AIDS Epidemic Takes Toll on Black Women

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=82 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="05bfd523.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Cape Fear Regional Bureau For Community Action, Inc.</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="Cape Fear Regional Bureau For Community "><U><B>home</B></U></A></div> <div> <A HREF="id73.htm" TARGET="_top" TITLE="Educational Articles"><U><B><IMG SRC="04e0e0e0.png" border=0 width="14" height="14" ALT="up" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B>  </B><IMG BORDER="0" SRC="1x1.gif" HEIGHT="14" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" WIDTH="14"><B>    </B><A HREF="id90.htm" TARGET="_top" TITLE="2002 In Review"><U><B><IMG SRC="04d0e0e0.png" border=0 width="14" height="14" ALT="previous" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B>  </B><A HREF="id76.htm" TARGET="_top" TITLE="FDA Approaves 20Minute HIV Test"><U><B><IMG SRC="04f0e0e0.png" border=0 width="14" height="14" ALT="next" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="http://www.capefearregionalbureauforcommunityactioninc.org/mf.htm" TARGET="_top" TITLE="http://www.capefearregionalbureauforcomm"><U><B>Click Here For Site Map</B></U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" bgproperties="fixed" background="23fd2993.jpg"> <bR> </td> <td valign="top" height=398 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I><B>AIDS Epidemic Takes Toll on Black Women</B></I></div> <DIV ALIGN="LEFT"></DIV> <div> <B><U>THIS EMAIL FOWARD TO THE BUREAU IS MOST INFORMATIVE</U></B></div> <bR> <div> <B>Dated: 12/26/02</B></div> <div>  <A NAME="aids_black_women"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> Ron Valdiserri </div> <div> Deputy Director NCHSTP </div> <div> DHHS/CDC/NCHSTP/OD </div> <div> Building: CPSQ </div> <div> Duty station: ATLANTA GA </div> <div> Mail stop: E07 </div> <div> Phone 404-639-8002 </div> <div> Fax 404-639-8600 </div> <div> Internet e-mail <<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>mailto:rov1@CDC.GOV</U></FONT>> </div> <div> Ron Valdiserri et al: </div> <div> Please review the following articles and abstracts. Be aware in advance, that some of the content is abrasive and direct. </div> <div> The Money Trail by Kemba Johnson -- Dollars Don't Always Follow New Trends in AIDS Cases <excerpt> "<B>You had a wonderful mix of federal government, corporate funding and private foundations, individual funding and Hollywood interest. That's not there now that the [AIDS] epidemic is blacker, browner, younger, and female</B>." To read the entire text of this article, please see: <<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.villagevoice.com/issues/0030/johnson.php</U></FONT>> </div> <div> Other points of interest are highlighted in the text below, </div> <div> respectfully submitted, </div> <div> Kevin P. Nuttall - "NK0525611" </div> <div> State & Federal Affairs Director </div> <div> North Carolina AIDS Policy Center </div> <div> 81 Baird Street, Suite 105 </div> <div> Asheville, NC 28801-2093 </div> <div> p: 828.251.2229 / f: 828.285.0080 </div> <div> <<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>mailto:retroart@buncombe.main.nc.us</U></FONT>> </div> <div> --- page break --- </div> <div> Quarterly Newsletter, Volume 5, No. 2 -- June 2002 <excerpt> </div> <div> In the Headlines </div> <div> <U>http://www.hrc.org/publications/lawbriefs/v05n02.asp</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Centers for Disease Control and Prevention Release Findings on "Down-Low" Phenomenon in <U>African-American </U><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B><U>GLBT</U></B></FONT><U> Community</U>. </div> <div> <B>[Note: The NC AIDS Policy Center does not endorse labeling African American MSMs "on the Down Low" as "</B><B><U>GLBT</U></B><B>."]</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Many gay and bisexual African-American men keep their sexual orientation a secret. Some are living what they call the "down-low" lifestyle. Down-low men have sex with other men, but in order to keep appearances, they also maintain relationships with wives or girlfriends. Unfortunately, some of these men do not use condoms, and though much research remains to be done, some experts believe this phenomenon </U><B><U>may be a significant factor in the increase in HIV infections among African Americans, and particularly among women.</U></B> According to a CDC survey conducted in seven cities, 30 percent of black men ages 23 to 29 who have sex with men are HIV-positive. The same study found that among black men ages 15 to 22, one in six who had sex with other men also reported recently having sex with other women. Coincidentally, 64 percent of all new HIV infections arise among African-American women. </div> <div> --- page break --- </div> <div> In a six-part series <hyperlinks shown below> the Village Voice [a paper from New York City] explored many issues that cloud understanding of a complex public health crisis which disproportionately affects black communities in New York State. Even as AIDS deaths decline among other groups, the disease remains the leading killer of African Americans aged 25 to 44. The series highlighted the efforts of community leaders working to stem the rise in cases. </div> <div> --- page break --- </div> <div> <U>http://www.villagevoice.com/issues/0024/wright.php</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> AIDS and Black New Yorkers </div> <div> by Kai Wright </div> <div> Emergency Call </div> <div> How AIDS Is Hurting Black Communities </div> <div> June 14 - 20, 2000 </div> <div> Lenox Avenue from 132nd to 137th buzzes with people -- all of them targets for Tyrone Johnson's cadre of HIV-positive outreach workers -- milling about bodegas, playgrounds, and fast-food eateries. The goal is to get people into a van parked nearby for a free HIV test. Johnson's got it down to a science. "They see free, and they'll stop," he says. </div> <div> <B>Four years ago, when Johnson first walked these streets handing out condoms, new drugs emerged that finally beat back AIDS death rates. People with AIDS whispered of relief; the media screamed victory. "When Plagues End," a New York Times Magazine cover story, explored the aftermath of the epidemic since AIDS had become a chronic disease rather than a death sentence.</B> </div> <div> <B>But in black communities like Harlem, the plague was just beginning. "What you see uptown, it's almost like a whole different world. It's almost like HIV/AIDS in 1983, 1984,"</B> sighs Johnson's boss, Harlem United's deputy director for prevention, education, and policy, Soraya Elcock. </div> <div> Nationally, AIDS is the number one cause of death for African Americans between 25 and 44 years old. One in 50 black men and one in 160 black women are HIV-positive -- compared to one in 250 and one in 3000 white men and women. <B>The U.S. Centers for Disease Control and Prevention in Atlanta estimates that almost 60 percent of all new HIV infections are occurring among blacks.