“Why?” When it comes to this year’s double-digit increase in HIV rates among Minnesotans, that’s a simple question with a very complex answer. The Minnesota Department of Health (MDH) has launched a study to analyze the the 25 percent increase in HIV cases statewide, including a 27 percent increase in HIV cases among young gay and bi men, but many prevention advocates say the situation is murky, and none of the many HIV health workers and educators interviewed for this story could cite a new development that could account for the sudden jump in new cases.

The MDH study will be published in January.

“I could think of five or six things just off the top of my head,” said Nick Schrott, a health educator with the Minnesota AIDS Project’s Positive Link program, in an interview last week. Schrott suggested the surge in diagnoses was likely linked to a “perfect storm” of a broad range of factors: a decline in comprehensive sex ed in Minnesota’s public schools, emotional health, infidelity, the rise of arranging hook-ups via websites like Craigslist.org, a sense that the risk of contracting HIV has dropped, and HIV’s new public image of a manageable disease instead of a death sentence.

Many other health workers echoed Schrott’s words, but some cautioned that not everyone impacted by HIV is influenced by the same set of circumstances. “There are mini-epidemics within the larger epidemic that are incredibly distinct from each other,” said Rob Yaeger, a member of of the Minnesota Department of Health’s HIV and STD unit. “We can’t be thinking about one-size-fits-all about prevention and care.”

Take the internet’s possible role. As Schrott described it, sites like Manhunt.com or Craigslist.com dramatically simplify the sometimes-trying process of finding a casual sex partner at a bar, and increases the ease with which more and more people can connect who potentially don’t know their HIV status. It would be easy to place much of the blame on something so pervasive — because of how popular internet hookups are — and Yaeger and his MDH colleagues say they will be focusing part of their study specifically on their impact.

But talk to health workers Jennifer Houston, Antonio Marante, and Mario Villeda Maldonado from St Paul’s WestSide Community Health Services, a community clinic that specializes in working in bilingual populations notably the Latino and Hmong communities, and they will point out that most of their newly HIV-positive clients have little regular access to the internet. Even without the internet, Houston, WestSide’s Manager of Community Health and Outreach, says that the organization has seen an increase in new HIV cases that is quite similar to the statewide data.

“I’m not sure if the ‘perfect storm’ description is exactly right,” said Charlie Tamble, a Community Health Specialist with Minneapolis’ Red Door Clinic. However, Tamble agreed with others health workers, saying that, based on what trends he was noticing in his new patients, the ground was fertile for a big increase in HIV cases.

“If a community of individuals are used to not using condoms, and they’re sexual with each other, and there’s a low incidence of HIV among that group, then the chances of transmission [through anal sex] are quite small,” Tamble said. “Then, if HIV is introduced into that community through a few folks who don’t know their status, the risk of HIV increases astronomically.”

But why not use condoms? Schrott suggested that some men may be lulled into a false sense of security by getting frequently tested for HIV. “I know, based on anecdotes, that there are many folks out there getting tested 4 times a year. Their last test was negative, the one before was negative, so they start thinking ‘why won’t the next one be negative, as well?'”

The dangers of unprotected anal sex outside of a long-term monogamous relationship then start to seem small, said Gary Novotny, the Program Manager for MDH’s Health Education Risk Reduction Unit. “This is a generation of folks who haven’t seen their best friends die…and gone to 50 funerals a year,” Novocny said.

Other men, suggests Tamble, fall victim to relationship naiveté. “At the start of a relationship, people always want to appear squeaky clean,” Tamble said, “so they don’t always talk about their status early on. People can assume that if something was wrong their partner would tell them, or they’re embarrassed to even bring [the issue of HIV status] up.”

Much of this behavior, health workers say, is fueled by ignorance of the risks of contracting HIV, based on a lack of comprehensive sex education in schools, and a sense that HIV is no longer a death sentence.

“We’ve got a generation of very under-informed youth and we may be seeing the result of that,” MDH’s Novocny said.

“[At the Minnesota AIDS Project], we’re still getting questions like ‘can I get HIV from kissing someone?'” said Schrott. “We thought those questions had gone away.”

“Young gay and bi men are just not informed,” said Collette Lawrence, a Case Manager and Community Health Educator with the Indigenous People’s Task Force. “They’re taking themselves out of that risk group, and there’s a real lack of knowledge about risky behavior!”

Alan Horowitz, the head of St. Paul Public Schools Out for Good program, agreed that most schools in the suburbs and in Greater Minnesota did not have sex ed programs that dealt sufficiently with HIV, but even where young gay and bi men have access to good sex ed programs, the lack of a “fear factor” keeps students from taking the disease seriously. “I don’t think we’ve figured out how to present things to adolescents that will help them make smart decisions,” he said.

“There’s a bittersweet message that’s come along with the many types of [HIV] medications that have come out in recent years,” said MAP’s Schrott. “It starts to paint a picture that HIV is no big deal, and people start thinking ‘if I contract HIV I can take one pill a day and I’ll be fine.'”

In some parts of Greater Minnesota, said Lawrence, some treat HIV is simply a “city problem,” and decline to take risks seriously, or help prevention programs spread their message.

“On reservations, the farther north you get, the more resistance you get,” Lawrence said. “I literally had a guy say to me ‘There’s nobody living on this reservation living with HIV.'”

No matter what the MDH study turns up as a chief cause behind this dramatic rise in HIV cases, though, health workers say they will still be hamstrung as they try to address the problem without additional prevention funding from the state.

“Flat funding can only serve to maintain what’s been working,” said WestSide’s Jennifer Houston.

This is the second of a four-part series on the dramatic increase in reported incidence of HIV among gay and bisexual Minnesotan men, ages 15-24. Stay tuned for our report on the health system’s limitations as it tries to respond, and what the young men impacted and threatened by this crisis think.