April 5, 2004 - The New York Times AIDS Fears Grow for Black Women By Linda Villarosa

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HOUSTON - Once a week, the five friends, all members of the Abundant Life Cathedral here, get together to eat sushi, sip wine and talk. But one recent afternoon, the women chose a different activity: They went to see "Not a Day Goes By," a musical about black men on the "down low" who, while not calling themselves gay or bisexual, have sex with other men, often behind the backs of their wives and girlfriends.

To these women, it was a subject of increasing urgency.

"Once I found out how prevalent the down low was in our community, I was very afraid," said one of the women, Tracy Scott, a 37-year-old government relations consultant.

Her friend Misha King, 35, said she needed to get as much information as she could, as quickly as she could.

"I've been on field trips to the gay bars and have seen guys that look like men you would date," Ms. King said. "I treat every man as a bisexual because I don't want to end up as the sister with H.I.V."

In the past, concern about black women and AIDS was mainly focused on those who had used drugs or had had sex with users. But increasingly, women like Ms. Scott and her friends have begun to worry, too.

In government studies of 29 states, a black woman was 23 times more likely to be infected with AIDS than was a white woman, and black women accounted for 71.8 percent of new H.I.V. cases in women from 1999 to 2002. Though new cases of H.I.V. among black women have been stable in the past few years, the number of those who have been infected through heterosexual sex has risen.

In 2001, according to the Kaiser Family Foundation, a nonprofit group focusing on health issues, an estimated 67 percent of black women with AIDS contracted the virus through heterosexual sex, compared with 58 percent four years earlier. Black women accounted for half of all H.I.V. infections acquired through heterosexual sex, in men or women, from 1999 to 2002, the Centers for Disease Control and Prevention said.

Though heterosexual transmission has risen for all women, researchers say a black woman has a greater chance of coming into contact with the virus when she has sex with another black person because, compared with the general population, there is a higher rate of H.I.V. among black Americans.

Recent studies suggest that 30 percent of all black bisexual men may be infected with H.I.V., and up to 90 percent of those men do not know they are infected. Researchers for the Centers for Disease Control have referred to these men as a "bridge" to infection from gay men to heterosexual women.

In February, health officials identified a fast-spreading outbreak of infections among 84 men, primarily black students at 37 colleges in North Carolina. The majority were infected through sex with other men, but a third reported that they had had sex with men and women.

"What we learned from the research we did with college men here is the potential for H.I.V. to enter the mainstream population of the black community," said Dr. Peter Leone, medical director of the North Carolina Department of Health and Human Services H.I.V. prevention unit and a co-author of a study of the 84 men.

"This is a big change and may be a defining moment," Dr. Leone added. "I don't mean to sound like Chicken Little, but if we don't react to this very quickly and aggressively, it'll be like the 80's all over again. Instead of gay white men, though, we'll be dealing with large numbers of young black men and their female partners."

The fear of H.I.V. among blacks is not new, and the down low has been part of the black lexicon at least since the mid-1990's, when E. Lynn Harris's novels about bisexual black men who lead double lives first appeared on best-seller lists.

AIDS prevention efforts have generally focused on drug users and men who have sex with men. But the North Carolina findings made it clear that H.I.V. had the potential to spread to a wider circle of blacks. In particular, the new research has alarmed black women. Now in online chat rooms, at book clubs, on radio call-in shows and in whispered conversations with friends, many are trying to piece together information to figure out if men, whether one-night stands or their husbands, may have secret lives putting them at risk.

"H.I.V./AIDS is a disease of opportunity, not socioeconomics," said Phill Wilson, executive director of the Black AIDS Institute in Los Angeles. "The research out of North Carolina reveals that among black folks, no matter who you are or who you think you are, you are not safe from H.I.V."

Dr. Robert S. Janssen, director of the Centers for Disease Control's divisions of H.I.V./AIDS prevention, warned that evidence was lacking about what was driving infection in black women.
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"Yes, the risk of contracting H.I.V. is highest in the African-American community and there's no question black women are at higher risk compared to other women, but there's still a lot we don't understand," Dr. Janssen said.