</B> </div> <div> New York State mirrors the national trend. Over 40 percent of the state's cumulative AIDS cases to date are among blacks, who account for only 14 percent of the population. Over 56 percent of all children under 12 with AIDS are black. In counties outside of New York City, blacks and Latinos account for around 10 percent of the population and 60 percent of the cumulative AIDS cases. </div> <div> <B>So in the last two years, black policy makers and community leaders have begun sounding alarms. "We're looking at the funding numbers, and [asking] why doesn't the money go to where the epidemic is?"</B> says Christopher Gray, a Long Island AIDS activist who recently convinced the HIV Prevention Planning Group, an advisory body to the New York State AIDS Institute, to recommend a new focus on blacks. </div> <div> For years, Gray and others argue, public health officials and community groups alike have failed to target resources appropriately. As early as 1983, African Americans accounted for 26 percent of national AIDS cases. In New York State, African Americans have accounted for at least a third of reported AIDS cases yearly since 1982. </div> <div> <B>"Even in the beginning, there was a disproportionate representation [among blacks]," laments Dr. Helene Gayle -- who is black -- director of the National Center for HIV, STD, and TB Prevention at the CDC. "People did not necessarily pay as much attention to it."</B> </div> <div> That is gradually changing. The CDC began earmarking funds for minority community initiatives in 1988, but those funds were relatively insignificant until the Congressional Black Caucus prompted President Clinton to declare AIDS a "state of emergency" in the black community in 1998. In reaction, Congress has annually earmarked $245 million for initiatives in communities of color. State health officials, skittish about declaring a hard number, estimate the state spent almost 80 percent of its total HIV-prevention funds (separate from the federal funds it receives) on programs targeting communities of color in 1997, and they plan to increase that share in coming years. </div> <div> <B>But if the epidemic has had a disproportionate impact on black communities, why are public health officials, AIDS activists, and black community leaders only now, 20 years later, pointing it out?</B> </div> <div> <B><U>Harlem United's Elcock blames both the CDC and local AIDS groups for excessively focusing on injection-drug users and gay men</U></B><B>, allowing everyone else to avoid confronting their own risk. "And </B><B><U>any time you looked at the television or read something, it was about the Gay Men's Health Crisis, it was about white gay men</U></B><B>, it was about ACT UP. And so the black community separated from that; [AIDS] didn't belong to us."</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Nor did the black community want to own it. The virus's impact among black injection-drug users and black gay and bisexual men has always been visibly dramatic. <FONT SIZE="4" COLOR="#0000FF" FACE="Arial" ><B><U>It's the straight black women, blacks upstate, seniors, and middle-class blacks, Elcock says, who are now getting infected and driving the epidemic to a new level.</U></B></FONT> </div> <div> --- page break --- </div> <div> <U>http://www.villagevoice.com/issues/0123/wright.php</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> A New Black Sexual Identity May Be an Incubator for AIDS </div> <div> The Great Down-Low Debate </div> <div> by Kai Wright </div> <div> June 6 - 12, 2001 </div> <div> Richard Pryor used to do a bit where he joked about his experiences "fucking the faggot." He wasn't declaring himself gay, far from it, and no one listening assumed as much. He was just admitting that he could get off by screwing another guy. Pryor made his living parading life's dirty little secrets on stage. In this case, the fact that a lot of black men "get with dudes," as we now say when being circumspect. </div> <div> That was 1971, before identity came to America's bedrooms. <B>While some black folks have since assumed our place in the gay rainbow, many have rejected sexual identity</B> in favor of keeping Pryor's secret undercover. <B><U>In a much discussed 2000 U.S. Centers for Disease Control survey, a quarter of black men who acknowledged that they have had sex with other men identified themselves as heterosexual, compared to around 6 percent of their white counterparts.</U></B> </div> <div> A more recent CDC study, released this February, has shoved these men under the microscope like never before. The report estimated that over 30 percent of twentysomething black <FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B>"men who have sex with men," the CDC's deliberately neutral term</B></FONT>, are HIV positive. It put the number at 33 percent in New York City, which is a higher rate of infection than in the general population of any sub-Saharan African country other than Botswana. </div> <div> <B>The study has left everyone trying to figure out why African American gay men seem uniquely immune to HIV prevention efforts. Increasingly, people believe the answers will be found only when we figure out what makes guys like Tevin (a fake name) tick.</B> Born and raised in New York City, this self-assured 25-year-old is a portrait of the young, savvy urban black male. Dressed hip-hop casual -- in a baggy sweater, khakis, and spotless white kicks; with his smooth, dark skin, tight goatee, and cornrows, <B>Tevin is a lady's dream. But he's also the Don Juan fantasy of a certain group of men: guys who live "on the down low," or DL.</B> </div> <div> "I like girls. I have a girl," Tevin says with a smirking shrug. "But every once in a while, 'cause women can be very stressful, I might chill with a dude. And it's just having fun. If something pops off, it pops off. Give each other a pound and meet up later." </div> <div> <B>Tevin won't have anything to do with gay culture, doesn't know anything about it and couldn't care less.</B> By and large, his thoughts on the subject are in lockstep with most of black America's: It's all good if it's your thing, but I ain't no punk. </div> <div> <B>Nor is Tevin willing to accept a sexual orientation. "I consider myself just sexual," he professes. "A freak!"