What stands out are his eyes. Big, round, dancing eyes. Eyes that are scrutinizing yet revealing, angry but not hard, pleading but not soft. They’re not the eyes you’d expect. They’re not ashen, vacant or set in sunken sockets. They’re shining out of a full, handsome, African-American man’s face, and they’re 32 years young. Adrian […]
What stands out are his eyes. Big, round, dancing eyes. Eyes that are scrutinizing yet revealing, angry but not hard, pleading but not soft. They’re not the eyes you’d expect. They’re not ashen, vacant or set in sunken sockets. They’re shining out of a full, handsome, African-American man’s face, and they’re 32 years young.
Adrian is a black man from Milwaukee who’s been HIV-positive since age 19. He says he contracted the virus from his first male partner, a man who knew he was “positive” but kept it a secret. At the time, no one had yet realized a new AIDS epidemic was breeding in Milwaukee among young men just like Adrian. Healthy. African-American. Maybe gay, maybe not.
Adrian – who requested that his real name not be used for this story – works as an administrative assistant in Milwaukee, where he lives in an inner-city neighborhood. He’s going back to school for a degree in communications, a pursuit he says was delayed in part by his diagnosis. He’s a “pretty decent writer and a good orator,” he says, but he’s uncharacteristically deadpan when describing how he acquired the human immunodeficiency virus.
His partner was several years older, 26 or 27, and had never said a word about AIDS. He hadn’t, either, until a routine test at a Downtown health center came up positive for HIV.
He remembers his doctor calling and saying he should come in.
“I had sort of braced myself,” he says, “but I was like, ‘Oh my God.’”
The news was tough to hear.
Adrian doesn’t consider himself gay or bisexual. He sees himself as just one of many people who have a same-sex attraction they’d rather be rid of, he says. But whether he appreciates those feelings or not, he’s a member of a demographic that, for the last decade, has contracted HIV at a devastatingly high rate.
In Centers for Disease Control and Prevention lingo, Adrian is an MSM (an acronym standing for “men who have sex with men”). He was a young one (under the age of 30) when his system was first infected with HIV. According to estimates released by the state Department of Health Services in August, more than one out of every three black MSMs in Milwaukee County is HIV-positive. And young black MSMs, Adrian’s former demographic, accounted for almost a third of all new diagnoses reported by the county in 2011.
During that year, black residents were eight times more likely than white ones to contract HIV. This rapid rate of infection was largely responsible for the county outpacing the rest of the state in new cases, as it has for several years. Statewide, the number of HIV cases has held steady, but here, incidences rose 20 percent between 2007 and 2011.
Experts name a laundry list of causes: internalized homophobia within the black community, poor access to health care, a local epidemic of other sexually transmitted diseases that preceded the HIV rise, and plain old poverty. The CDC has verified that a sharp increase is actually happening – it’s not a mirage caused by more testing, the federal agency says. Its research points to homophobia and the stigma surrounding HIV as major factors driving the outbreak, which is often spread under a cover of secrecy that resists intervention.
Among its victims are African-American women living in Milwaukee County, who were diagnosed with the virus at a rate 27 times higher than that of white women from 2007-2011. In the rush to slow the spread among men such as Adrian, some local AIDS workers warn that infection rates among women, Latinos and other groups could worsen as resources are diverted.
Milwaukee’s predicament coincides with a new national effort to funnel funding into services for young black MSMs. Milwaukee could stand to benefit, but city officials say that as a smaller city, we’re hobbled under current funding formulas, which favor megalopolises on the order of Chicago and New York.
But in the meantime, a number of health-, LGBT- and AIDS-focused groups, such as the city-backed Diverse and Resilient nonprofit, are pushing their limits. Along with the “new” epidemic, a new spirit of experimentation has arisen – new ad campaigns to prod comfort zones, HIV testing in thunderous dance clubs and an unprecedented network of peer educators.
Outreach is also extending to black churches, with activists remembering that almost half of Milwaukee’s black MSMs called homosexuality a “sin” in a recent survey. AIDS workers hope that churches can become influential partners in the fight, as some already have.
