By: Herndon L. Davis

“HIV/AIDS is a disease that thrives in poverty and silence and in DC, we have far too much of both.”

–Donald Blanchon, chief executive officer of the Whitman-Walker Clinic

The nation’s capital is in the midst of an enormous and rapidly growing healthcare epidemic: 3 percent of its population is living with HIV/AIDS and 76.3 percent of these people are black.

Even worse, the numbers are likely to be severely undercounted as the race to identify more residents who unknowingly are HIV positive or have full-blown AIDS continues.

What is behind the crisis? According to experts, a dangerous blend of not knowing who has HIV; poverty and lack of healthcare; people having more than one relationship and unprotected sex; the “down-low” phenomenon and the stigma of being honest about one’s sexual choices; the politics of needle exchange; and lack of outreach to black gay and bisexual men.

‘A Modern Epidemic’

The Centers for Disease Control (CDC) declares an HIV epidemic when more than 1 percent  of the population is infected with the disease. The District is three-fold that threshold, twice as high as New York City and five times as high as Detroit. Since 2003, the number of people living with HIV/AIDS within the District has steadily increased.

The District’s HIV/AIDS crisis is so severe that Shannon L. Hader, director of the District’s HIV/AIDS Administration, told The Washington Post, “Our rates are higher than West Africa. They’re on par with Uganda and some parts of Kenya.”

So, are some parts of the poverty-scarred nation’s capital reminiscent of a Third World country? Could there be a little Africa in the nation’s capital?

Harvard-trained economist Emily Oster, writing in Esquire magazine, theorized that the epidemic in Africa will not be contained by billboards, speeches and radio addresses. It is driven by different aspects of the human conditions, such as the proliferation of other sexually-transmitted diseases whose effects, such as open sores, make the transmission of HIV much easier.

It is the poor or nonexistent medical care which exacerbates the problem, because if people don’t receive regular medical care, these secondary infections will continue to provide easy passages for HIV.

All this looks and sounds very familiar, much like certain communities of Washington, D.C.

Washington has its own peculiarities beyond the marble halls of power, not unlike those in the desolate reaches of Africa, which help to explain the capital’s epidemic.

“The District of Columbia has a modern epidemic-modern because of its sheer size and complexity,” Hader said. “There is no simple answer as to why we have a high burden of disease but the combination of our high level of HIV, multiple modes of transmission and lack of risk perception among many District residents contribute to our large epidemic.”

Five Key Causes

Recently, experts on HIV as well as political, religious and community leaders identified five key social elements that serve as the combustible mix igniting and spreading the epidemic across the District, where 55 percent of the residents are black and 27 percent live in poverty.

1. Not Knowing HIV Status

No one knows exactly who has HIV and who doesn’t.  So, in 2006, Washington D.C. became the first city to regularly test its residents for HIV after the District’s rate of new AIDS cases became the highest of any major U.S. city. The District is now treating AIDS testing as routinely as it does checking blood pressure, blood sugar levels and cholesterol to make sure those who are infected with the disease are aware that they have it.

With increased HIV testing, health officials began to discover a widening presence of HIV/AIDS across the District, explained Dr. Ron Simmons, president of Us Helping Us, an African-American AIDS prevention group. “Last year, DC tested 70,000 people as opposed to 40,000 the year before,” Simmons said. “We don’t know if the infections identified are new infections or just old infections that are now being diagnosed.”

District health officials warn that their data only count residents who have already been tested or treated for HIV/AIDS, but not those who are unaware of their HIV-positive status. With the new increase in city-wide HIV testing, the number of newly diagnosed infections is likely to substantially increase over the next few years, officials said.

Dr. Richard Wolitski, acting director of the Division of HIV/AIDS Prevention, Centers for Diseases Control said that far too many of those infected with HIV remain undiagnosed, or are diagnosed very late in the course of their infection, “when neither prevention nor treatment can have an optimal effect.”

2. Poverty and Lack of Healthcare:

Nearly 1 in 5 District residents live in poverty, and among African American residents, 27 percent are poor. “We face problems in DC with large areas of poverty, which leads to less access to regular healthcare and less education about healthcare in general and HIV/AIDS in particular” said Donald Blanchon, chief executive officer of the Whitman-Walker Clinic. “HIV/AIDS is a disease that thrives in poverty and silence and in DC,” he said. “We have far too much of both.”

For many of Washington’s poor, healthcare “is not even within the structure of their lives” said Rev. Derrick Harkins, pastor of 19tth Street Baptist Church, which conducts HIV outreach to the District’s homeless community.  “It’s not that they don’t have the money, but the wherewithal to even take advantage of clinics that may be available.”

Of the nearly 20 percent of District residents living in poverty, close to 40 percent are families with a female householder, with no husband present and  children under the age of 18.

According to Hader, major efforts are already underway to protect these communities. “We’re partnering with our hospitals and birthing centers and successfully reduced the number of babies born with HIV from 10 in 2005 to 1 in 2007, while maintaining our goal to reach zero babies born with HIV.”

But with the continually stressful-indeed, often devastating-problems of poverty facing many D.C. residents, this presents a significant challenge, explains Dr. Simmons. “If you are dealing with such social factors, protecting yourself from HIV is not a high priority.  Sex may be the only recreation you can afford, and condoms may be a hassle in terms of how they feel or getting your partner to agree” to use and to purchase especially if you’re living in poverty.

3. Concurrent Unprotected Sexual Relationships and Stigma

Health researchers studying heterosexual relationships and HIV in the District revealed that 75 percent of survey participants indicated that they were in a committed relationship, yet 45 percent said they had sex outside of their relationship. Forty-six percent believed their last sexual partner was having sex with someone outside of the relationship. Forty-nine percent did not know their last sexual partner’s HIV status; and 70 percent did not use condoms.