</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> But this polished detachment doesn't quite veil a much more complicated set of emotions. The brother is in love. He met Jason (also a fake name) at a fight party eight months ago, and the two have been "in each other's face" ever since. Although they don't mess with other men, Tevin is quick to make it clear that doesn't mean they are "quote unquote dating." Still, there's a lot more popping off here than sex. </div> <div> "It's crazy but, yeah, the feelings are strong," he admits. </div> <div> Tevin's met guys in the past who have claimed to be "DL." But they always proved to be fakers and ended up acting queer. Jason's not like that. He has no interest in women, but he still flirts with them. He doesn't try to be affectionate with Tevin in public. And most important, he doesn't flame out. </div> <div> "I think if you're a dude, you should act like a dude, look like a dude, talk like a dude. If you're a chick, you should act like a chick," Tevin explains. "When you start mixing 'em up, that makes me nervous. I wouldn't disrespect people who act like that, but it just turns me off." </div> <div> This cult of masculinity is at the heart of being DL. <B>Men like Tevin style themselves as prototypes of black manhood, and gender benders don't cast well in that role. Nathan Kerr, a gay Caribbean American whose Brooklyn marketing firm produces safe sex ads targeting DL men, says he's conducted focus groups where even flamboyantly feminine black men rejected the gay label because of its perceived weakness.</B> "Gayness was seen as the whole sissy fag thing," he explains. </div> <div> Feminist cultural critic Bell Hooks argues that this perceived conflict between gayness and black macho also underpins homophobia in the community today, and dates back to the Black Power movement of Pryor's years. For Hooks, when Black Panther Eldridge Cleaver declared of his gay brother, "The white man has robbed him of his masculinity, castrated him in the center of his burning skull," it stuck. </div> <div> Ironically, openly gay writer James Baldwin, Cleaver's primary target, was then -- and for years remained -- one of the movement's most vocal defenders. Baldwin even excused Cleaver's attack as the misguided defensiveness of a "zealous watchman" over blackness. But decades later, the watchman's words still echo through hip-hop culture. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B><U>As Ice Cube has reminded us, "true niggas ain't gay."</U></B></FONT> </div> <div> This homophobia, argues Hooks -- whose latest book, Salvation, dissects what she sees as a communal "crisis of lovelessness" -- is indicative of a larger discomfort with sexuality. <B>"Black folks can't even talk in a healthy way about straight sex," hooks complains. "How are we going to talk about gay sex and s/m and bisexuality and so on?"</B> </div> <div> <B>In the meantime, the problem with gay identity for men like Tevin is that it disqualifies them for the Black Man identity they prefer. And since sexual liberation has robbed them of the right to simply slip off and "fuck the faggot," they've developed the DL.</B> </div> <div> <B>Of course, DL is itself a way of organizing one's life around the common trait of sexual desires, complete with a unique language. Solicitors in personal ads and chat rooms signify degrees of authenticity with coded monikers such as "serious DL brotha" and "real roughneck nigga." </B>The latter splinters off into the related but distinct "homo-thug" identity, which allows Pryor's faggot of today to still qualify for the violent conception of black masculinity popularized by gangsta rap. </div> <div> <B>But many unambiguously gay African Americans have responded to the DL and homo-thug trends by declaring these guys nothing more than repackaged closet cases. And they warn that the segmented lives such identities create are dangerous -- both for the guy on the down low and his unsuspecting female partner.</B> Tevin, like most DL men, has never told his girlfriend, with whom he lives and has a child, that he sleeps with men as well. He asserts his burgeoning affair with Jason in no way conflicts with his love for her, and that his concealment of it is thus not lying. </div> <div> Tevin also says he always uses condoms. But even if so, is he an anomaly? </div> <div> <B>There's little research to determine how often black men eschewing sexual identity use protection with their male or female partners, but both the CDC and gay-identified blacks working in AIDS prevention point to the 2000 report for guidance. All of the men in that survey were positive, and many believe the respondents who called themselves straight help form an "HIV bridge" that is responsible for skyrocketing infection rates among both African American women and homosexual men. It's why, some gay activists say, public health needs to encourage DL brothers to be more honest with themselves and their lovers of either gender.</B> </div> <div> "You can't address the risk if you don't talk about the context in which it happens," sighs Timothy Benston, who coordinates Soul Food, a Gay Men's Health Crisis program that targets African Americans. <B>"Black gay men lead schizophrenic lives."</B> </div> <div> <B>If so, retort those in another corner of the intensifying debate, </B><B><U>it's schizophrenia caused by "gayified" blacks trying to shove a white concept down the community's throat.</U></B> "One of the assumptions gay makes is that if you don't call yourself gay then you're in the closet," snaps Cleo Manago, an Oakland area AIDS activist who is a leader in the "Same Gender Loving" movement on the West Coast. </div> <div> That <B>movement aims to discard pink triangles and rainbow flags -- symbols created by and for Europeans -- and</B> build a new identity around words and concepts created by and for black people. <B>Among the first to go, Manago says, is the in and out of the closet dichotomy that serves only to emphasize separation from the larger community.</B> "Instead of demanding that people respect you because of how you fuck, do something within the community," Manago rails. </div> <div> <B>And when it comes to HIV prevention, he says, the problem has been that the "old guard" black gays leading the effort "still pull a defiant gay anchor around," pushing an out-of-touch political agenda that alienates those they are trying to reach.</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> But gay activists respond that Manago is peddling a cultural relativism that should stop at the closet door. "Most people in our community are saying, 'Represent! Represent,' " pleads Maurice Franklin of Gay Men of African Descent. Franklin notes that he and others like him live and socialize as open gays in the black community. <B>"It doesn't mean that we have to go out carrying rainbow flags," adds activist Keith Boykin. "But we do have to acknowledge sexual orientation."</B> </div> <div> <B>[Note: The NC AIDS Policy Center views attempts to promote acceptance of sexual orientation as an agenda of self-identifying gays, and not as an agenda which will necessarily help slow the spread of HIV.]