“When HIV was first introduced to us as a country, you had doctors wearing full-body suits and gloves when they were dealing with a person who was HIV-positive,” says Jim Addison, coordinator of the African-American HIV/AIDS program at the Black Health Coalition of Wisconsin. “It seems like those first impressions have really had a hard time leaving.”
Milwaukee’s epidemic started mildly enough with a few medically treatable STDs. Syphilis, gonorrhea and chlamydia – all relatively common and easily cured with medication – have flourished here since the 1990s. For many of the past 15 years, Milwaukee has ranked as a top-five city for both chlamydia and gonorrhea, which set the stage for an HIV outbreak. “We did not get here overnight,” says Bevan Baker, Milwaukee’s health commissioner.
These diseases, along with syphilis, increase the likelihood of HIV transmission. State and local health officials have struggled to bring them under control, but to little avail. “With all the efforts that we’re putting forth, the goal is to turn this thing around,” says Mari Gasiorowicz, a state epidemiologist. Prevailing evidence, however, including an outbreak of syphilis that spanned late 2011 and early 2012, suggests that risky sex continues unabated.
The HIV outbreak followed closely on the heels of the STD scourge: In 2009, state officials reported to the CDC that HIV diagnoses had risen 144 percent among black MSMs between 2000 and 2008. Along with the Milwaukee Health Department, they invited the CDC to investigate whether the rise was caused by an actual increase in transmission or just an uptick in testing.
Agency officials explored the situation on the ground in Milwaukee and concluded that – while intensified testing accounted for some of the new diagnoses – real, verifiable transmission was definitely on the rise. Researchers also concluded that negative cultural attitudes within Milwaukee’s African-American community, specifically anti-HIV stigma and anti-gay discrimination, were playing a significant role in the spread of the virus among young black MSMs. These men were avoiding medical care and testing for fear of being labeled “fags” or “homos.”
When AIDS was first recognized by the CDC in 1981, it was primarily affecting intravenous drug users and homosexual men showing symptoms of Pneumocystis carinii pneumonia, an opportunistic lung infection found in people with weakened immune systems. Most of these men were white, a pattern that held true into the late ’80s and early ’90s as AIDS was hitting the mainstream. Many African-Americans, along with other segments of society, came to see the condition “as a gay, white disease,” says Addison, “and it never really lost that moniker.”
As money and media attention helped to limit the epidemic in the white community, it ran rampant among African-Americans. By 2009, the CDC was reporting that among MSMs nationwide, whites accounted for 39 percent of new infections, compared to a figure of 37 percent for blacks, who were a much smaller segment of the population. Milwaukee saw a similar trend of black MSMs, particularly young ones, bearing the brunt of new diagnoses. In 2011, those under 30 accounted for 31 percent of all new cases in Milwaukee County, up from just 9 percent in 2002.
Milwaukee isn’t alone, and some experts insist we’re no worse off than other cities of similar size. Gasiorowicz points to a 2009 ranking by the CDC that ranked the city 60th out of 82 metro areas in the United States for the greatest number of HIV cases. Chicago placed higher (28th) and so did Indianapolis (35th), Detroit (37th) and Minneapolis (56th). “I don’t think that we have evidence that [HIV] is worse in Milwaukee,” she says. “I think we may be ahead in the response, in taking a look.”
Baker says Milwaukee may have fewer cases, but its rate of infection is nothing to downplay. “We need the CDC and other agencies to understand that other cities may have larger raw numbers, but our incidence rates suggest that Milwaukee needs to be in the mix.”
He’s referring to money, of course. In New York and Miami, Baker says, he witnessed comprehensive approaches to combating the disease that relied on an “influx of public and private dollars,” something Milwaukee’s not getting. The city, he says, “can’t even apply for the funding that we know we desperately need,” because we’re not viewed as a Chicago, New York or even a Detroit, cities that can pursue the largest pots of federal money available to fight AIDS.
