Eleven years ago, Marcya Owens's life seemed blessed. She was in college, studying psychology, running track and working as a volunteer at her Seventh-day Adventist church. Her friends predicted she would marry a minister. Owens was only mildly surprised to discover she was pregnant during her junior year at Georgia's traditionally black Clark Atlanta University. She'd had a number of boyfriends--middle-class achievers from well-regarded schools like her own--and had sometimes been lax about contraception. But she had never thought twice about HIV/AIDS. She was a straight black woman, after all, not a gay white man. And she had never dated a needle user. Yet there it was, starkly revealed on her first prenatal blood test: she was HIV-positive. "I never thought I was at risk," Owens says. "When you think of AIDS, you don't think of someone like me."
Dick Cheney and John Edwards certainly don't. This fall, when the two candidates were asked how the government should address the toll that AIDS is taking on African-American women, Cheney said he was "not aware" of the disparity, and Edwards took the occasion to talk about health-care reform. Unfortunately, the question was not a trivia quiz. America's AIDS epidemic has changed dramatically since it vanished from the headlines in the late 1990s. Women now account for 26 percent of newly diagnosed AIDS cases--nearly four times the proportion they --made up in 1986--and girls account for the majority of new HIV infections among teens. Most of these women and girls are infected through ordinary heterosexual relationships. Most of them are black. And many are still dying. "People talk about AIDS in developing countries," says Dr. Victoria Cargill of the Office of AIDS Research at the National Institutes of Health. "They need to see what's happening right here. Women are in the cross hairs, and they're being mowed down."
Why is this happening, and what can be done about it? Traditional notions of AIDS risk don't offer much insight into the issue. "Two decades ago the U.S. epidemic looked simple and homogenous," says Ana Oliveira, executive director of the New York-based Gay Men's Health Crisis. "AIDS was a problem for gay men--and the vocal ones were white, educated and affluent." The take-home lesson of the 1980s--that HIV spread through specific, preventable "risk behaviors"--had a big impact on affluent, educated people. But in communities already burdened by crime, poverty and ill health, HIV was just more bad weather--and women were uniquely vulnerable, both biologically and socially. As Oliveira puts it, "Safer sex is a faraway concept if you're struggling with addiction, living with domestic abuse and facing the prospect of homelessness. You're not in a position to tell your partner to use a condom."
Many of the country's first female AIDS patients fit that profile perfectly. Olga Arroyo was in her 20s when she contracted HIV in her Harlem neighborhood two decades ago. She'd been sexually abused as a child, taken up heroin at 17 and moved on to crack cocaine, selling sex to support her habit and her kids. In the world she inhabited, a high-risk encounter was the one that could leave you dead on the sidewalk in 10 minutes, not the one that could compromise your immune system over 10 years. The crack epidemic was short-lived, but HIV has persisted in many of the communities that lived through that era, creating new dangers for every subsequent generation. "It's like growing up in Botswana," says Dr. Wafaa El-Sadr, an infectious-disease specialist at Harlem Hospital and Columbia University's Mailman School of Public Health. "You don't have to be promiscuous to encounter the virus. Many of the women in our clinic have had the same partner for years. They have no idea how they got infected."
The forces sustaining this problem are complicated, but experts agree that prisons are a big part of the story. "Instead of treating the crack epidemic as a health problem, we treated it as a law-enforcement problem," says Dr. Mindy Fullilove of the New York State Psychiatric Institute. "Young men were imprisoned at astonishing rates, and their disappearance from the community changed the male-female dynamics within." When the men in a community are cycling in and out of jail, the women left behind have fewer partners to choose from, and less leverage within their relationships. --And when so many of the potential partners have spent time behind bars--where high-risk anal sex is common and sometimes forced--monogamy is no guarantee of safety.