</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Which is just fine with Tevin. And as for whether or not he's lying or repressed, and what it means for his and his partners' HIV risk, that's not his question to answer. "I don't feel like I'm pushing anything back," he claims. "I'm not saying how you choose to deal with your situation is wrong, but I'm good where I'm at." </div> <div> GMAD will host a conference June 14-17 at Brown University in Providence, Rhode Island, to discuss HIV and black gay men. Reverend Jesse Jackson Sr. will be among the speakers. For more info, call 212-929-8750. </div> <div> *** </div> <div> other articles: </div> <div> Black, Gay, At-Risk by Kai Wright </div> <div> Homophobia, Racism, and Rejection Fuel Rising Infections </div> <div> <U>http://www.villagevoice.com/issues/0025/wright2.php</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> The Tuskegee Effect by Kemba Johnson </div> <div> For Blacks, a 28-Year-Old Study Is One of Many Barriers to HIV Prevention </div> <div> <U>http://www.villagevoice.com/issues/0026/johnson.php</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Double Jeopardy by Kai Wright </div> <div> In NY State Blacks Rank Highest Among HIV-Positive Inmates </div> <div> <U>http://www.villagevoice.com/issues/0027/wright.php</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Black Women and HIV by Sharon Lerner </div> <div> Rising Infection Rate Reflects an Age-Old Gender Imbalance </div> <div> <U>http://www.villagevoice.com/issues/0029/lerner.php</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> --- page break --- </div> <div> <U>http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4901a2.htm</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Weekly -- January 14, 2000 / 49(01);4-11 </div> <div> Please note: A clarification has been published for this article. To view the clarification, please click here. </div> <div> <U>http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4904a4.htm</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> [This clarification has also been substituted in the text below.] </div> <bR> <div> _ _ _ _ _ _ _ _ _ _ HIV/AIDS Among Racial/Ethnic Minority Men Who Have Sex with Men -- United States, 1989-1998 _ _ _ _ _ _ _ _ _ _ </div> <bR> <div> <B>In the United States, racial/ethnic minority populations account for an increasing proportion of acquired immunodeficiency syndrome (AIDS) cases, including cases among men who have sex with men (MSM)</B> (1). This report presents recent trends in AIDS incidence and deaths among MSM who belong to racial/ethnic minority populations*, and compares data on human immunodeficiency virus (HIV) diagnoses with AIDS diagnoses during 1996-1998 among racial/ethnic minority MSM in the 25 states** that have conducted confidential HIV surveillance and AIDS case surveillance since 1994. <B>The findings indicate that among MSM, non-Hispanic black and Hispanic men accounted for an increasing proportion of AIDS cases and had smaller proportionate declines in AIDS incidence and deaths from 1996 to 1998.</B> Of HIV and AIDS diagnoses among racial/ethnic minority MSM, the proportion who are young (aged 13-24 years) is higher than among white MSM. </div> <div> Trends in AIDS incidence during 1989-1998 among MSM aged greater than or equal to 13 years from the 50 states, the District of Columbia, and U.S. territories were analyzed by race/ethnicity, age, and geographic area of residence. During 1996-1998, AIDS incidence per 100,000 population was calculated using race/ethnicity-specific Bureau of the Census estimates of males aged greater than or equal to 13 years for the corresponding years. The number of HIV infection and AIDS diagnoses and deaths among persons with AIDS was adjusted for reporting delays on the basis of cases reported to CDC through June 30, 1999, and for the anticipated reclassification of cases initially reported without HIV-infection risk-exposure data (1). Trends examined were from 1989 through 1998 and from 1996 through 1998, the period of highly active antiretroviral therapy (HAART). During 1996-1998, for the 25 states with confidential HIV surveillance, age and race/ethnicity of MSM whose disease status was HIV infection (not AIDS) when initially diagnosed were compared with MSM who had AIDS-defining conditions when first diagnosed. </div> <bR> <div> _ _ _ _ Characteristics of MSM with AIDS _ _ _ _ </div> <div> During 1996-1998, 64,685 MSM were diagnosed with AIDS (Table 1); 31,866 (49%) were racial/ethnic minority MSM. Among this group, 1492 (5%) were aged 13-24 years and 4498 (14%) were aged 25-29 years, compared with 2% and 9%, respectively, of white MSM in those age categories. Metropolitan statistical areas (MSAs) of greater than or equal to 500,000 population accounted for 27,097 (85%) AIDS cases in racial/ethnic minority MSM. The AIDS incidence in MSM per 100,000 adult male population decreased 32% from 1996 to 1998 (Table 1); rates were highest for black MSM in all years. </div> <div> The five MSAs that accounted for the largest number of racial/ethnic minority MSM with AIDS during 1996-1998 were New York, 3673 (12%); Los Angeles, 2811 (9%); Miami, 1554 (5%); Washington, DC, 1251 (4%); and Chicago, 1075 (3%). New York and Los Angeles had the largest number of AIDS cases among non-Hispanic black and Hispanic MSM, respectively. Los Angeles and Phoenix were the MSAs with the largest number of AIDS cases among Asian/Pacific Islander (A/PI) and American Indian/Alaska Native (AI/AN) MSM, respectively, compared with New York for white MSM (Table 2). </div> <bR> <div> _ _ _ _ Trends in AIDS Incidence and Deaths Among MSM with AIDS _ _ _ _ </div> <div> During 1989-1998, AIDS was diagnosed in 290,582 MSM. In 1989, racial/ethnic minority MSM accounted for 7609 (31%) of 24,444 AIDS cases among MSM, and by 1998, racial/ethnic minority MSM accounted for 9429 (52%) of 18,153 AIDS cases among MSM. The proportion of MSM with AIDS who were non-Hispanic black and Hispanic increased from 19% and 12%, respectively, in 1989, to 33% and 18%, respectively, in 1998. A/PI and AI/AN each accounted for less than 2% of AIDS cases among MSM throughout this period. </div> <div> AIDS incidence among all MSM declined 22% from 1996 to 1997 (Table 1). The rate of decline slowed to 12% in 1998 compared with 1997. During 1996-1998, AIDS incidence declined among MSM in all racial/ethnic groups: A/PI (43%), non-Hispanic white (39%), AI/AN (35%), Hispanic (26%), and non-Hispanic black (23%). Overall, the proportionate declines in AIDS incidence from 1997 to 1998 were smaller than those from 1996 to 1997. From 1997 to 1998, AIDS incidence declined 29% among AI/AN, 17% among A/PI, 15% among non-Hispanic white, 10% among non-Hispanic black, and 9% among Hispanic MSM. </div> <div> Deaths among all MSM with AIDS declined 49% from 1996 to 1997 (Table 1). The rate of decline slowed to 23% in 1998 compared with 1997. From 1996 to 1998, AIDS deaths declined among all racial/ethnic MSM: A/PI (69%), non-Hispanic white (65%), AI/AN (63%), Hispanic (60%), and non-Hispanic