RALEIGH, N.C. - Fiddling with a cigarette, Louise, a straight-talking 23-year-old who has been living with H.I.V. for four years, grimaced as she discussed life in the black neighborhood of her small town, a sleepy outpost east of the state capital.
The only jobs, she said, were generally at fast-food places, farms or factories. Entertainment consisted of hanging out on the street corner or at the strip mall. And as for men, she said, with an air of resignation, "They've either been in prison, they're married or they're gay."
It never seemed unusual, said Louise, who asked that her last name be withheld because some people close to her are unaware of her H.I.V. status, that nearly all the men she had been involved with - including the one who passed the virus on to her - had been in prison.
"In a grocery store you have a big selection of meat laid out in front of you, and you can chose which grade you want," she said. But in her town, she added, "you don't have that choice. There is no way to really decide the good from the bad. It's all what you decide you can deal with."
As health specialists continue to grapple with global challenges to combating AIDS, Louise, a black woman living in the South, infected through heterosexual sex, represents the continuing struggle with the epidemic in the United States. Her story also illuminates a complex domestic issue: the link between high rates of imprisonment among African-Americans and high rates of H.I.V. and AIDS.
While many studies have documented the prevalence of the disease in prisons, researchers are now examining how patterns of incarceration affect its transmission beyond prison walls.
The health consequences cut across lines of class, said Dr. Peter Leone, medical director of the H.I.V. and sexually transmitted disease division of the North Carolina Department of Health and Human Services. "You're not even looking at six degrees of separation in most black social networks between a disenfranchised former inmate and someone who is in college or highly respected in the community," he said.
Researchers say high incarceration rates increase risk behaviors associated with H.I.V. by skewing the ratio of women to men, worsening economic conditions and increasing the social capital of men who are not imprisoned.
"H.I.V. is an opportunistic disease that thrives on disruptions of social networks," said Dr. David Wohl, an infectious disease specialist at the University of North Carolina, where several studies on the subject are under way. "You can hardly get more socially disruptive than removing double-digit percentages of men from communities for extended periods of time."
Blacks now account for more than half of all new H.I.V. infections, according to the Centers for Disease Control and Prevention. Black women account for 72 percent of all new cases among women. During the decades that the AIDS epidemic has spread, the number of people incarcerated has also soared, to nearly 2.1 million, according to the Bureau of Justice Statistics. Of that total, more than 40 percent are black.
As the number of people living with H.I.V. increases, and with roughly 600,000 prisoners re-entering society each year, researchers are starting to address the two issues as intertwined epidemics requiring combined prevention and treatment strategies.
In North Carolina, African-Americans make up more than 70 percent of all existing H.I.V. and AIDS cases, and about 60 percent of the state's roughly 35,000 prisoners. James Thomas, a University of North Carolina epidemiologist conducting a county-by-county study of the data, found "a robust correlation" between incarceration rates and the rates of H.I.V. and other sexually transmitted diseases.
Doctors and social workers in the state say prison, either directly or indirectly, affects many of their H.I.V. patients. An infected woman near Chapel Hill, for example, suspected her boyfriend of having sex with men in prison and after he got out, but could never bring herself to ask him about it. Mary, a former nurse from Charlotte, ignored her husband's infidelities because so few men were available.
"I had the whole world in front of me, living fine, until this blow came," said Mary, 50, who asked that her last name be withheld to protect her grandchildren, whom she is raising.
For Louise, who grew up in Wake County, in a rural town of 4,000 where blacks are clustered on the poorer south side, H.I.V. has quietly joined poverty, drugs and prison stints as part of the tattered fabric of daily life.
The oldest of four siblings in a family that struggled to make ends meet on her father's factory wages, Louise became sexually active at 13. Nice homes and good jobs seemed reserved for whites on the other side of town. The dead-end jobs where most blacks ended up made school seem irrelevant. Sex, she said, was an easy way to pass time, and a drug dealer's ready supply of cash outweighed whether he had come from - or might soon go to - prison or jail.
"Most of the guys I dealt with had a drug charge at some time," she said.
