，過了45分鐘得知自己確實被感染了。儘管當時已經是下班時間，一名顧問立即跟他碰面，並馬上爲其預約了第二天的醫生看診。

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.

在舊金山市綜合醫院(San Francisco General Hospital)著名的86號H.I.V.病區(Ward 86)，醫生給了他五天的藥量，又爲他開了處方好讓他可以買到更多藥。因爲他暫時賦閒在家，這名大夫將他介紹給了一名顧問，後者幫助他申請了一份公共醫療保險，每年報銷3萬美元的治療費。

“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.”

“他們很幫忙，這讓我感到寬慰，”拉斐爾說。出於隱私考量，他與本文其他幾位接受採訪的男性都堅持僅以姓氏相稱。“他們提供給我一個很好的機會，讓我能夠全心專注於自己的健康。”

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.

儘管在一夜情的輪盤賭中撞上黴運，但拉斐爾也有幸運之處：他住在舊金山，這是一座扭轉了防治艾滋病頹勢、堪爲其他城市效仿的楷模城市。這裏曾經是艾滋病的重災區，多虧實施了一系列富有創意的方案，感染率急劇降低，現在這裏每年只有幾百例新病例。

“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.”

“我大愛舊金山市的這個模式，”美國國家過敏症及傳染病研究所(National Institute of Allergy and Infectious Diseases)所長安東尼·S·福西(Anthony S. Fauci)博士說。“如果堅持目前的做法，我堅信他們一定能成功地終結現在的疫情。我不是說這樣就能消除所有的病例——恐怕我們永遠也做不到這一點，但大體上消滅疫情是完全可能做到的。沒有理由不這麼做。”

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.

上週，世界衛生組織(World Health Organization, W.H.O.)對舊金山模式表示了基本的贊同。該機構印發了新的H.I.V.防治指南，呼籲世界其他地區以舊金山爲榜樣：一旦H.I.V.檢測呈陽性，患者就應該儘快開始服用抗逆轉錄病毒藥物，而不是等到免疫系統功能指標衰退後再治療；此外，該機構還指出，應該向所有高危人羣提供預防性藥物。5年前，舊金山市已經率先實踐了上面的第一條——“檢測即治療”，2013年又實施了第二條。這又帶動了其他的一些措施，比如預約醫生的快速通道、跟蹤比較麻煩的患者等，拉斐爾正是受益於前者。

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.

這些舉措成效驚人。去年，舊金山市僅新增了302例H.I.V.確診病歷，創歷史新低。而在疫情最嚴重的1992年，曾達2332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，該市有1641人死於艾滋病。到了去年，只有177名艾滋病病毒感染者死亡，而且其中大多數實際上是死於心臟病、癌症或其他老年病，舊金山市衛生部H.I.V.預防研究的負責人蘇珊·布赫賓德(Susan Buchbinder)博士如是說。

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.

用其他指標衡量，舊金山市同樣居於領先地位。美國疾病控制和預防中心(Centers for Disease Control and Prevention, C.D.C.)2012年估計，在所有受到H.I.V.感染的美國人中，只有39%曾到專科醫生處就診，只有30%能堅持服藥直至達到“病毒抑制”（此時他們不再具有傳染性）。相比之下，在舊金山的居民中，82%的H.I.V.感染者都接受了治療，72%達到了“病毒抑制”狀態。86號病區中的患者要麼沒有醫療保險，要麼依靠公共救濟過活，但他們中的抑制率也已達到了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.

舊金山市具備一些天然的優勢：有錢、一貫力挺抗H.I.V.鬥爭的政治領導人（他們這麼做的部分原因是因爲同性戀人羣是一大票倉）、密切合作的醫學界。許多抗艾領域的高官都曾在加州大學舊金山分校(University of California, San Francisco)一起學習、培訓，並共同完成研究項目。

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.

藉助科技繁榮的東風，10年之內，市政廳的財政預算從50億美元增長到了近90億美元。對於無法獲得聯邦或州府醫保救助的患者，該市提供了自己的醫保計劃：健康舊金山(Healthy San Francisco)計劃。目前它已足以應對聯邦政府AIDS基金的削減。

“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.”

“我面臨的最重要的預算問題始終是：‘按照瑞安·懷特法案（Ryan White，瑞安·懷特是美國抗擊艾滋病和消除艾滋病歧視的標誌性人物，1990年他去世之後，美國國會通過了美國最大的針對艾滋病患者及攜帶者的免費治療法案——譯註）我們應該得到的撥款是不是又被砍了？’ ”市長李孟賢(Edwin M. Lee)在接受採訪時說。“2011年以來，我們補上了2000多萬美元的資金空缺——幾乎沒有引發什麼爭議。”

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.