black (53%). From 1997 to 1998, AIDS deaths declined 38% among AI/AN, 37% among A/PI, 24% among non-Hispanic white, 22% among Hispanic, and 21% among non-Hispanic black MSM. </div> <bR> <div> _ _ _ _ HIV and AIDS Diagnoses Among MSM in 25 Areas with HIV/AIDS Surveillance _ _ _ _ </div> <div> During 1996-1998, HIV infection or AIDS was diagnosed in 23,680 MSM in 25 states with HIV reporting; 11,313 (48%) were racial/ethnic minority MSM: 9497 (40%) non-Hispanic black, 1551 (7%) Hispanic, 113 (less than 1%) A/PI, and 152 (less than 1%) AI/AN. Among MSM whose initial diagnosis was HIV infection, the proportion aged 13-24 years varied by race/ethnicity: 16% non-Hispanic black, 15% A/PI, 15% AI/AN, 13% Hispanic, and 9% non-Hispanic white. Among MSM whose initial diagnosis was AIDS, the proportion aged 13-24 years also varied by race/ethnicity: 6% Hispanic, 6% A/PI, 5% non-Hispanic black, 1% non-Hispanic white, and less than 1% AI/AN. </div> <div> Reported by: State and territorial health departments; Div of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention; and an EIS Officer, CDC. </div> <bR> <div> _ _ _ _ Editorial Note: _ _ _ _ </div> <div> <B>These HIV/AIDS surveillance data highlight the importance of increased efforts to promote HIV prevention and treatment services in racial/ethnic minority communities, particularly among non-Hispanic black and Hispanic MSM. These groups had higher AIDS rates and the smallest proportionate decreases in AIDS incidence.</B> The annual number of AIDS cases remains high, although AIDS incidence and deaths have declined among racial/ethnic minority MSM. These declines reflect the beneficial impact of HIV prevention programs, HAART, and opportunistic infection prophylaxis. Young non-Hispanic black and Hispanic MSM remain at high risk for HIV infection as indicated by higher proportions of AIDS and HIV cases among non-Hispanic black and Hispanic MSM aged 13-24 years compared with white MSM. </div> <div> The disproportionate impact of HIV/AIDS on racial/ethnic minority MSM indicated in this report is probably a minimum estimate. The use of all men aged greater than or equal to 13 years as a denominator (instead of MSM) results in an underestimate of the rate among MSM. Small numbers of cases among A/PI and AI/AN MSM limit the ability to assess trends, although in some locations A/PI and AI/AN MSM might be at substantial risk. HIV/AIDS surveillance data also may underestimate cases among racial/ethnic minorities because of misclassified race/ethnicity in medical records (2), which is greatest among AI/AN, A/PI, and Hispanic groups. States that conduct HIV reporting are not representative of the geographic regions with large Hispanic populations. <B>Race/ethnicity itself is not a risk factor for HIV infection; however, among racial/ethnic minority MSM, social and economic factors, such as homophobia (3), high rates of poverty and unemployment, and lack of access to health care, are associated with high rates of HIV risk behavior (4). These factors also may be barriers to receiving HIV prevention information or accessing HIV testing, diagnosis, and treatment.</B> </div> <div> <B>Characteristics of persons in whom HIV infection (without AIDS) is diagnosed reflect more recent trends in the epidemic than do characteristics of persons with AIDS. In states with confidential HIV surveillance, a larger proportion of racial/ethnic minority MSM were young (aged 13-24 years) when first diagnosed with HIV infection (without AIDS) compared with white MSM, suggesting that racial/ethnic minority MSM may become infected at younger ages compared with white MSM.</B> Trends in AIDS incidence and deaths are affected now by HIV incidence and by HAART; pre-HAART diagnoses of AIDS were not as substantially affected by treatment. HIV case reports may reflect targeted testing patterns in at-risk populations or differences in test-seeking behavior. However, <B>the increased proportion of racial/ethnic minority MSM among MSM with AIDS and the trends in HIV infection diagnoses, particularly among non-Hispanic black men, are consistent with data from seroprevalence and incidence studies among MSM (5,6), which document the high risk for HIV infection among young racial/ethnic minority MSM. Together with AIDS data, HIV data highlight the extent of the need for prevention and treatment to reduce HIV-related morbidity and mortality in this population.</B> </div> <div> <B>To reduce infection rates and improve the likelihood of survival, prevention programs for racial/ethnic minority MSM need to focus on both HIV-infected and uninfected populations. Challenges to the design and implementation of HIV prevention programs among racial/ethnic minority MSM include reaching MSM who may not identify themselves as homosexual or bisexual</B>, <B><U>recognizing the importance of representing racial/ethnic minority MSM in HIV prevention planning</U></B>, addressing language barriers, and improving access to HIV testing and health care. Within racial/ethnic minority communities, the stigma attached to acknowledging homosexual and bisexual activity may inhibit racial/ethnic minority MSM from identifying themselves as homosexual or bisexual (7), and they may be more likely to identify with their racial/ethnic minority community than with the MSM community (8). In a CDC-sponsored study of 8780 MSM with HIV infection or AIDS, 24% of non-Hispanic black MSM, 15% of Hispanic MSM, and 11% of A/PI MSM identified themselves as heterosexual compared with 7% of AI/AN and 6% of non-Hispanic white MSM (CDC, unpublished data, 1999). <B>Racial/ethnic minority community leaders should </B><B><U>promote dialogue about issues of sexual orientation</U></B><B> to overcome social barriers to HIV prevention for racial/ethnic minority MSM (3), especially among young men.</B> </div> <div> <B>[Note: The NC AIDS Policy Center does not view the promotion of "dialog about issues of sexual orientation" as a broad enough approach to overcoming social barriers to HIV prevention among racial/ethnic populations.]</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> MSM remain a population at high risk for HIV infection, and continued efforts to promote behavioral risk reduction among at-risk youth are needed. Serologic surveys, HIV/AIDS case surveillance, and supplemental research and evaluation studies of racial/ethnic minority MSM and other HIV-infected and at-risk populations are needed to target intervention programs (9). <B>In 1999, CDC funded a special program to enhance HIV prevention services for racial/ethnic minority MSM</B> (10). CDC and other federal agencies are collaborating to facilitate links between prevention and treatment services for infected and at-risk populations. </div> <bR> <div> _ _ _ _ References _ _ _ _ </div> <div> 1. CDC. HIV/AIDS surveillance report. Atlanta, Georgia: US Department of Health and Human Services, CDC, 1999;11(1). </div> <div> 2. Kelly JJ, Chu SY, Diaz T, et al. Race/ethnicity misclassification of persons reported with AIDS. Ethnicity and Health 1996;1:87-94. </div> <div> 3. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African-American men who have sex with men. AIDS Educ Prev 1998;10:278-92. </div> <div> 4. National Commission on AIDS. The challenge of HIV/AIDS in communities of color. Washington, DC: National Commission on AIDS, December 1992. </div> <div> 5. CDC. National HIV prevalence surveys, 1997 summary. Atlanta, Georgia: US Department of Health and Human Services, CDC, 1998. </div> <div> 6. Valleroy L, MacKellar DA, Rosen D, Secura G. HIV and predictors of unprotected receptive anal intercourse for 15-to-22-year old African American men who have sex with men in seven cities, USA. Presented at the 12th World AIDS Conference, Geneva, Switzerland, June 30, 1998. </div> <div> 7. Doll LS, Beeker C. Male bisexual behavior and HIV risk in the United States: synthesis of research with implications for behavioral interventions. AIDS Educ Prev 1996;8:205-25. </div> <div> 8. Health Resources and Services Administration. HIV/AIDS Work Group on Health Care Access Issues for Gay and Bisexual Men of Color. Washington, DC: US Department of Health and Human Services, 1995:33. </div> <div> 9. CDC. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR 1999;48 (no. RR-13). </div> <div> 10. CDC. Community-based HIV prevention services and capacity-building assistance to organizations serving gay men of color at risk for HIV infection; notice of availability of funds. Federal Register 1999;64:33293-305. </div> <div> * Non-Hispanic black, Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander men aged greater than or equal to 13 years who have sex with men. </div> <div> ** Alabama, Arizona, Arkansas, Colorado, Idaho, Indiana, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. </div> <bR> <div> _ _ _ _ Table 1 _ _ _ _ </div> <div> see: </div> <div> <U>http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4901a2.htm</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> _ _ _ _ Figure 1 _ _ _ _ </div> <div> see: </div> <div> <U>http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4901a2.htm</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> _ _ _ _ Table 2 _ _ _ _ </div> <div> see: </div> <div> <U>http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4901a2.htm</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div>  <img src="HTMLobj-325/aniGif.gif" border="0" align="bottom" width="119" height="121">  </div> <bR> <div> July 3, 2001</div> <bR> <div> New York Times Headline</div> <div> AIDS Epidemic Takes Toll on Black Women</div> <div> By KEVIN SACK</div> <bR> <div> REENWOOD, Miss. - Here in the rural South, the image of AIDS today looks very much like Tyeste W. Roney.</div> <div> Not a gay white man. Not a crack-addicted prostitute. But a 20-year-old black woman with a gold stud in her nose, an orange bandanna covering her braids, and her nickname, Easha, tattooed on one leg.</div> <bR> <div> In the back of her mind at least, Ms. Roney had known for years that she could contract HIV by having unprotected sex. Her mother had been telling her so since Ms. Roney was 13, when she lost her virginity. But either the lesson did not stick, or Ms. Roney did not have the power to negotiate safer sex with older lovers. She says that many of the men she can count as partners did not use condoms.</div> <bR> <div> In February, after enduring 10 days of bleeding, Ms. Roney went to a health clinic. First a nurse surprised her by telling her that she had been pregnant and had miscarried. Then the nurse asked Ms. Roney if she knew she was carrying the virus that causes AIDS.</div> <bR> <div> "I said, `Get out of here, that can't be so,' " Ms. Roney recalled. "I just broke down and cried. I thought I wasn't going to be here long. Maybe a month."</div> <bR> <div> It is a scene that has become all too familiar for poor black women here in the Mississippi Delta and across the rural South. Even as the AIDS epidemic has subsided elsewhere in the United States, it has taken firm root among women in places like Greenwood, where messages about prevention and protection are often overtaken by the daily struggle to get by.</div> <bR> <div> Researchers say that in many ways the epidemic in the South more closely resembles the situation of the developing world than of the rest of the country. Joblessness, substance abuse, teenage pregnancy, sexually transmitted diseases, inadequate schools, minimal access to health care and entrenched poverty all conspire here to thwart the progress that has been made among other high-risk groups, particularly gay men.</div> <bR> <div> While AIDS rates in the United States remain lower among women than men, women now account for a fourth of all newly diagnosed cases, double the percentage from 10 years ago. That growth has largely been driven by the disproportionate spread of the disease among heterosexual black women, particularly in the South.</div> <bR> <div> For those who contract HIV or AIDS in the rural South, life can become intensely isolated. Because of widespread misunderstandings about the ways HIV is transmitted, the stigma facing those who are infected is often suffocating.</div> <div> Many women are terrified to tell even their families, and they find their only comfort in the monthly meetings of a support group. One woman here, who lives with her son, is convinced that he would make her eat on paper plates and would keep her away from her grandchildren if he knew of her illness. Ms. Roney, who has informed only her family members, said she lost several neighborhood friends after they saw a health department van pull into her driveway to pick her up for a clinic visit.</div> <bR> <div> Black women, who make up 7 percent of the nation's population, accounted for 16 percent of all new AIDS diagnoses in 1999, a percentage that has grown steadily since the syndrome was first identified 20 years ago. By comparison, black men made up 35 percent, white men 27 percent, Latino men 14 percent, and white and Latino women were each 4 percent.</div> <bR> <div> While the number of new AIDS cases in the United States began to decline in the mid-1990's, the reversal started later for Southern black women, and the drop has been slower.</div> <bR> <div> From 1981 to 1999, 26,522 black women developed AIDS in the 11 states of the former Confederacy. In Mississippi and North Carolina, statistics show that more black women than white men have contracted HIV over the epidemic's course.</div> <bR> <div> Unless a cure is found, the share of AIDS patients who are black and female is likely to rise. The trend is strikingly visible in Southern states with large black populations. Here in Mississippi, 28.5 percent of those reporting new HIV infections in 2000 were black women, up from 13 percent in 1990. In Alabama, the number rose to 31 percent, from 13 percent. In North Carolina, it rose to 27 percent, from 18 percent.