"I remember this one guy, I saw the gold in his mouth and I thought,
'Ching, ching. He can give me what I want.' But then I was also thinking,
'Is this really what I want?' "
She was dumbfounded, she said, when a blood test she took as part of a gynecological exam when she was 19 showed she was H.I.V. positive. She never found out how or where the former prisoner who infected her had picked up the virus, though she assumed it was from sex because she never saw him use intravenous drugs.
"When you think about the things that might happen, you think as long as you don't have a baby you're O.K.," Louise said. "You think about the guy you're dating, how he might violate probation and go to jail again and you'll be alone. But you never think that he could have this disease. You never think about that."
Many inmates enter prison already infected. The prevalence of confirmed AIDS cases in prisons is three times as high as it is in the general population, according to the Bureau of Justice Statistics. H.I.V. cases are harder to count, because only 19 states conduct mandatory H.I.V. testing of inmates. But many researchers believe the number of prisoners with H.I.V. to be far higher than the 1.9 percent most recently documented by the justice agency.
Correctional health experts say the rampant sexual activity among prisoners depicted in television shows like the HBO prison series "Oz" is exaggerated. But sex in prison certainly occurs. And because the distribution of condoms is banned in most correctional facilities - North Carolina's state prison system included - any sex between inmates carries a high level of risk.
Add the element of drug addiction, which often goes untreated in prisons and is frequently accompanied by risky sexual activity, said Robert E. Fullilove, associate dean at the Mailman School of Public Health at Columbia University, and the risk of H.I.V. transmission both inside and outside prison increases exponentially.
"The war on drugs took the group that was at greatest risk for H.I.V. infection and made sure that they would be locked up, without ever considering what to do when they got out," Mr. Fullilove said.
Newly released prisoners often plunge immediately into dangerous sexual behavior. "Many inmates who have been locked up for a while want two things when they come out," said Dr. Wohl, who regularly sees current and former inmates in his clinical practice. "One of them is a Big Mac. The other is sex. If you're going to get to them with condoms or health messages, you have to be quick."
Thomas Clodfelter, 44, a former felon with H.I.V. who now counsels other ex-convicts in Greensboro, said that for some men, the first weekend after release is consumed with sex - with prostitutes, old flings, fresh one-night stands or a combination thereof. Condoms, he said, are often an afterthought.
Mr. Clodfelter, who was infected through heterosexual sex and who served four prison terms for offenses including drug possession, robbery and a shooting, said people were quick to blame men for spreading the virus. But in neighborhoods where self-esteem runs low and desperation high, he said, women often pursue risky sex as aggressively as men.
"A lot of women, they are looking for a man to give them a sense of strength, a sense of authority," he said. "Men come out of prison, they're all big, got muscles, looking good. And the women, they're all up on them. It's not like people don't know they are putting themselves at risk. They just don't care."
Such obvious risks, Mr. Clodfelter and others say, are compounded by the difficulty many felons have in re-entering society - hurdles that often push them back into dangerous social and sexual behavior.
Sitting recently in a tidy one-bedroom apartment in the city of High Point, William, a two-time inmate with AIDS, looked troubled. On his coffee table, next to a cousin's kindergarten graduation picture and a book titled "Foods That Heal," were two letters bearing bad news.
One was from the Social Security Administration, informing him that although he had AIDS, he did not qualify for financial benefits. The other was from the Guilford County Department of Social Services, explaining that because he had been denied Social Security, he was ineligible for Medicaid, a benefit he needed to pay for his twice-daily regimen of five AIDS medications. The side effects of those same drugs, he said, made it difficult to work the physically demanding jobs he was qualified for with only an eighth-grade education.
William, 36, who asked that his last name be withheld to protect his identity as he looked for a job, had also applied for help from the federally financed AIDS Drug Assistance Program. But the waiting list in North Carolina includes more than 800 people, the longest in the country.
"I guess you got to be half dead for them to start giving you some money," he said, looking down at the bureaucratic hurdles spelled out before him. " If I didn't have a place to stay, I'd probably resort to crime again."
