When the District of Columbia's health department released its shocking statistics in March—3 percent of the city's residents have HIV or AIDS—one name came immediately to my mind: Patricia Nalls. Nalls runs the Women's Collective, an advocacy group for women with HIV in D.C., and she has been tangled up with the virus almost from its start. Diagnosed in 1986, three years after HIV was first identified, she's made it her mission to protect and empower women. I first visited Nalls in 2006. Now, I wanted to know what she thought about the epidemic in D.C., where the rate of AIDS cases is twice as high as New York City and five times higher than Detroit. How could it be so bad?
Nalls is compassionate, dedicated and enormously frustrated. "HIV/AIDS isn't over. People are still dying," she told me, with clear exasperation. "We need to bring back the sense of urgency." The Collective is at full capacity, serving 350 women a year; several die every month because they can't afford their meds, can't deal with the side effects or succumb to related illnesses, like hepatitis. Most of the women who come to the Collective are black and poor, making them especially vulnerable. The report found that blacks make up three quarters of those infected with HIV, and almost 60 percent of infected black women get it through heterosexual sex. Why the ongoing transmission? A new behavioral survey of D.C. residents believed to be at high risk for HIV found that 70 percent hadn't used condoms the last time they had sex; nearly half had sex outside of a committed relationship; 39 percent didn't know their own HIV status; and half didn't know their partner's. Add that up and it's clear that the actual number of people infected in D.C. is even higher than the startling 3 percent who already know it.
Some women practice unsafe sex knowingly. But transmission is far more complicated when it comes to women whose lives are broken by poverty and inadequate health care. It's easy to blame them—they should insist on condoms, they should get tested—but look at the reality, Nalls says. Awareness campaigns don't target black women; husbands and partners don't know or aren't truthful about their status; and condoms only work when men agree to wear them. Women who've tried to insist on protection have been beaten or even raped in some cases, says Nalls. Many of these women are single heads of household, too, with myriad things to worry about: paying the rent, feeding their kids and keeping them safe. And they often struggle with their own chronic diseases, mental-health problems and drug addiction. As a result, women who should get tested, don't. "I don't think they really want to find out," says Nalls. "There's the fear that now I'll have to deal with something else."
The Collective is trying to help. Outreach workers walk D.C.'s streets to educate residents and hand out condoms. Women are offered HIV testing on site or in a mobile van. Counselors organize medical care and housing; support groups provide resources. Nalls takes it all very personally. She was diagnosed at 29 after her husband, who was clean but had done drugs 10 years earlier, learned he had the disease. Within six months, she buried him and a 3-year-old daughter, Tiffany, who was infected unknowingly in her mother's womb. Nalls's two other children, 4 and 8 at the time, kept her going. "I was determined they weren't going to be orphans," she says. Nalls hid the bouts of nausea and fatigue so her kids wouldn't be scared. She's had good and bad years ever since. Today, at 51, she's taking five pills a day and doing well. Her big hope is that scientists will find an effective microbicide that women can use to protect themselves against HIV. For now, she'll keep shoring up those who are suffering. And reminding us: we need to bring back the urgency.