</div> <bR> <div> "While the HIV epidemic is also increasingly affecting men in the South and black men, the overall trends for women are distinct," concluded researchers with the Centers for Disease Control and Prevention in a paper published in March in The Journal of the American Medical Association. "The HIV epidemic in women initially centered on injection drug-using women in the urban Northeast, but now centers on women with heterosexual risk in the South."</div> <div> An Explosive Increase</div> <bR> <div> In 1997, Dr. Hamza O. Brimah, a Nigerian- born physician who received training in AIDS care in London and New York, opened the Magnolia Medical Clinic in a strip mall here in affiliation with the Greenwood Leflore Hospital. Dr. Brimah is the only AIDS specialist in a nine-county area. He started with fewer than 10 AIDS patients. Now he has 185. He assumes he is seeing only a fraction of those who are actually infected.</div> <div> "In the beginning, I remembered everybody's name," Dr. Brimah said. "Now I have a hard time. Who's this? Who's that? They're coming at me so fast."</div> <bR> <div> Sixty percent of Dr. Brimah's AIDS patients are women and 95 percent are black, in an area where 61 percent of the population is black. Almost all were infected through heterosexual transmission, and a majority, he estimates, came to him with a history of sexually transmitted disease.</div> <bR> <div> Research has shown that people with sexually transmitted diseases like syphilis, gonorrhea and chlamydia have twice to five times the risk of contracting HIV, because the diseases cause ulcerations in protective mucous membranes. The South has consistently had the country's highest rates of sexually transmitted diseases. In 1999, for instance, 9 of the 10 states with the highest rates of gonorrhea and syphilis and 7 of the 10 with the highest rates of chlamydia were in the South, according to CDC. figures.</div> <bR> <div> Dr. Brimah hears from his patients that HIV is often the least of their worries. "There are issues," he said, "of looking after children, trying to get insurance, the lack of a father in the home, alcohol, drugs. They have so much going on."</div> <div> Because of that, he said, women rarely seek out HIV testing for themselves or their partners. Many of his patients, like Ms. Roney, learn that they are positive only when they become pregnant.</div> <bR> <div> The other thing Dr. Brimah hears repeatedly from his patients is that they understood before they were infected that HIV could be transmitted heterosexually. Typically, they hold no misconceptions that HIV victimizes only gay white men. And yet, like smokers, speeders and drug users, they place themselves knowingly at risk.</div> <bR> <div> Dr. Brimah told of one patient who dutifully took annual HIV tests for three years, who clearly understood the nature of the virus and who then tested positive in the fourth year. "She was clued up, but she took the risk," he said. "She really couldn't explain it."</div> <bR> <div> The women often struggle to explain their recklessness. They look down at the floor when asked to discuss their sexual behavior. Even those who have had many sexual partners will say that they were choosy, that they had known their partners for years, sometimes for a lifetime, and that they trusted them. Over and over, they say, they just did not think it could happen to them.</div> <bR> <div> "I just wasn't thinking about no HIV, and I wasn't thinking about no AIDS and I wasn't thinking about no pregnancy," Ms. Roney said. "I was just being hardheaded. I don't know any other way to break it down."</div> <bR> <div> Jean, a 44-year-old woman with AIDS who did not want her last name used, said she fell into a fast lifestyle after getting divorced in 1987. She said she might have had 30 to 35 partners over the last 10 years, and that they only occasionally used condoms.</div> <bR> <div> "I guess I just blocked it out of my mind," she said. "I thought I had a good heart so it wouldn't happen to me. I knew it could happen, I guess, but I was just being stupid."</div> <bR> <div> Health workers and researchers who hear these stories say that such high-stakes risk- taking may seem to make no sense, but that it must be viewed within the context of lives defined by fatalism, faith and powerlessness. Often they say, there is little to break the tedium and despondency of life here, and certainly little that provides pleasure, other than sex.</div> <bR> <div> "There's a sense that you don't control your life that much, and if God wants me to have HIV I'll get it," said Kathryn Whetten-Goldstein, an assistant professor of public policy at Duke who has been studying AIDS in Southern states. "All of their life experiences teach them that they have very little control over their future."</div> <bR> <div> Some girls start having sex at extremely young ages, almost always with older men, and find they have little ability to persuade their partners to use condoms.</div> <bR> <div> "Most times I asked them to use one," said Ms. Roney, a ninth-grade dropout, "but you know how guys are. They do their little sweet talk. `It doesn't feel the same. Let's use one next time.' I just went along with it. I fell into that trap."</div> <div> Poverty, Drugs and Risk</div> <bR> <div> Often, though not always, drugs and money play a vital role as well. Indeed, Dr. Brimah said the desperate need for money had become an HIV risk factor in the Delta in the same way that needle-sharing was in the cities.</div> <bR> <div> The Mississippi Delta, where the young green cotton crop shares the summer landscape with immense catfish farming ponds, has for years been among the poorest regions in America.</div> <bR> <div> The median income here in Leflore County was $21,027 in 1997, more than $7,000 below the state median, which is itself the second lowest in the country. Three of every 10 Leflore residents live below the poverty line. The unemployment rate in April was 7.1 percent (some neighboring counties have broken well into double digits) and the recent closing of several large plants has made work even harder to find than usual.</div> <bR> <div> The poverty is apparent on the rough streets and unpaved alleys of black neighborhoods like Baptisttown and McLaurin, where men and women sweat out steamy nights on the porches of dilapidated shotgun shacks. Just across the Yazoo River lies another world of brick mansions and lovingly tended lawns, where the white people live.</div> <div> As everywhere, some poor women here make ends meet through prostitution. But the more common practice is a less formalized sex-for-money exchange in which nothing is negotiated up front. Rather, several women and health workers explained, there is an unstated assumption that a woman who engages in casual sex with a man will be rewarded with a little financial help, perhaps in paying the rent, perhaps in buying groceries. As one woman explained it to Dr. Brimah: "You know how it is with men, doc. No honey, no money."