Thank you. i'm going to make an effort to read it soon.
Here's an article from today's NYT on the rising incidence of AIDS among Southern black women. How much data will it take for some people to understand that AIDS is not a punishment from God against gay men?
NB: This is a very long, and very sad, read.
July 3, 2001
AIDS AT 20 / In the South, a Different Face
AIDS Epidemic Takes Toll on Black Women
By KEVIN SACK
REENWOOD, Miss. — Here in the
rural South, the image of AIDS today
looks very much like Tyeste W. Roney.
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.
In the back of her mind at least, Ms. Roney
had known for years that she could contract
H.I.V. 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.
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.
"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."
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.
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.
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.
For those who contract H.I.V. or AIDS in the rural South, life can become intensely
isolated. Because of widespread misunderstandings about the ways H.I.V. is
transmitted, the stigma facing those who are infected is often suffocating.
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.
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.
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.
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 H.I.V. over the epidemic's course.
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 H.I.V.
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.
"While the H.I.V. 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 H.I.V. 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."
An Explosive Increase
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.
"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."
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.
Research has shown that people with sexually transmitted diseases like syphilis,
gonorrhea and chlamydia have twice to five times the risk of contracting H.I.V.,
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
C.D.C. figures.
Dr. Brimah hears from his patients that H.I.V. 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."
Because of that, he said, women rarely seek
out H.I.V. testing for themselves or their
partners. Many of his patients, like Ms.
Roney, learn that they are positive only
when they become pregnant.
The other thing Dr. Brimah hears repeatedly
from his patients is that they understood
before they were infected that H.I.V. could
be transmitted heterosexually. Typically,
they hold no misconceptions that H.I.V.
victimizes only gay white men. And yet, like
smokers, speeders and drug users, they
place themselves knowingly at risk.
Dr. Brimah told of one patient who dutifully
took annual H.I.V. 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."
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.
"I just wasn't thinking about no H.I.V., 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."
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.
"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."
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.
"There's a sense that you don't control your life that much, and if God wants me to
have H.I.V. 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."
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.
"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."
Poverty, Drugs and Risk
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 H.I.V. risk factor in the
Delta in the same way that needle-sharing was in the cities.
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.
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.
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.
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."
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."
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."
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.
"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."
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.
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.
Tracing Sexual Networks
Because of the breadth and casualness of
sexual networks here, an infection can be
virtually impossible to track and control.
In the first half of 1999, for instance, health
officials untangled a trail left by two
H.I.V.-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.
A study of the cluster by the C.D.C. found
that half of those interviewed had a history
of other sexually transmitted diseases, that
some of the H.I.V.-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.
"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 S.T.D.'s."
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.
Dr. Hader also found a lack of knowledge about H.I.V. treatment. Five of the seven
infected members of the Greenwood cluster had no idea that those with H.I.V.
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.
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.
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.
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.
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 H.I.V. to AIDS. Congress changed the formula last year so that
money will eventually be based on H.I.V. counts, but the new system might not take
effect for years.
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.
"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."
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.
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.
"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." |
