AIDSWEEKLY Plus; Monday, December 1, 2003
Staff Medical Writers

A research scientist at the University of Alabama has come up with an explanation, based on hundreds of clinical interviews conducted over nearly a decade: a deadly mix of bisexuality, abuse of women and drugs, all in an environment of oppressive need.

"Poverty is the driving force," the researcher, Bronwen Lichtenstein, said.

While one longtime AIDS educator disagreed with some of the conclusions, most said the findings mirrored what they see going on in areas like Alabama's Black Belt, a poor, rural region where Lichtenstein performed much of her work.

"It's quite a complex situation," said Marilyn Swyers, director of East Alabama AIDS Outreach. "Because of this behavior we are seeing a lot more African American women coming in."

AIDS was long considered a disease of gay white men and IV drug users, even as the virus that causes it spread most rapidly in the black community. In Alabama, about 60% of AIDS sufferers over the past 2 decades are blacks, mostly black men, even though blacks make up only about a quarter of the state's population.

Lichtenstein's work has shown that with homosexuality even less accepted among blacks than whites, some rural men are having "sneaky" sex with other men - sometimes because they like it, sometimes for cash or drugs.

"In poor communities you just try to make a buck. It's a way of survival," said Lichtenstein, a member of the governor's AIDS commission.

But those same men often are in sexual relationships with women, sometimes several at one time, she said. In a form of domestic abuse, men pass along the AIDS virus to women, who usually have no idea their partner is bisexual or infected.

"Some men know they have it; some don't," Lichtenstein said. "But the women feel very victimized."

Men prone to transmitting HIV often are physically abusive, the research showed, and many are involved in the drug trade - another proven link to HIV transmission. But even with two strikes against them, such men are able to maintain their relationships with women who fear being left without a breadwinner, sending them deeper into poverty, according to her research.

The findings run counter to cultural perceptions of strong family relationships and masculinity in the rural South, and one expert said Lichtenstein may be overestimating the role of bisexuality in spreading AIDS in rural areas.

"I think 100% of it is linked to drug use or the drug trade," said Tony Morris, executive director of AIDS in Minorities in Birmingham.

But other AIDS professionals said the findings were on target.

"That goes right in line with what we're seeing," said Karen Musgrove, executive director of Birmingham AIDS Outreach.

A co-chairman of the Southern AIDS Coalition, Dr. Gene Copello, said the problems Lichtenstein uncovered in her research in Alabama are the reasons the disease has spread in the region, particularly in small towns where the social stigma of AIDS has made it hard for health workers to peel away layers of secrecy and get to the root cause of the disease's spread.

"The South hasn't received enough attention, and we have the largest number of new AIDS cases in the country," said Copello, executive director of Florida AIDS Action in Tampa. "It's basically exploding here."

AIDS is the leading cause of death in the United States among blacks aged 25-44. About 40% of all U.S. AIDS patients live in the South, and 46% of the newly diagnosed cases are in the region.

About 46% of the state's AIDS sufferers are black men, and 14% are black women. By comparison, white men account for 34% of the cases and white women, 4%.

To learn about the problem of domestic abuse, Lichtenstein interviewed about 55 black women with HIV at the Montgomery AIDS Outreach Center, which serves 23 mostly rural counties in south and west Alabama - much of it known as the Black Belt. The region, named for its rich soil, has some of the state's highest rates of AIDS infection.

Every woman who was interviewed reported being a victim of abuse at some point, including forced sex. Research has shown that in heterosexual relationships, the virus most commonly is spread from man to woman.

Separate research by Lichtenstein found that some HIV-infected black men consider themselves to be heterosexual but also have paid sex with men - a huge risk factor in spreading the AIDS virus. Such male prostitution is most common among young men, she found.

Older men involved with drugs or bisexuality seem to be infecting the most women, the research showed. Those men, who often have been in jail or prison, generally don't tell their girlfriends or wives about their gay affairs and still have straight sex, usually unprotected and sometimes through coercion or outright force, Lichtenstein said.

Morris, whose Birmingham-based organization promotes AIDS education and testing among blacks, sees bisexuality as less of a transmission factor in rural areas than crack cocaine and alcohol.

People are swapping drugs for sex, he said, and substance abusers are at the greatest risk for the kind of sexual behavior that spreads AIDS.

Also, he said, AIDS sufferers in rural areas are less likely to seek treatment than people who live in big cities, helping the disease spread.

"The stigma toward HIV and AIDS is so rampant that many people who know or suspect they have it won't do anything," said Morris.

A physician at Montgomery AIDS Outreach who assisted Lichtenstein, Laurie Dill, said she has heard many women tell of being physically abused by the men who infected them.

"It's a scary picture," said Dill. "I think domestic violence is a major barrier for women to be able to protect themselves from HIV."

This article was prepared by AIDS Weekly editors from staff and other reports.

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