This year, the CDC began aggressively channeling its AIDS spending into services that directly address the black MSM epidemic. Paradoxically, the shift caused one of Wisconsin’s major categories of federal funding (“Category A: Core Prevention Services”) to fall by more than 20 percent. Other cities felt a similar dip. David Holtgrave, a professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore, says the CDC’s realignment has left populations in some cities “ripe for continued or worsening epidemics.”
But it’s also forcing local agencies to narrow their focus. Getting money from the agency for AIDS is now tied to the “CDC’s commitment to high-impact prevention,” says agency spokeswoman Salina Cranor. And that means rules on who, how and where health departments can exercise their outreach and prevention efforts. Populations with astronomical HIV rates – particularly young black MSMs – stand to benefit most from the changes.
“When I first started, with the money we were getting, the CDC basically said just go out and test everybody,” says Kathy Donovan, HIV program director at the Sixteenth Street Community Health Center. “But all the years I’ve been working with HIV, the number of infections reported hasn’t gone down.” So, year after year, the CDC has amped up its oversight of local service providers such as Sixteenth Street, which went from testing everyone to just serving the LGBT community to now targeting “only bisexual men in the black community.”
Also ending is the old era of testing quotas. “It used to be a battle among agencies that got funding to try to get your numbers,” Donovan says. “All people were worried about was trying to get an adequate number of people in order to stay funded. But I think we all realized that was ridiculous.”
One front where the health centers and departments of Wisconsin are winning is in stopping deaths linked to AIDS. Annual deaths have declined noticeably since peaking at 373 in 1993. In 2009, the last year for which data is available, only 105 were reported. Also, the median age of death has gone up, from 42 in 2000 to 50 in 2009. Advanced medications mean HIV is no longer a death sentence, but in some ways, effective treatment makes spreading awareness of its risks even more difficult.
Donovan says she’s been to schools where “young black kids are absolutely convinced, no matter what you tell them, that Magic Johnson was cured of HIV.” The basketball star brought AIDS to the attention of heterosexuals in the early ’90s, and his personal wealth paid for medical care that stopped his HIV infection from devolving into full-blown AIDS.
In July, the Food and Drug Administration approved a new HIV-prevention drug called Truvada, a combination of two antiretroviral drugs that reduces the risk of catching the virus by an estimated 75 percent. Truvada is expensive and carries side effects but could be used (along with condoms) by couples trying to stop HIV from spreading between partners.
But the drug also has its critics, especially for widespread use. “Personally, I think it’s crazy, but a lot of people are crazy for it,” says Donovan. And Adrian worries that the condition he copes with is no longer viewed as a mortal threat.
“We de-villainize HIV so much, people aren’t afraid of it anymore,” he says. “It’s like, ‘My goodness, it’s just a cute operation. It’s a free handout, free medical [insurance], free dental, all these wonderful services. So now, you’re joining a club if you get HIV. And you’re not going to die. You just take some pills.”
There’s no one way a young black MSM becomes infected in Milwaukee. Poverty, family strife and homelessness may play a role. A 16-year-old, for example, may come out to his family as gay, only to be kicked out of the house. Like the estimated 3,000 homeless youth living in Milwaukee, he’s alone and desperate, forced to do whatever it takes to survive, sometimes trading sex for a place to sleep or a meal. Maybe the man doesn’t use a condom, and maybe he’s HIV-positive. Such scenarios aren’t uncommon. Experts say they’re part of the reason for a disproportionate rise in HIV among young MSMs, and anecdotal evidence tells a similar story.
Adrian says the HIV-positive men who prey on boys are “self-centered vultures,” hookup sharks who do and say anything to get what they want. “I’m not talking about the people that don’t know [their HIV status]. They know. They’ve had their CD4 [T-cell count] and their viral count for the last 10 years. They know that they’re positive, and they will still have sex with you.”
The CDC investigation blamed homophobic attitudes in the black community for driving Milwaukee’s HIV outbreak underground, where it’s difficult to confront. To turn back the tide of anti-gay prejudice, city and state officials contracted with Diverse and Resilient, an LGBT health services organization based in Milwaukee. Its first step was to partner with the Medical College of Wisconsin’s Center for AIDS Intervention and Research on a “Community Readiness Assessment.” This assessment ultimately rated Milwaukee’s African-American community as slightly higher than a 1 out of 9 in terms of understanding and accepting homosexuality.
