The brewing dispute in Los Angeles is being carefully watched by the national Centers for Disease Control and Prevention, as well as public health directors in other cities and counties.
HIV infections are on the rise among gay men nationally, said Dr. Ronald O. Valdiserri, deputy director of the National Center for HIV, Sexually Transmitted Diseases and Tuberculosis Prevention for the CDC. At the same time, growing numbers of gay men appear to be engaging in unsafe sexual practices, Valdiserri said. The Los Angeles study, he said, supported anecdotal evidence from other surveys that showed that bathhouses and sex clubs continue to be key venues for high-risk behaviors.
"Across the United States, directors of sexually transmitted disease programs are very concerned about the role of bathhouses," Valdiserri said.
The Los Angeles County study, which was funded by the CDC, highlighted a number of disturbing trends, according to several public health officials.
The research, which was centered at two clubs in 2001 and 2002, showed new diagnoses of HIV infection in 11% of those who underwent testing at the clubs during that period.
By comparison, just 1.5% of HIV tests conducted within the general population were positive, according to Trista Bingham, the epidemiologist who conducted the county study.
Even among gay men, Bingham said, the numbers for bathhouse patrons were high: Of gay men in Los Angeles County who have undergone HIV testing, 5.5% tested positive.
The same study showed that 71% of customers came specifically to have anonymous sex. More than a third said they engaged in higher risk behaviors in the clubs than in other locations, 16% said they engaged in group sex and 10% said they engaged in anal sex without using a condom.
About 36% of respondents reported using drugs before going to the clubs, which health officials say encourages unsafe behavior. Among the most widely used drugs, experts say, are methamphetamine combined with Viagra. The combination loosens inhibitions and allows patrons to have sex repeatedly with different partners.
"This is a major, moral issue of life and death," said Supervisor Zev Yaroslavsky, who sponsored the motion directing the health department to develop better ways to regulate the clubs. "And shame on us if our discomfort in talking about this results in people dying."
The issue of regulating or closing gay bathhouses and sex clubs has long been viewed as politically risky in Los Angeles, because public health officials -- and their elected bosses -- worry that such moves would infringe on the civil rights of gays and alienate voters.
The county already has the power to shut down some bathhouses that allow patrons to engage in unprotected sex. The existing ordinance, passed 16 years ago at the height of the AIDS crisis, also requires health inspectors to examine the venues quarterly.
But John Schunhoff, chief of operations for the Los Angeles County Office of Public Health Programs and Services, said that the law is vague, and that a subsequent court settlement that lays out specific protocols for the clubs only applies to two of the facilities currently in operation.
Moreover, he said, inspecting the facilities has proved fruitless: As soon as word goes out among the patrons and staff that the health department has arrived, inappropriate activity ceases.
As a result of the limitations in the existing law, and the difficulty conducting inspections, the department has not moved to shut down a bathhouse in more than a decade, Schunhoff said.
In their meeting with bathhouse and club owners, health department officials plan to discuss changing the law to include all gay sexual encounter venues, whether or not they offer baths, and a requirement that all clubs offer free HIV testing on the premises. Also under consideration is a requirement for all of the clubs to obtain licenses from the health department. These licenses would probably require the facilities to enforce safe-sex rules or risk being closed.
It is not clear how the county would enforce the new regulations. Schunhoff and Fielding said they are not inclined to send undercover inspectors to the clubs, partly because of the expense and also because in any case it would be difficult to prove that patrons are engaging in unsafe practices.
Some bathhouse operators say the county should emphasize voluntary efforts to inform patrons of the dangers of HIV infection and ways to prevent it.
"You don't get HIV from going to the baths," said Scott Campbell, who manages two gay bathhouses and a sex club. "You get HIV from having unprotected sex."
Campbell said his facilities already offer HIV testing four days per week, and require patrons to use condoms. He said he would not fight an ordinance that codified the prevention efforts that his clubs were already engaged in voluntarily.
And so an old dilemma has come back.
"It's deja vu all over again," said Dr. Mervyn Silverman, the former San Francisco public health chief who braved a political storm to close that city's bathhouses in 1984. "To me it seems like it should not even be an issue today."