與此同時，金錢也在以一種更爲殘酷的方式減輕該市的負擔：飆升的房租令許多貧困居民不得不離開此地。舊金山三分之二的H.I.V.感染者是白人或亞洲人。而縱觀整個美國，63%的感染者是黑人或西裔美國人。與年輕黑人和西裔男性這個疫情增長最快的人口亞羣相比，年齡較大、較爲富裕、且已經出櫃的白人同性戀男性擁有保險的可能性更高，對各種風險瞭解得也更加充分。

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.

但該市最大的優勢之源是願意先行一步，在C.D.C.和W.H.O.這樣的公共衛生機構認可之前，就迅速應用那些在試點項目或臨牀試驗中有效的策略。

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，該市開設了第一個艾滋病專用病房。1987年，它試用了第一種抗逆轉錄病毒藥物AZT（疊氮胸苷）。1992年，它開始向癮君子們分發潔淨的針頭。

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，該市推行了“檢測即治療(test-and-treat)”策略，只要患者的檢測呈陽性即儘快給予抗逆轉錄病毒藥物治療。2013年，它開始實施預防用藥方案，即使用特魯瓦達（Truvada，一種抗逆轉錄病毒藥物，主要成分爲恩去他濱和提諾福韋——譯註）爲無醫保人羣免費提供暴露前預防(PrEP)。據估計，該市的男同性戀中有15%正在服用特魯瓦達。

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.

近期的衆多研究顯示，每天接受抗逆轉錄病毒治療者不僅壽命更長，其循環系統中的病毒也極少，即使發生了無保護的性行爲，傳染他人的可能性也很小。

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，將防治策略轉變爲立即上藥仍然困難重重。該市H.I.V.預防部門的負責人格蘭特·科爾法克斯(Grant Colfax)博士遇到了來自醫生們的阻力，他們反對的理由是：藥物的副作用太厲害，不適合推行發現後立即治療的原則；一部分未感到死亡威脅的患者治療的積極性不高，很可能不好好服藥，以致因此產生耐藥性病毒株。

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.

社區團體也不高興。之前許多社團都跟市政簽訂了利潤豐厚的合同，負責分發安全套和宣傳抗艾指南。根據該市重新起草的新指南，他們還需要協助進行檢測，並提供醫療服務。

“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.

“別人指責我們‘對H.I.V.過度醫療化’，'“科爾法克斯博士說。“這讓我覺得很有諷刺意味。”新發感染率11年未變過。“我們不能再繼續過去的做法了，”他說。

He persisted, and won.

他堅持了下來，並取得了勝利。

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.

爲了甄別感染者，該市增強了檢測力度，並創建了快速通道（Rapid program），確保受感染者可以儘快得到醫生的看診（如有必要，甚至還報銷去醫院的出租車費），並幫助他們獲得醫療保險。拉斐爾就是該方案的受益者之一。

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.

爲拉斐爾診斷的磁鐵診所(Magnet Clinic)去年進行了9600例H.I.V.檢測。這家診所坐落在舊金山市掛滿了彩虹旗的同性戀者聖地——卡斯特羅街區(Castro)的中心地帶，外觀就像一個明快的手機店：候診區裏設有沙發、鮮花、迪斯科音樂和“無盡耽溺姐妹”（Sisters of Perpetual Indulgence，一個男扮女裝的同性戀者劇團——譯註）的照片。在檢查臺上方，還懸掛着一些帶有微笑表情的陰莖玩具。

“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.”

“我們不想讓人覺得這裏像是牢房，”護理部主任皮埃爾-塞德里克·克勞奇(Pierre-Cedric Crouch)身着診所標誌性的“不責備/不羞愧(No Blame/No Shame)”T恤說道。“我們這裏不做評判。你走進來說你跟20個男人上過牀，而且從不知安全套爲何物，我們也不會責難你。我們只提供幫助。”

Magnet’s social workers will enroll patients in insurance or, if they have coverage, fight to make sure it covers what they need.

磁鐵診所的社工會動員患者參加保險，如果他們已經參保，則會爭取確保它可以報銷他們的所需開銷。

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.

福利經理傑恩·加利亞諾(Jayne Gagliano)說自己經常需要向外州的保險公司解釋使用特魯瓦達預防H.I.V.感染實際上已經經過了美國食品和藥品監督管理局(Food and Drug Administration, F.D.A.)的審批。

“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.

