Then there's the much ballyhooed "down low" phenomenon. Some men on the DL are becoming infected by anal intercourse with men and then spreading the infection to their female partners, a transmission route that became widely discussed earlier this year with the publication of J.L. King's On the Down Low: A Journey Into the Lives of "Straight" Black Men Who Sleep With Men. But the great unknown is how frequently this occurs, and whether it's truly different in blacks versus whites or Hispanics.
Because of a flurry of media coverage about the DL link, including an Oprah show featuring King and a New York Times Magazinestory, many who study AIDS in the black community cringe at its mention. "I'm sick of hearing about it," says Victoria Cargill, an epidemiologist at the Office of AIDS Research at the National Institutes of Health. Cargill, who also works at a clinic in poor, black Southeast D.C., says the high prevalence of HIV/AIDS in women can clearly be attributed to a host of factors that have nothing to do with the DL. "I'm not saying it doesn't exist, but if we start adding up how many people this affects, this is the eye of the needle," says Cargill. "Let's start talking about the needle." CDC epidemiologist Greg Millett says that when it comes to the DL phenomenon, there simply are more questions than answers. "The truth is there are very few studies that deal with bisexual black men and even fewer that deal with the down low," says Millett, who has put together a provocative PowerPoint presentation on the topic.
A fascinating CDC study published last year specifically looked at men who have sex with men and do not disclose their sexual orientation versus those who do disclose. The study recruited participants from only six gay bars (which already tilts the results away from DL men who may not go to gay bars), but the findings were startling. More black men were nondisclosers (18 percent)—that is, on the DL—than white men (8 percent), and all nondisclosures reported having more sex with women than with men. But nondisclosers of all races were also less likely to be infected with HIV than disclosers, and black nondisclosers in particular reported significantly less unprotected anal intercourse with men than did black disclosers. Several other recent studies have found higher proportions of bisexual black men than white men, but it's unclear whether how much of an HIV "bridge" they are to black women.
Phill Wilson, executive director of the Black AIDS Institute in Los Angeles, suggests, rather, that the single biggest driver of the heterosexual spread to black women is the incarceration of black men. "The prison industry in America is an almost exact replication of the mining industry in South Africa, where you take large groups of men and move them from their families for an extended period of time," says Wilson. As studies conducted in South Africa have shown, men who leave their homes for the mines often have new sexual partners—as do the women they leave behind. The increased sexual mixing spreads HIV in both the migrant men and their regular partners. When they return home, the men may infect their regular partners—or vice versa. This pattern of sexual networking is called concurrent partnering, which means that relationships overlap, and there's nothing that HIV likes more.
Wilson and others argue that with so many men cycling in and out of the African American community, women end up at a greater risk because of similar disruptions of sexual networks and the resultant concurrency patterns: They mix with new partners when their men leave and often reunite with them when they are released. Incarceration also exposes many men to anal sex, whether by coercion or choice, and injection-drug use, the two most efficient ways to spread HIV. And if the locked-up man was the main wage earner, poverty can be a factor, too.
One superb study of concurrency in African Americans in rural North Carolina found that 53 percent of the men and 31 percent of the women reported concurrent partners during the preceding five years. Interestingly, 80 percent of the men in the study who said they had been incarcerated for more than 24 hours reported having had concurrent partners within five years; that percentage plummeted to 43 percent if a man had not been locked up for a day or longer.
Equally important, black women have a small pool of black men to choose from at any given time. "African American women are the only group in the United States where there are fewer men than women," says Gail Wyatt, an associate director of the AIDS Institute at the University of California, Los Angeles. "The availability of a partner who shares the same values is much less likely. The women are more likely to be educated than their partners. They're more likely to be employed." As a result of the shortage of black men, black women are vulnerable to becoming involved with men who are engaging in risky behaviors that they don't know about, whether it be having unprotected sex with other partners, female or male; visiting sex workers; or injecting drugs.
The muddy truth is that the high rate of HIV infection and AIDS among African American women is due to a combination of all these factors. "It's a perfect storm of issues," says NIH's Cargill.
And there's one more factor to consider, says Wilson: Politicians ignore this population. "It's both a cause and a symptom of the problem that our government really is not interested in the health and well-being of black people and in particular black women," says Wilson. "How is it that Dick Cheney can tell you how many machine guns are in Baghdad, but doesn't have a clue about issues that are killing black women a stone's throw from his office?"
Gwen Ifill, for her part, received so many queries about this particular question that she wrote out a response, refreshingly candid, that her publicist gave out to people who inquired. "I have to say I was surprised that neither the Vice President nor the Senator had an answer on this," wrote Ifill. "As a black woman, I also found it depressing. The good news is that, in the feedback I have gotten since the debate, folks got that. These debates have been very useful for smart and involved likely voters. They have gotten to see what these folks do, and don't, care about."