Sharon Lipscomb, William's case manager, said his challenges were not unique. As a director of services in High Point for the Triad Health Project, an AIDS service organization, she has 65 to 100 clients at a time struggling with issues like housing, mental illness and myriad chronic diseases. William, she said, was among the more motivated, having aggressively sought medical and social support upon his release.
When he first agreed, more than two months ago, to talk to a reporter about his reintegration into society, the former inmate was upbeat. But in subsequent weeks, after a series of disappointments, he grew increasingly pessimistic and destructive.
A gay man who had mused in an early interview about "finding a serious woman" to appease his Pentecostal family, William had recently begun to move through precarious sexual relationships. There was a 26-year-old man from a neighboring town whom he met on a telephone chat line and a 19-year-old man from Georgia who hurt his feelings by moving in with another man.
William said he had used condoms with both men. But he admitted, with a measure of guilt, that he had stopped taking his medications because the side effects were too much to deal with along with all of his other struggles.
Mr. Clodfelter said hard-luck stories like William's often turn ugly fast. "People head back to their same old playgrounds - drugs, hustling, whatever," he said. "And soon the cycle starts itself all over again."
Looking for Solutions
The link between former inmates like William and women like Louise is not that distant, experts say. "It doesn't matter whether you're straight or gay, poor or middle class," Ms. Lipscomb said. "In black communities the networks are very close. A man he's having sex with may have a wife or a girlfriend, who would rather not know what's going on. What happens to him has an effect on what happens to a lot of people."
Dr. Adaora A. Adimora, an infectious disease specialist and epidemiologist at the University of North Carolina medical school, found that high levels of incarceration even decrease monogamy between women and men who have never been in prison, because the men left behind are in high demand.
That is especially true, Louise said, if the man is a "roller - someone to pay your bills, take you out to eat, take you shopping." If he's a real roller, she said, "it's almost a given he's got a chick on the side. You're not really his woman. It's more like rental property. It's all temporary."
She talked disapprovingly of three women she recently saw riding in a car together who were knowingly sharing the same man. "He's got money, so they don't talk about it and act like they don't care," she said. "They're not looking at how stupid they look."
Researchers trying to prevent the spread of H.I.V. are urging strategies that connect education and treatment among three groups of people: inmates, those recently released, and those in the social networks through which they move.
The University of North Carolina has a contract with the state's corrections department to operate weekday medical clinics in three of the state's 77 prisons. Every Wednesday a university-based team of physicians, nurses, social scientists and health policy professionals called the Prison Working Group meets over pizza to discuss their research.
Pre-release planning for H.I.V.-infected inmates varies from state to state. In North Carolina, infected inmates get counseling, a 30-day supply of medications, a prescription for 30 more days and contact information for health service organizations before they are released.
In a new project, case managers from the university group will begin accompanying patients to their first medical and social service appointments outside prison, overseeing their progress for six months after release.
More difficult than experimenting with new treatment approaches, members of the group say, is stripping away the stigma that still shrouds much discussion of H.I.V. among blacks in the South.
As with William, Louise's infection is mostly unacknowledged in her family. When a male relative died recently of AIDS, she said, his illness was generally referred to within the family as sickle cell anemia.
It is not uncommon, several doctors said, for patients, especially women, to seek treatment in another city or county because of shame. Mary, the nurse from Charlotte who was infected by her husband, said she drove to Atlanta for two years to seek treatment to keep people close to her from finding out she had contracted the disease.
Reluctant at first, Louise said she eventually came to view her conversations with a reporter "as testimony, so people will start to be honest." Now in what she termed a secure relationship, she said she viewed the compromises she once made as "plain stupid." Had she not become infected, she said, "there's no telling where I'd be now, but it sure wouldn't have been nowhere good."
With a full-time job as a security guard, she is hoping to save enough money to pay for cosmetology school. Her current boyfriend was briefly in jail, but he has a good job in construction and a house, which they share. He knows she is H.I.V. positive, she said, and he is very supportive.
After a moment of hesitation, Louise admitted that they do not always use protection.
"He says if he gets infected he'll just deal with it," she said with a shrug of her shoulders and a raised eyebrow that hinted at disbelief.
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