"However, we are concerned enough to tell women of all socioeconomic groups to ask their partners about their sero status and if they are having sex with men," he said, referring to H.I.V. status.

A tangle of factors heightens the risk for black women.

No one knows for sure how much the spread of the AIDS virus among blacks can be attributed to the behavior of bisexual men. Some reports have suggested that black men are more likely to keep their bisexuality a secret for a variety of reasons, but that, too, is hard to quantify.

Still, researchers say it comes down to a numbers game: blacks make up roughly 12 percent of the nation's population but in 2002 accounted for 42 percent of people living with AIDS and more than half of all new infections. Blacks tend to have sexual relations with other blacks, experts say, which works to confine the virus within the African-American "sexual network."

"A high prevalence of infection in the pool of potential partners can spread sexually transmitted infections rapidly within the ethnic group and keep it there," said Dr. Adaora A. Adimora, an infectious disease physician and associate professor at the University of North Carolina School of Medicine in Chapel Hill.

She and others cite several other factors. Perhaps the most vexing may be the shortage of black men as potential partners. This gender gap, experts say, may lead black women to make unsafe sexual decisions and raise their risk of infection.

"Large numbers of black men are in prison, or unemployed, or dead, so there is simply a smaller pool of available partners to choose from," said Dr. Gail E. Wyatt, a psychiatry professor and an associate director of the University of California, Los Angeles, AIDS Institute. "So while women are quite concerned about being infected with H.I.V., the threat of death is not enough to persuade black women to protect themselves if it means being alone, childless and with less income."

Though women outnumber men in the general population, the gap is wider among blacks. According to 2002 census data, there are 12.6 million black women 21 or older, compared with 9.9 million black men. On college campuses, the numbers are particularly lopsided: in 2000, according to the National Center for Education Statistics, more than one million black women were enrolled in degree-granting institutions, compared with 635,000 black men.

"Many of the women on campus are panic-stricken because of the feeling of scarcity," said Dr. Beverly Guy-Sheftall, professor of women's studies and English at Spelman College in Atlanta. "This shortage of desirable partners creates a sense of desperation. I see a lot of problematic sexual decision-making among black women across class and age lines."

The shortage of available black men can contribute to the spread of H.I.V. in other ways.

"Because of the lack of marriageable black men, marriage rates have dropped among African-Americans," said Dr. Edward O. Laumann, a professor of sociology at the University of Chicago and an editor of the new book "The Sexual Organization of the City." In 2002, according to the census, 37.7 percent of black men 15 or older were married and living with their spouses, compared with 58.5 percent of white men. Among women 15 or older, 29.2 percent of blacks were married and living with their spouses, compared with 54.3 percent of whites.

"When marriage rates are low, there is a higher likelihood of concurrence - the pattern of having more than one partner at the same time," Dr. Laumann said. "The less educated and the higher educated are more likely to be in these kinds of fragile relationships, which can facilitate the spread of sexually transmitted diseases."

Dr. Adimora said the research did not suggest greater promiscuity among blacks. "No one is saying that black people don't care about long-term, stable relationships," she said. "But the lower number of economically viable black men destabilizes marriage and long-term partnering. One pattern is the man who has sex with one girlfriend, goes back to a previous girlfriend and then returns to the new one. This kind of pattern can increase H.I.V. spread."

Vanessa Johnson said she wished she had been more careful a decade ago. She did not learn that her boyfriend and the father of her son was bisexual until he contracted an AIDS-related illness. She learned she had H.I.V. in 1990, right after she graduated from law school.

"I understood that there was a possibility he was seeing other people, but I was willing to overlook it," said Ms. Johnson, now 46, who is deputy director of the Capital District African American Coalition on AIDS in Albany.

Ms. Johnson said that she forgave her boyfriend, who died in 1994.

"His infection most likely came from having sex with another man," she said, "but he was afraid to say that."