Each day, African Americans are stitching new panels of the AIDS Memorial Quilt for their loved ones. African Americans-who compose 13 percent of the U.S. population-now account for 40 percent of all people with AIDS in the United States.

African Americans are being diagnosed with AIDS at a rate six times faster than that of whites, a proportional disparity that increases each year. Yet interpreting this disparity in simple numeric terms can create a distorted view, for race often shrouds the complex knot of medical, social, and economic risk factors that ties the African American community to AIDS.

"Looking at AIDS as a 'black' problem sometimes obscures the issues," says Alvin Poussaint, professor of psychiatry at Harvard Medical School. Poussaint believes that while studying the intersections between AIDS and race may be useful, the questions themselves need to be reevaluated. "What would these data look like if we were to control for factors such as poverty?" he asks. "It may be more apt to compare AIDS rates in terms of socioeconomic class."

Robert Fullilove, associate dean at the Columbia University School of Public Health, agrees. "Not all African Americans are at higher risk for HIV," he says. "We don't want to talk about race as a risk factor so much that it implies that membership in a racial group puts you at risk of HIV."

Legacies of Injustice
"A better model for examining what's going on with HIV in communities of color is not related to race," Fullilove adds, "but to social realities that are the legacies of slavery and segregation." Understanding the HIV epidemic among African Americans requires an examination of how factors such as poverty, denial, and the constant thread of racism combine with the virus to kill.

As with members of all other racial and ethnic groups, African Americans can be found at every point on the socioeconomic spectrum. Ethnographic studies conducted over the past thirty years in poorer communities of color, however, have demonstrated several trends that have resulted in limited education and employment opportunities, including a loss of jobs, the expansion of an underground economy, and the increased availability of drugs. As a result, individuals living in these communities often face a lack of choices that can lead to behaviors that make them vulnerable to HIV.

"When a virus doesn't make you sick for ten or fifteen years, it gets placed on the back burner," Fullilove says. "It's not that people don't know about HIV or aren't aware of the dangers, it's just that they have to prioritize their needs. Some of these same neighborhoods often have increased rates of violent crime and drug use. If you're worried about being hit by a bullet tomorrow, why worry about a virus that won't kill you for another fifteen years?"

While noting that Americans tend to use drugs at fairly constant rates across all demographic categories, Fullilove observes that the kinds of drugs used vary across places and populations. In the inner city, injection drugs are prevalent, and, Fullilove says, "where there is exposure to injection drugs, there is likely to be use."

In many African American communities, such use has led to high rates of HIV transmission. "We need to examine the dynamics in a community that make all this possible," Fullilove says. "We need to look at the intersection of who you are, where you are, and what you do, and deal with these three things in the aggregate. This epidemic is not about skin color."

Distrust and Denial
What the epidemic is about-to a large degree-is an ever-rising number of infections. More than half of all children who have been diagnosed with AIDS in the United States are African American. By the end of 1995, nearly 175,000 African Americans had been diagnosed with AIDS. The latest U.S. data suggest that more African Americans are now infected with HIV than all other racial and ethnic groups combined.

According to the Centers for Disease Control and Prevention, African American men tend to be infected through sex with another man or through injection drug use, while African American women often acquire the virus through injection drug use or through sex with an infected man.

The risk of HIV infection stems from more than the dynamics of impoverished communities. African Americans are also at risk because of a history of distrust and denial. "People keep expecting us to act as if we are the dominant culture, in total control," says Wilbert Jordan, director of the AIDS clinic at King/Drew Medical Center in Los Angeles. "But we aren't."

For African Americans, the AIDS epidemic began with a loss of trust. In 1980, the 300,000 Haitians fleeing a repressive political regime were accused of bringing HIV into the United States. The Centers for Disease Control and Prevention designated all Haitians as high risk and included them in the "4-H club" along with homosexuals, heroin users, and hemophiliacs. For these individuals, the stigma derived not from their risk behaviors, but solely from their membership in a group.