Faced with antagonistic responses, many young black men don’t feel comfortable living outside of the closet, whether gay or bisexual. Others aren’t sure what to make of their sexuality, even as they’re experiencing same-sex attraction.
“A lot of people don’t know who they are, gay or straight,” says Marcus, a 41-year-old black man who is HIV-positive (and also asked that his real name not be used). “They just know they don’t want to be called what you might call them. Because of that, they don’t want to be helped. If I’ve got to be a fag, then I don’t want fag help. I want man help. I don’t want to be labeled as a man who has sex with men.”
Johnny, another HIV-positive African-American man who asked for anonymity, says he’s noticed that the men and boys coming to the AIDS Resource Center of Wisconsin in Downtown Milwaukee are only getting younger (“They’re literally babies,” he says), straighter (or at least “straight-looking and acting”) and blacker (“it’s all black guys that come in here”).
Johnny, 47, believes this younger crowd is driving homosexuality further underground. “There’s this subculture of young folks on the down-low,” he says, “of guys that smoke pot and drink and meet online and have a certain lingo. If you’re not youthful enough, you’re not privy to this new subculture that doesn’t want the stigma or the association with being gay and lovey-dovey.”
The down-low is a secluded place. “Those individuals are not marching in the parades with the pink feathers and holding hands,” Johnny says. “It’s undercover behavior. They’re not getting these messages of prevention and safety.”
Baker says Milwaukee also needs to confront the societal issues surrounding HIV: low high school graduation rates, high unemployment, persistent housing instability and poor access to health care. “There are pinning, hard-line, recessionary issues of economic instability and joblessness that have driven many young black men in this community to take risks in ways that one normally wouldn’t,” he says. “When you have no education, no job, no home and no hope, you will take those chances because you’ll say, ‘What do I have to lose?’”
After a slow start to the night, Club Tropical, a South Side dance club, is coming alive. Through a white haze of smoke and flashing LED lights, Miss Gay Brew City emerges from behind a curtain to claim her pageant crown and electrify the crowd with a final dance. Club Tropical is typically a Hispanic club, but on this night, it’s filled with a diverse mix of young people – black, Hispanic, white – who’ve come to see a drag show sponsored by the Sixteenth Street Health Clinic. Strategically placed around the bar are pamphlets on safe sex and bowls full of condoms that don’t appear to be getting much attention. But Hugo Jimenez, a Sixteenth Street staffer who helped to organize the event, estimates later that “at least 90 percent” of the club’s patrons walked away with free contraception.
What’s truly radical, however, is what’s happening near the door. Behind a curtain, Sixteenth Street is conducting licensed HIV testing, and out of the 140 people dancing this night, 15 stop in to get tested. Jimenez calls this “a good number.”
Club Tropical isn’t the only example of a local HIV agency breaking out of its comfort zone. Donovan says the CDC’s new rules on AIDS funding are driving prevention efforts out of the office and into the street. “There were a lot of agencies that lost their funding,” she says, because they failed at performing outreach. Waiting for clients to show up out of the blue is no longer enough.
The AIDS Resource Center of Wisconsin – a statewide HIV health care provider with a clinic in Downtown Milwaukee – runs a program called Shear Genius that sends volunteers into local barbershops to give their proprietors a crash course in HIV education. The hope is the barbers will strike up casual conversations about HIV with their customers. ARCW, which also gives the shops cigar boxes filled with condoms, has so far trained more than 50 of these educators armed with clippers.
“We understand that with the stigma, a lot of the behaviors are underground,” says Scott Stokes, director of prevention for ARCW. “But we hope that by providing these materials to a large part of the population, we can reach some of the high-risk folks as well.”
Another ARCW program, Many Men, Many Voices, revolves around a substance abuse and HIV program funded with a $1.5 million federal grant. It’s trained about 60 clients to turn around and act as community leaders. The idea is they’ll exercise more influence than “a bunch of white people telling young African-American men what to do,” Stokes says.