“支離破碎的美國保險體制是我們最大的障礙之一，”舊金山市綜合醫院H.I.V.部門的負責人黛安娜·V·哈夫利爾(Diane V. Havlir)博士說道，她曾目睹一些患者因爲醫保報銷問題而被迫停藥。

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.

卡斯特羅區的東面是田德隆，一個充斥着單身公寓旅館、無家可歸者收容所和酒類專賣店的可怕街區。這個城市中超過四分之一的無家可歸者是同性戀者或變性人，其中許多人都生活在這裏。有的人用性來交換毒品或落腳地，結果感染了H.I.V.。

Four years ago, San Francisco created Linkage into Care teams — Lincs for short — to track such patients.

四年前，舊金山市創建了聯動護理團隊（Linkage into Care teams，簡稱Lincs）來追蹤這類患者。

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年間，Lincs的“領航員”對315名失蹤的H.I.V.患者展開了搜尋，並將其中116人納入了醫護項目，其餘的人要麼是沒找到，要麼是已經死亡或被關進了監獄，也有的拒絕接受幫助。“領航員”們給患者們打電話、發短信、看望他們，甚至陪他們去看醫生。

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的患者中有約73%堅持了治療，且達到病毒抑制狀態的可能性是出於類似狀況的非Lincs患者的兩倍。

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“領航員”埃琳·安圖內斯(Erin Antunez)在當天的工作主要圍繞着三個人展開：一名當天上午剛從監獄釋放出來的年輕男子，一個住在市場街旅館裏的癮君子，還有一個是生活在曾經的AIDS安養院的一位36歲母親。

The former prisoner “was not a big red flag,” she said. He usually took his pills and had a clinic appointment that afternoon.

那個刑滿釋放人員“不是什麼大問題”，安圖內斯女士說。他經常領取藥物，而且還預約在當天下午接受診療。

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.

癮君子經常玩失蹤。前一陣子他還發短信問她：“在哪兒做膿腫引流可以不用忍受那些麻煩的繁文縟節？”她給他發了若干消息，但之後就杳無迴音了。

“A lot of this work is ‘Where’s Waldo?’ ” Ms. Antunez said.

安圖內斯女士說：“我的工作有很多時候都像是在玩《沃爾多在哪裏？》（‘Where’s Waldo?’，由英國插畫家Martin Handford創作的一套兒童書籍，讀者需要在人山人海的圖片中找出沃爾多——譯註）”

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.

這一天，她首先前往某住宅區一家名爲Maitri 臨終關懷中心(Maitri Hospice)的安養院。網站介紹其創辦者“原先是個吸毒成癮的男扮女裝者，後來成爲禪宗大師”。安養院裏裝飾着佛像和紙鶴，還設有獨立的吸菸門廊以供吸菸和醫用大麻。

The young mother was not dying, although she had survived two types of AIDS-related pneumonia.

她要探視的這位年輕母親並無性命之憂，不過之前熬過了兩種不同的AIDS相關肺炎。

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.

更確切地說，她“只是需要從她住處的甲基苯丙胺狂歡節中脫身，好好休息一下”，因爲她只能隨便找張空沙發睡覺，完全忽略了吃藥這件事。

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.

她今天穿上了綠松石色的背心和印花短褲，還戴了一頂白色的Tilley帽子，正等着乘坐城市公交車前往86號病區。

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.”

安圖內斯女士問起她的新紋身。她很害羞，一直看着手機，喃喃地述說着孩子般天真的答案，直到她誤以爲記者是來評估安圖內斯女士工作的主管，一下子跳了起來，爲她辯護道：“埃琳很棒！你看得出來有些人其實並不心甘情願想跟你扯上關係。但她來敲我的門，打電話給我，我們還一起玩電話捉迷藏的遊戲。”

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，安圖內斯女士下午要拜訪的客戶卻沒待在唐納利酒店(Donnelly Hotel)他的房間裏。她大聲地敲他的房門，怕他是昏過去了。

A manager said he had “shown everyone his abscess” and then left.

酒店經理說他“向所有人展示他身上的膿腫”，然後就走了。

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.

安圖內斯女士很擔心他會自己去挑膿腫，於是她利用Lincs的權限訪問了數個數據庫，查看了公共門診的所有就診者和已安排好的所有H.I.V.檢測。

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.”