Just ask Precious Jackson. The clear-eyed 33-year-old grew up with her protective, churchgoing grandmother in South Los Angeles. She excelled in high school and was attending community college when she fell for a man who had traveled the path from her neighborhood to prison and back. His answers were vague when she asked if he'd been tested for HIV, so she suggested they use a condom when they became intimate. "He said, 'Don't even ask'," she recalls. "He didn't like to use condoms." Jackson went along reluctantly--and discovered the consequences in 1998, when the Red Cross rejected her boyfriend's blood donation and tests showed they were both HIV-positive. "It's not the [sex workers] out there walking on Figueroa who are getting it," she says. "It's not the woman with a crack pipe in her mouth. It's women like me."
The feminization of AIDS is not just an inner-city phenomenon. HIV has also raced through the South in recent years, pushing women's infection rates into the stratosphere. Poverty and a lack of health care are clearly part of the story, but many experts suspect that traditional morality may also play a role--by discouraging assertiveness among women and openness among men. "Religious faith affects the way women perceive themselves in many communities of color," says Janet Cleveland, deputy director of the National Center for HIV, STD and TB Prevention in Atlanta. "As a woman you're raised to be trusting and submissive. But those same qualities can place you at risk." UCLA psychologist Gail Wyatt has found, for example, that women raised to value what she calls "interconnectedness" over assertiveness often "allow partners to make decisions about contraceptive use and sexual behaviors," and tend to "trust partners without asking questions."
By the same token, traditional morality--and the pressures that come with it--can make it harder for men to acknowledge their sexual orientations. Why would that endanger women? "When homosexuality is tolerated, gay men tend to be openly and exclusively gay," says Dr. Helene Gayle, director of HIV/AIDS and TB for the Gates Foundation. Men who lack that freedom are more likely to see each other on the "down low" while maintaining heterosexual relationships--and those who contract HIV are more likely to share it with wives or girlfriends. No one knows the true scale of the down-low phenomenon, or how large a role it has played in driving up female infection rates. But no one denies that the phenomenon is real and dangerous. In anonymous surveys of men who have sex with men, respondents who identify themselves as African-American also tend to identify themselves as straight. And some seem to believe that sex between "straight" males is safer than sex between "gay" ones. "[A man on the down low] may say, 'Hey, dog, you married, right?' " says J. L. King, a Chicago-based activist and author of the best-selling book "On the Down Low." "[He won't] mess with gay men, because gay men might have HIV."
Causes aside, the changing U.S. epidemic poses new challenges and it may demand new approaches to care, treatment and prevention. Most of the nation's HIV-positive women have children--a rare exception among infected men--yet they're less likely than men to have health insurance, less likely to receive treatment and more likely to die of AIDS. The federal government has long subsidized anti-HIV medication for people lacking drug coverage, but the need has outstripped the funding for the past two years, and 11 states now have AIDS patients on waiting lists. With persistence, almost anyone can find subsidized drugs before it's too late, but many women die because they lack the time, will or wherewithal to advocate for themselves. As one woman told Cargill of NIH, "I know my HIV infection is the top priority on your list. But if I don't have food today, and I can't get someone to care for my children, and my toilet is backing up, it's No. 50 on my list."
The best clinics have found creative ways to support such women--setting up peer networks, helping them navigate bureaucracies, offering legal assistance, providing on-site child-sitting. "Treatment doesn't work unless you can draw people into it," says El-Sadr of Harlem Hospital. "The clinic has to be a haven--a place where people feel welcome and supported, not a place where they feel powerless and isolated."
The larger challenge is to stop the growth of this scourge, and neither condom campaigns nor abstinence campaigns are likely to do the job. Instead of retooling old messages for a new audience, the pioneers in AIDS prevention are now striving to address the root causes of women's vulnerability--and finding that empowerment can do what information and indoctrination can't. "Most programs try to inoculate people with HIV 101," says Emory University researcher Gina Wingood, cofounder of a group called Sisters Informing Sisters About Topics on AIDS (SISTA). "We start with ethnic and gender pride. The goal is to say, 'You are beautiful, you're strong'." Owens, Arroyo and Jackson have all learned that lesson the hard way. With conviction and luck, the next generation won't have to.