</div> <bR> <div> Gina M. Wingood, an assistant professor of public health at Emory University who has studied AIDS in rural Alabama, said: "It's just trying to make ends meet, day-to- day survival. We sort of see it in terms of prostitution, but they see it as how they have to frame their lives, especially if they have children or elderly parents to care for."</div> <div> Jean, the 44-year-old AIDS patient, said she regularly operated that way. "Some of them would pay me for sex but it wasn't like I was out on the street," she said. "The guy would just give me a little something sometimes. I had an apartment and had bills and I wasn't working."</div> <bR> <div> Jerome E. Winston, a health department worker who tracks the sexual networks of infected people in the Delta, said he had heard complaints from some women about other women who accepted insufficient compensation for their companionship.</div> <bR> <div> "What we had said to us a couple of times by the older girls is that the younger girls are messing up the system because they're giving it away virtually for free," Dr. Winston said. "They don't negotiate anything except for maybe a new CD or a pair of shoes."</div> <bR> <div> Sex is also sometimes exchanged for drugs, particularly crack cocaine, though this seems to be more common in larger towns in the southern part of the state.</div> <bR> <div> Sharyn Janes, a professor of nursing at the University of Southern Mississippi, said she heard horror stories while conducting interviews with people considered at high risk of infection. One man, she said, told her that he once drove a woman out of town when she refused his demand for sex after he gave her crack. He told her that "nobody gets a free ride" and left her to walk home, Ms. Janes said.</div> <bR> <div> Tracing Sexual Networks</div> <div> Because of the breadth and casualness of sexual networks here, an infection can be virtually impossible to track and control.</div> <bR> <div> In the first half of 1999, for instance, health officials untangled a trail left by two HIV positive men in Greenwood who had had sex with 18 women over a three-year period. Two of the women had had sex with both men. Five were themselves infected with the virus, and they in turn had had sex with 24 other men.</div> <div> A study of the cluster by the CDC. found that half of those interviewed had a history of other sexually transmitted diseases, that some of the HIV infected women were as young as 13, and that the median age of the infected women was 16, compared with 25 for the infected men. </div> <bR> <div> "The teenager's concept is that this guy is older so he's going to know what he's doing and he will take care of me," said Dr. Shannon L. Hader, a Centers for Disease Control researcher who studied the Greenwood cluster. "The reality is that older men have had more partners and are therefore more likely to have STDs."</div> <bR> <div> Clearly, Dr. Hader said, messages about prevention are not getting through. The rural South is politically conservative, and prevention programs in the schools tend to be episodic and focused on abstinence. Parents of students in the Greenwood schools must grant written permission before their children can be taught about condoms. Many local pastors are also reluctant to encourage explicit discussions about sex.</div> <bR> <div> Dr. Hader also found a lack of knowledge about HIV treatment. Five of the seven infected members of the Greenwood cluster had no idea that those with HIV could now live for long periods with the help of antiretroviral drugs. That misconception has made it difficult to get patients into care, where they could also receive information about not spreading the virus.</div> <bR> <div> Those who do seek care have few options. Before Dr. Brimah opened his clinic here, AIDS patients had to travel more than two hours to Jackson or Memphis, a trip that many could not make. Sandra Moore, a 32- year-old Greenwood woman who first learned that she had AIDS in 1990, would sometimes drive as far as New Orleans for treatment. Ms. Moore had withered to 60 pounds when she first visited Dr. Brimah, and was seemingly weeks away from death. Now on medication, she has increased her weight to 105 pounds and talks of living to see her four young children graduate from high school. </div> <bR> <div> The cost of treatment is also prohibitive for many here. The pills typically prescribed by Dr. Brimah can cost up to $1,200 a month. Medicaid covers many of the poorest patients, and other state and federal programs help. But the working poor often have trouble qualifying for the programs.</div> <bR> <div> Last year, Dr. Brimah received a three- year, $1.2 million grant under the Ryan White Care Act, the primary source of federal money for AIDS treatment. He uses the money to pay staff members, to buy equipment, supplies and medication, and to provide transportation to needy patients.</div> <bR> <div> But in general, many Southern states have received a disproportionately small share of Ryan White funds. The money is appropriated to states by a formula based on the number of people living with AIDS in that state. But the growth of the epidemic in the South has been relatively recent, and many of those infected have not progressed from HIV to AIDS. Congress changed the formula last year so that money will eventually be based on HIV counts, but the new system might not take effect for years.</div> <bR> <div> The other factors obstructing treatment, and thus prevention, are denial and stigma. Many infected women here never tell family members and close friends for fear of being shunned and abandoned.</div> <bR> <div> "A lot of people don't understand about it," said Jane Smith, who has only told her pastor and her mother-in-law since learning two years ago that she has AIDS. "I guess they're scared they can catch it from being around people with it, if they cough on them or shake their hands."</div> <bR> <div> One married couple, both infected, said they were open about their status when they lived in New York but had told no one since moving to Mississippi, not even their friends at Narcotics Anonymous meetings. "Everybody would scatter if they knew," said the wife.</div> <bR> <div> Jean has lied to her family members, telling them that she has cancer, and has batted away their questions. Her joy, she said, is her grandchildren, and she is convinced that her son would not let her near them if he knew.</div> <div> "I want to tell my family," she said, "but I know they're not going to accept it, and I'm just not strong enough right now for them to reject me. It would just send me over the edge."</div> </td> </tr></table></body>