Besides ARCW, the other behemoth on the HIV battlefield is Diverse and Resilient, the city’s partner in fighting anti-HIV and anti-gay stigma. The nonprofit’s most visible initiative – and the one with the most riding on its success – has been Acceptance Journeys, an advertising campaign designed to gradually introduce communities to ideas of homosexual acceptance. Ads show men embracing each other, or an aunt embracing her nephew. A website presents photos and stories of local gay men and women, including many African-Americans. State Rep. Sandy Pasch (D-Shorewood) tells how she learned her son is gay, and Mayor Tom Barrett describes his friendship with Leonard Sobczak, owner of the Wisconsin Gazette, an LGBT-focused newspaper based in Milwaukee. Funding for Acceptance Journeys comes from both the state government and the New York-based MAC AIDS Fund, which is injecting national dollars into the local program.
Cards bearing the stories and pictures of local gay people are going out to churches and community groups. Electronic ads are appearing at General Mitchell International Airport and at the Downtown Intermodal Station, and more conventional ads – including some 50 billboards, 110 bus ads and a number of radio spots – are popping up around the city.
Still, there are some who say Acceptance Journeys is moving too conservatively. One Sixteenth Street staffer says he was “very upset” when he first saw the billboard of an aunt kissing her nephew because there was no mention that the man was gay. And Sherri Daniels, the prevention and education coordinator at Pathfinders, a low-income health services provider in Milwaukee, had a similar reaction. She recognized the people pictured, she says, so she understood the ad’s message. “But if I just saw that picture, I’d think that’s a boy and his mama. And since it said, ‘Acceptance Journeys,’ I’d think they were going on a trip.”
Daniels also worries that the campaign is appealing to the existing gay community and not reaching a broader demographic, including young people on the down-low.
Others maintain that Diverse and Resilient and the Acceptance Journeys project are exactly what the city needs. Ronnie Grace, who oversees a team of counseling, testing and referral specialists at the organization, says the campaign has thus far been “very successful.” As the CDC has directed, Grace and others at Diverse and Resilient aren’t sitting behind their office’s spotless windows on North Holton Street, waiting for the epidemic to pass. “We’re in the community interacting with people and enlightening them,” he says.
Before taking his current position, Grace, now 54, was one of the original peer educators at Comprehensive Health Education, a nonprofit co-founded in 2001 by Carol Calvin, a longtime registered nurse. Among other services, it maintains a network of HIV-positive peer educators.
Grace was “our star,” she says. Today, he sports a clean-shaven head and neatly manicured goatee. He’s been HIV-positive for 25 years, but he’s hardly the picture of the frail AIDS patient associated with the condition two decades ago.
Grace says he’s “a victor, not a victim.”
Even dynamic role models such as Grace face an uphill battle when speaking to groups about AIDS. “Every place my [peer educators] go, they always have to worry if people are going to find out [about their status] and how they’ll be treated,” Calvin says. “And if it leaks out even for a moment, everyone will move away from you or leave the room or make a facial expression.”
Sometimes, educators run into an irrational fear that HIV can spread by touch alone. The Black Health Coalition’s Addison – an imposing, goateed man with a background in marketing – recalls an “AIDS 101” class he once gave to a roomful of kids enrolled in an alternative-to-incarceration program. He asked the students if they would mind an HIV-positive man visiting the class. “They were like, ‘No, no!’” Addison says. “So I asked them why, and some of the answers I heard were just, like, ‘Wow.’” He was struck by how naive and uninformed the responses were. One student claimed it could spread through the air.
And sometimes, educators run into
discrimination in their personal lives. Grace was once at a gay bar (he won’t say which one) to meet some friends when the manager came up to him and said the establishment didn’t permit soliciting. They exchanged “some words,” Grace says, and the manager called security to escort him from the premises. The lights came on. He was shocked to find himself in this situation. A professional man visiting a bar open to the public, he was kicked out, he felt, due to his appearance.
“Being a gay black man in Milwaukee presents its challenges,” he says. “All these identities we have to deal with. It’s like a juggling act.”
