This past summer I visited San Francisco, a town I had lived in for more than a quarter century. Actually, my residency there overlaps exactly—and eerily—with the start of the AIDS epidemic in 1981. One of my favorite places is a neighborhood park, perched above the Castro; there's a tennis court, a community garden and a dog run. From the park, you can watch the August fog roll over Twin Peaks, down into Eureka Valley (the original name for the Castro), blanketing the original epicenter of the epidemic.
Those of us who lived there in the mid- to late '80s can't forget the sight of legions of gay men with wasting disease (yes, you can be too thin), or those with Kaposi's sarcoma lesions marring otherwise handsome faces, and even the solitary figure I remember shuffling down Castro Street, plastic bags hanging from each hand, diarrhea having soiled him. Around this same time, someone placed a bench in the park, overlooking the valley, bearing witness to time and history.
There's a plaque on the bench that reads: "In memory of San Franciscans who lost their lives to AIDS."
As I visited this summer, I remembered that plaque; once it had been shiny and bright and it seemed strange to me then to be commemorating those who had died from the plague while the disease still raged on and on (and in ways quite unimagined). This summer, no longer shiny nor bright, the plaque has the patina of an historical monument—like those for wars past. How strange this seemed, too, as though the epidemic itself now belonged to another time.
Twelve years ago, Andrew Sullivan, the gay and HIV-positive philosophe, penned a New York Times Magazine essay called "When Plagues End," hailing the end of the epidemic. He wrote: "The power of the newest drugs called protease inhibitors, and the even greater power of those now in the pipeline, is such that a diagnosis of H.I.V. infection is not just different in degree today than, say, five years ago. It is different in kind. It no longer signifies death. It merely signifies illness." At the time, his article engendered heated debate, but it wasn't long after that I heard someone in San Francisco refer to the AIDS epidemic that had "ended sometime around 1995." Perhaps I shouldn't have been surprised when, last month, the paper of record (in a story about the changing nature of the Castro) contained this sentence: "The epidemic beginning in 1990 and ending in 1995 decimated San Francisco's gay community."
As a journalist who has covered the AIDS beat since the beginning, and especially these later chapters, I know the ever-disheartening statistics. More than 1 million AIDS cases to date in the U.S; half a million dead; 40,000 new infections each year still, and the increasingly disproportionate caseload among the poor and people of color—not to mention women. (And that's not even leaving our borders, outside of which is a political and public health catastrophe of harrowing proportions.)
Closer to home, I didn't know that the South—and North Carolina in particular—is the new ground zero, the literal and metaphoric epicenter of the 21st century HIV/AIDS epidemic. According to Evelyn Foust, the state's longtime AIDS director, "the South has the highest percentage of AIDS cases and new infections [in the country], and North Carolina is right in the middle of this." Recent data from the federal Centers for Disease Control and Prevention unequivocally supports this view: 45 percent of all new U.S. HIV infections and fully half of all AIDS deaths occur in the South.
But there's more to know, especially as the state and local AIDS service organizations join in marking World AIDS Day this week. John Paul Womble, an HIV-infected gay man and the director of development and public affairs at the Alliance of AIDS Services Carolina, told me in a recent interview that "a huge percentage of people are testing positive [for the HIV virus] and being diagnosed with AIDS in the same day." With his characteristic candor and passion, he did not mince words: "It's un-fucking-heard of." Simply, this means people here aren't getting tested until their HIV disease has progressed to the point where their T-cell count has collapsed and their viral load exploded so that they present with one of the specific diseases associated with an AIDS diagnosis. Says Womble: "You see folks who don't want to know their status so they're not getting tested. They're also not getting care." It also means that these folks are unknowingly infecting their partners. All of a sudden, it's easy to understand the explosion of HIV/AIDS cases in the South. What especially angers both Womble and Foust is that the warning signs have been there for years.
For the past five years, at the very least, the South hasn't received the focus or the funding truly reflective of the region's expanding number of cases. Two years ago POZ magazine reported that "dozens of prevention workers, educators and people living with AIDS in the 16-state region told us . . . that they felt federal officials had given up on the area—even though it had [already] emerged as the [new] epicenter of the epidemic in the U.S." One of them, Kathie Hiers, the head of AIDS Alabama, told the magazine in 2005: "The status quo is going to kill Southerners."
Indeed it has. To date nearly 200,000 have died in the South from HIV/AIDS; this is the highest cumulative number of estimated deaths among the regions. The reasons are well known; the solutions less clear. Unlike San Francisco, New York or Miami—the original epicenters of the epidemic—the South faces unique problems: deep and widespread poverty, a comparative dearth of federal dollars, its intrinsically rural nature, no national media close at hand, and the Bible Belt mentality once so forcefully advocated by former Sen. Jesse Helms and still clung to by his conservative disciples.
And there's one more crucial reason: The Southern epidemic is not an equal opportunity disease; it disproportionately afflicts women and communities of color. According to Womble, 98 percent of his agency's caseload is minorities; 40 percent are women; and among those women, 60 percent of them have kids. Foust is nearly apoplectic when discussing the changing color of North Carolina's AIDS cases. "I'm very concerned about the growing Latino population [here]. In five years, they've gone from 1 percent of all AIDS cases to 7 percent." Needless to say to most (but necessary to some), the expanding epidemic among Spanish speakers requires not only new prevention messages, but new ways to reach this community and to provide access to care. If the history of this epidemic teaches us one thing, it's that one size does not fit all.
But all is not dire. Foust is fierce in telling me that "for the state the epidemic remains a top priority. We know it's not over." Just this past year the North Carolina legislature provided a supplemental $2 million for HIV prevention, the first increase in more than a decade. Last year the state also bettered its formula by 100 percent for ADAP, also known as the AIDS Drug Assistance Program, allowing thousands more indigent folks access to health care and meds. Foust also told me that North Carolina contributes $12 million to the ADAP program, which, she says, is "among the top five or six states making contributions." Yet, another HIV/AIDS advocate told me, "We're still on the low side when it comes to ADAP eligibility, but at least we're not last anymore."
Foust's big fear, though, is the pervasive apathy among all of us. "We're adjusting to the fact that HIV/AIDS is just another chronic disease. We're getting used to this and I don't see the same energy and passion." Womble agrees: "People don't know or care about HIV/AIDS unless it directly affects them, like if my son has AIDS, or my brother or my father." Of course, Foust's fear that AIDS is now "just another health problem" was what Andrew Sullivan prophesized—and hoped for—more than a decade ago. As they say: Be careful what you wish for.
From time to time I still think about that bench in San Francisco—the one that is creaky and rickety and has withstood two decades of ever-growing losses. In our backyard, my partner, Jim, and I also have a witness. Jim's late partner, Howard Goldberg, died from AIDS just after turning 40 in 1992, and last year we planted a sycamore in his memory. We call it the "Howard tree," and we're rooting for the sapling as it fights for its life in this historic drought— and reaches for the sky. That's a metaphor, too, for this historic epidemic, which is not over and has come home to all of us here.
Steven Petrow is the author of four books about the AIDS epidemic and the former president of the National Lesbian and Gay Journalists Association.