結果顯示，她負責的那個刑滿釋放者和癮君子在那天下午都接受過醫生診查。“好極了！”她揮舞着拳頭喊道，在椅子上手舞足蹈。“真是順利的一天”。

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.批准使用特魯瓦達預防H.I.V.感染後不久，舊金山市開始向整個高危人羣提供這種藥物。有些男同性戀者管服用了特魯瓦達就不使用安全套的人叫“特魯瓦達男娼(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 ...’ ”

凱薩醫療機構(Kaiser)也是最早提供預防藥物的組織之一，其H.I.V.部門的負責人布拉德利·C·黑爾(Bradley C. Hare)博士說：牴觸情緒基本已經消退了。他將首先嚐試預防藥物者“比作在蘋果零售店外面徹夜排隊等着買最新款iPhone手機的人”。如今，“第二次浪潮”已經出現，他說。“這些人需要更多的教育，現在他們終於意識到：‘我的朋友正在使用它，既然我們總是在做同樣的事情，那麼……’ ”

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.’ ”

在卡斯特羅區頗受歡迎的醫生莉莎·卡帕爾迪尼(Lisa Capaldini)博士說自己對預防藥的態度“仍搖擺不定”。因爲很多人服用預防藥後就不使用安全套了，她認爲“這就像特洛伊木馬一樣給了梅毒和淋病可趁之機。所以如果我有一個18歲的同性戀兒子，我會對他說：‘我寧願你使用安全套’。”

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.”

衛生部的布赫賓德博士表示了不同意見，她說：“因爲擔心患者會發生不安全的性行爲就拒絕對其應用預防藥，就像治療高膽固醇症的同行因爲怕患者有了他汀類藥物後會使勁吃冰淇淋而不肯給他們開藥一樣。”

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.

最近的一項研究考察了Kaiser的前657名接受預防藥物的患者，發現他們的安全套使用率確有下降，且更容易患上性病——但兩年內這些人中無一感染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)是一個24歲的芝加哥小夥子，身型單薄，說話輕聲細語，他剛剛開始用特魯瓦達。他不得不推遲一年用藥是因爲他需要先找到一份帶醫療保險的工作。之前，他的保險附帶在他父母的保單上，他生怕他們會發現特魯瓦達的處方。他的父母都是保守的天主教徒，知道他是同性戀後非常不滿。“我的父親甚至給我錢讓我去招妓，”他搖着頭說。

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.”

斯蒂芬第一次聽說這種藥是在他所在的天主教學院的同性戀學生社團裏。“我的朋友說，這種藥是給那些超級放蕩、做愛不戴套或者一有機會就鑽進小黑屋做愛的人用的，”他說。“我一點兒也不想跟它扯上關係。”

Now, he said, he considers it another form of protection, “something I definitely want to add to my bag of goods.”

但現在他知道這是另一種形式的保護，“是應該毫不猶豫照單全收的東西。”

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.

如果他從小在舊金山長大，很可能早就明白了這一點。如今，圍繞預防藥物的討論是公立學校九年級性教育課程的必修內容。

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.

舊金山的成功不僅在於它控制並縮小了疫情，還在於它以一種出人意料的方式改變着這裏的同性戀者對性行爲的心態。長期以來，美國的同性戀者已經習慣於生活在死亡的陰影之下，如今，這種恐懼正在逐漸消散。

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.

就拿布拉德利和保羅(Paul)這一對前往磁鐵診所接受淋病檢測的戀人來說吧。保羅現年53歲，是個面色紅潤、皮膚黝黑的夏威夷人，自稱“大恐龍”。他說自己大概在十幾歲時就感染了H.I.V.。很多朋友在數十年前就已經去世了。“我居然還活着，這簡直太好了，”他說。

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.

布拉德利來自亞特蘭大，他看起來就像是一名年輕20來歲的在讀預科學校的運動員；他未受感染。保羅解釋道，因爲他自己在服用三聯製劑Complera，而布拉德利在接受特魯瓦達，所以他們在一起感覺很安全。

“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.”

“是預防藥改變了一切，”他說。“布拉德利是我認識的第一個在使用它的人。他說自己寧願選擇一個檢測不出病毒載量的人，也不要跟一個自稱‘哦，我猜我應該還沒被感染’的人在一起。這讓我心態積極，不會感覺自己像一個社會棄兒。”

“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.”

“現在還能活蹦亂跳地看着年輕一輩重溫我們的經歷，感覺真不賴，”他補充道。“我成長於20世紀70年代，當時人們並不知道有什麼需要害怕。到了90年代，人們滿心恐懼。現在，年輕人又可以無所畏懼地安心長大了。”