HIV Prevention Fractures Into Local Struggles

Officials such as Gayle acknowledge today's prevention efforts favor groups that are politically organized and experienced in health advocacy, such as gay white men, and tend to leave out others, including some of those at the highest risk. How to reach these groups, and how to ensure that more than $ 400 million a year in federal funds for preventing HIV infection is being spent effectively, are the subjects of fierce debate within the CDC.

Some critics charge that the new approach has allowed the pendulum to swing too far toward local control. In many parts of the country, conservative political groups have successfully opposed the use of prevention strategies such as needle-exchange programs or sex education for teenagers.

Sauls's home state of South Carolina -- a state that is predominantly rural and politically conservative -- is, in many ways, a good place to examine how the nation's new approach to stopping the spread of HIV is working -- and how it isn't.

Throughout the 1990s, the epidemic has been growing faster in southern states such as South Carolina than in any other region of the country. In 1994 (the last year for which complete data are available), South Carolina ranked ninth among the 46 states that measured infection rates in pregnant women, with a positivity rate of 2.2 per 1,000 women tested. AIDS has become the second leading cause of death among people age 25 to 44 in the state.

The patterns of disease transmission generally mirror national trends. As in the nation as a whole, South Carolina blacks are disproportionately affected: seven times more likely than whites to be infected with HIV, five times more likely to have a diagnosis of AIDS. As in the nation as a whole, men who have sex with men continue to make up the majority of South Carolina AIDS cases, although the rates among both male homosexuals and injecting drug users are stabilizing or falling. And as in the nation as a whole, HIV and AIDS rates among women in South Carolina are climbing, a reflection of the growing importance of heterosexual transmission as a driving force in the epidemic.

"You have a sizable proportion of people in these rural areas who are infected who really only have heterosexual risk," said the CDC's John Ward. In many cases, a CDC study indicates, people become infected after exchanging sex for money or drugs -- particularly crack.

In Sauls's home town of Florence, a sprawling town of about 31,000 surrounded by tobacco and cotton farms, an average of six people test positive for HIV each month at the local public health clinic.

Even so, the first step in fighting the epidemic is convincing people that AIDS is a problem in eastern South Carolina. Many people still consider AIDS a disease of far-off northern cities. When someone in a small South Carolina town dies with AIDS, local activists say, family members usually ascribe the death to some other cause -- cancer, a respiratory infection.

"That is the southern way," said Krista Heybruck, an HIV/AIDS health educator working in three rural counties in the eastern part of the state. "That's just the way it is, and that's what we have to work with. They are private here."

Ericka Burroughs, a young anthropologist who grew up in South Carolina and works for a federally funded HIV prevention agency, drives hundreds of miles each week to teach safe-sex classes and talk about AIDS at jails, schools, mental institutions and drug rehabilitation centers. She taught Tameka Sauls's HIV training course at the local adult education center. "I hardly ever do a presentation where there isn't at least one person who cannot read," she said.

With the help of federal prevention funds, local residents are coming up with new ways to increase awareness of the disease in Florence. Last September, Anne Neely, a biology teacher at Sauls's former high school, began offering an elective course in which students learn about AIDS and make videotapes about the disease's impact on their community. However, school administrators warned Neely that she couldn't use the "C word" -- condom -- or allow one to be shown on a student video.

Neely paid for video equipment for her course with a $ 1,000 grant, part of approximately $ 1.1 million that South Carolina received last year from the CDC for local HIV prevention programs. Students learn the details of how HIV is transmitted. Then they produce videos to bring home the reality of AIDS to other students.