This injustice against Haitians was the latest example in a long history of abuse of medical power against African Americans. Between 1932 and 1972, for example, the U.S. Public Health Service denied treatment to approximately 400 poor, black men with syphilis in Macon County, Alabama-even after penicillin became the standard therapy in 1954. This Tuskegee Syphilis Study is still often cited to lend credence to rumors that AIDS is part of a plot to wipe out African Americans; in a 1991 survey published in the American Journal of Public Health, 35 percent of African Americans queried said they believed that AIDS is a form of genocide.

"Calling blacks 'paranoid' is unfair because of the history of medical experimentation in this country, and also because this is an issue of trust," Jordan says. Poussaint concurs that many African Americans have suffered-and continue to do so-within the mainstream medical establishment. At the same time, however, he says, "Community members who subscribe to conspiracy theories may use those beliefs as tools to avoid the responsibility of taking action against HIV infection."

Distrust of the medical establishment is not the only root of denial; the perception of AIDS as a disease of white homosexual men also helped denial take hold. Ten years ago, Belynda Dunn's fiancé suddenly left town without a word. "When I found out he later died of AIDS, I was shocked," says Dunn, African American education specialist at Boston's AIDS Action Committee. "He had been using injection drugs. I have no doubt he loved me, but this was 1986, when AIDS was still really stigmatized as a gay disease. Even today, denial remains a major factor among African Americans."

Janet Mitchell, director of obstetrics and fetal medicine at Interfaith Medical Center in Brooklyn, offers a slightly different perspective, suggesting that the African American community does not so much deny the epidemic as respond to it away from the public eye. "It's not actual denial. It's just that, in our culture, you don't air dirty laundry in newspapers," she says. "We don't resolve issues with everything hanging out in editorials. This is a cultural issue that gets misinterpreted. Among ourselves, where there is trust, we acknowledge AIDS."

Mitchell also emphasizes that AIDS is a powerful issue for African Americans across the full socioeconomic spectrum. "It's not just the poor and underclass who have been affected," she says. "We've all been personally touched by AIDS. When I lecture around the country, professionals always come up at the end of my talks to tell me that they're dealing with HIV infection, whether in themselves, their families, or their friends. This epidemic has become personal for almost everyone I know."

The Thread of Racism
Fullilove believes that running through each issue related to the epidemic among African Americans-whether persistent poverty, or distrust of the medical establishment-is the thread of racism. He contends that racism is the reason that the nation has not taken greater action against the epidemic among communities of color. "The epidemic has settled in so-called throwaway communities," he says. "These are the same communities that the country seems to refuse to see as worthy of respect, support, or resources."

Poussaint concurs: "One issue for African Americans is whether there is sufficient progressive leadership in white-controlled organizations. Are they concerned enough about blacks with AIDS? Or are they more concerned about black issues that affect whites, such as black crime or drug abuse?"

The Community Responds
Within the African American community itself, the AIDS epidemic has led to a search for leadership. Among the organizations looked to most often is the black church. "More than anything else, the church is the institution that has a history of being responsive in dire times," Fullilove says. "But for now, AIDS is still being dealt with poorly."

One study among African American ministers in New York City found that some were reluctant to address the epidemic because they identified AIDS with homosexuality. "The inability of these ministers to raise HIV awareness in their communities is related to the church's age-old dilemma between serving those in need and recognizing homosexual behavior," Fullilove says.

Fullilove thinks that the opinions of such religious leaders are changing, as they confront the harsh reality of the epidemic. "The black church has had to meet the issue head on, because AIDS has refused to go away," he says. "There have been just too many funerals for it to be ignored."

Others believe that the church has responded well. Belynda Dunn, for one, says she is a living testament to its power. Upon learning of her own infection several years after her fiancé died, Dunn says, "I was devastated. I appeared as a broken-down shell of a woman with no job, no home, no clothes. The church supported me and helped me find a home."

With the church to support her, Dunn decided not to remain silent about being infected. "I knew I couldn't be the only one who had this story to tell," she says. "I felt I had to be there for other people." Dunn, like many others, is working to untangle the complex knot that has tied the African American community to HIV.