Phill Wilson, chief executive officer and founder of the Black AIDS Institute, said it boils down to relationships. “You end up increasing the probability of transmission when you have a high percentage of HIV infection within the community,” he said, “and you have concurrent relationships.”

He also explained that straight people “do not perceive themselves to be at risk” because they stigmatize HIV as a gay disease. As a result, they don’t think they need to be tested.

According to recent Washington, DC health data, among blacks living with HIV/AIDS from 2003 to 2006, heterosexual sex was the leading mode of HIV transmission among blacks in the District, more evidence that straight people do not believe they can get AIDS. But they can, particularly if they have other sexually transmitted diseases.

In Africa, this similar dynamic also occurs: individuals with other sexually-transmitted diseases having concurrent sexual relationships sharply increases the chances of infection with HIV.

In Washington, and elsewhere in the United States, other sexually transmitted diseases work in concert to increase the risk of HIV infection by two to five times. In fact, nationwide between 2003 and 2007, the rate of syphilis infections increased dramatically among black people. In 2007, the rate for black men and women comprised 46 percent of the country’s total. And from 2000 to 2005 the number of infectious syphilis cases reported in the District increased by 168 percent giving Washington the highest such rates in the country.

Hence conversations within romantic and sexual partners about HIV/AIDS and other STDs must occur. Mayor, Adrian Fenty agrees explaining that his administration is calling upon DC residents to start conversations in “Defining what committed means in a relationship, and knowing that condoms keep one safe.”  However, Fenty also told a Washington Post reporter that preventative HIV messages often “literally go right in one ear and out the other.”

But Rahim Briggs, founder of the Al Sura Foundation, a social marketing HIV/AIDS prevention group, sees things differently. “I reside in Ward 8, which is the poorest section of the city , and I have been an HIV/AIDS advocate for over ten years,” he said. “I’ve yet to see HIV/AIDS messaging, billboards or any efforts geared towards our youth and at-risk adults in some of the poorest wards in the District.”

4. The Politics of Needle Exchange

For nearly a decade, a conservative Congress firmly tied the hands of District leaders by banning the use of local tax dollars to combat HIV among drug users through the use of a needle exchange program. The ban was lifted last year, but possibly too late, as 27percent of black women living with HIV/AIDS  in the District had by then contracted the disease through drug use.

“There have been policy decisions that have undermined our ability to fight the AIDS epidemic” Black AIDS Institute founder Phill Wilson said. “Things like abstinence-only programs and the federal ban on needle exchange programs. These are policy decisions that have helped drive the AIDS epidemic.”

Among black people nationwide with new HIV infections, 18 percent  contracted it solely through injection drug use. To date, of all black people living with HIV/AIDS in the District, 22.3 percent  of them contracted it through drug injection use, making this mode of transmission the third leading cause of the spread of HIV/AIDS among blacks living in the DC.

5. Lack of Outreach to Black Gay and Bisexual Men

Dr. Ron Simmons, president of Us Helping Us, said that the District is known as the “black San Francisco where many black gays and lesbians migrate from other parts of the country because of its perceived vibrant black gay and lesbian community.”

Despite the large gay population, safety does not come in numbers, leading many gay men to hide their homosexuality and not practice safer sex with men who may be closeted and/or engaged in heterosexual relationships.
“There is still strong stigma in the African-American community around gay men” said Whitman-Walker’s Blanchon. “Talking about HIV/AIDS openly and honestly, you create a sense of powerlessness and hopelessness among many African-American MSM [Men who have Sex with Men] that leads to things like unprotected sex and down-low behavior.

“They also tell us the same thing that we hear from many newly diagnosed African-American women: that they were afraid of losing their man if they asked him to use a condom.”

Among blacks in the District, the MSM mode of transmission ranks second overall but first for all new HIV/AIDS infections. Further, while black MSM comprise 24. 8percent  of all living AIDS cases in the District, when it is compared to MSM of all races, they comprise 58percent  of the total.

These high numbers have helped to provoke the fiery intolerance of unforgiving black churches, whose pastors have publicly fingered the blame of the spread of HIV/AIDS among black women directly to black gay and bisexual men. These men, often referred to as being on the “down-low,” are closeted individuals who maintain heterosexual relationships and marriages while having concurrent same- sexual relationships on the side.

Leaders of black churches throughout the nation often have had difficulty preaching and informing their parishioners about the dangers of HIV/AIDS from a non-accusatory stance. Pastor Cedric Harmon, of the City of Refuge congregation in Washington, is a consultant specializing in religious activism. He explains that historically, the black church’s “theological and doctrinal teachings with regards to same-gender-loving, homosexual and lesbian persons struggled with how to address this particular illness.” He added that with the exception of a few pioneering faith institutions, many mainstream black churches didn’t even join the fight against HIV/AIDS until just over a decade ago.

As a response to the reported sharp increase in the District’s HIV/AIDS rate, some black ministers now plan to develop prevention and HIV positive support groups for couples and promote HIV counseling and testing.

But other churches such as the 19th Street Baptist Church already have an active HIV/AIDS ministry and plan to  continue to utilize their successful “A-B-C”  approach to HIV prevention. This program focuses on “Abstinence, Faithfulness and Condoms” through both the lens of marriage and a committed relationship.

“From my perspective I look at a husband and wife as the paradigm and that is what I would support and advocate,”explains Pastor Derrick Harkins.  But he concedes, “In the realistic context of all of this we realize that not everybody who’s sexually active; that’s not limited to married heterosexual couples.”

Herndon Davis is a media consultant and can be reached at www.herndondavis.com