Many outreach efforts involve knocking on the door of a central institution in Milwaukee’s African-American community: the church. The Community Readiness Assessment procured by Diverse and Resilient found that 46 percent of black MSMs believe homosexuality is a sin; only 20 percent of non-black MSMs believe that.
“One of the things I’ve learned over the years is that the black community is reached with the church,” says Dr. Aaron Buseh, a Liberian-born associate professor of public health at the University of Wisconsin-Milwaukee. “The church is like a fulcrum. It forms the social norms in these communities.”
Calvin, who admits to hearing derogatory comments such as “Adam and Eve, not Adam and Steve,” in her own church, says it’s difficult to approach potentially blasphemous subjects such as homosexuality and the use of condoms.
Abstinence reigns supreme. “The religious influence is really strong in the African-American community,” she says. “You’re not supposed to be having sex at all unless you’re married.” So if someone has HIV or is even getting tested for it, he or she must be sexually active. That’s considered bad enough, but the implication of homosexuality only worsens the stigma.
“‘They’re not as good as us’ is the attitude of a lot of black Christians,” Calvin says.
But she adds that her church’s latest pastor is actively promoting HIV awareness and even pushing for on-site testing. It wasn’t practical at the church itself because of sanitation and maintenance precautions, but the congregation has hosted testing at a number of outdoor health fairs.
Addison – a Bible class teacher who once struggled with his own prejudices – says that progressive attitudes are becoming more common in black churches. He puts on HIV-centered workshops for pastors to share information with them about the condition and to open a dialogue.
“We’re finding a great appreciation for the workshops,” he says. “People don’t want to feel like they’re in the dark ages.”
Adrian sees progress, too, but only in small increments.
“A growing number of churches have HIV testing and HIV-prevention messages,” he says, “but overall, it’s still not a prevailing part of the ministry of black churches.”
According to statistics released by the Pew Research Center, 79 percent of African-Americans say religion is very important in their lives, and 53 percent attend church weekly. So Addison insists that the black church presents a powerful opportunity for education and awareness. He’s worked closely with dozens of local ministers over the years, he says, and has seen attitudes change for the better. No longer does HIV automatically equal homosexuality, or vice-versa. And no longer do faithful black Christians have to turn their backs on either one.
“People are being touched by [HIV]. It’s coming closer and closer to their doors,” he says. “It’s right in their faces now. … I don’t see churches shunning HIV because there’s no getting around it anymore.”
There’s some concern among Sixteenth Street staffers that shifting resources away from the Latino community could have detrimental effects. HIV rates in Hispanic females and males were six and three times higher, respectively, than those of white females and males in 2011. Donovan wonders whether, with fixed resources and strictures on which populations to target, HIV-infected Hispanics could find themselves abandoned. The same concern permeates other health-service agencies where HIV-related resources are being diverted from the general population and concentrated largely on black MSMs.
Daniels of Pathfinders, the organization providing health services to low-income people, says the diversion is especially worrisome because bisexual black men aren’t likely to stop having sex with heterosexual women anytime soon.
“Do I think there will be another, bigger epidemic with black women?” she says. “Most certainly. If nobody puts money out there for services that aren’t LGBT- or MSM-related, we’re going to have the same problem again with other people.”
Addison thinks “there already is” an epidemic growing among heterosexual black women. Recent statistics bear out his theory: Recall that from 2007-2011, black females living in Milwaukee County were 27 times more likely than white women to be diagnosed with HIV.
“I don’t think our African-American communities see it as our problem yet,” Adrian says. “It’s still being perpetuated as a gay disease.”
He’s sitting in a support group meeting at the Downtown ARCW location with four other HIV-positive men. One of them is Marcus, who sits solemnly in his seat until he’s asked for his thoughts. “How can you use the word ‘epidemic?” he asks in a subdued voice. “If it’s an epidemic, why is it not being addressed?”
Adrian has something of a prescription. “It’s like putting medicine in ice cream,” he says. “HIV messages can still be geared toward men who have sex with men because they are the most-impacted group. But the message should go out to all young men and young women, gay, straight, old and young.
“Because then it’s our problem, not the gay man’s problem.”