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First of two parts - While just a teenager in the 1970s, she danced on The Block, where she snorted cocaine and heroin and sold sex in back rooms. Later, with her addictions firmly rooted, she set out on her own, offering her body on the streets of West Baltimore as a deadly virus was spreading.
The years have worn away at Sharon Williams, whose deeply lined face, reddened eyes and pained expressions tell of poor health, nights in abandoned buildings and customers like the man who kicked her down a flight of stairs, breaking two ribs and puncturing a lung.
Yet she remained a prostitute to support herself and her habits. Not even the discovery 12 years ago that she had been infected with HIV changed that. She also counts herself among the many addicted women who, despite knowing the risks, have given in to customers who refuse to wear condoms.
"They'll do anything for a high," Williams said. "If they want money enough, they'll agree to it. I've slipped up once in a while."
The sale of sex for drug money is an important but largely overlooked reason why Baltimore has the nation's second-highest rate of AIDS diagnoses, trailing only Miami. By the end of last year, almost 16,000 city residents were living with HIV or AIDS.
Women desperate for their next fix and men willing to risk their health for cheap sex are partners in an epidemic that shows no signs of ending. Experts consider prostitutes to be "core transmitters" because of their high infection rates and large numbers of partners.
Therapeutic advances have prolonged life while education has lowered the overall HIV infection rate. Still, the death toll from AIDS continues to mount, reaching almost 9,800 in Baltimore since the epidemic began in the early 1980s. The disease has devastated families, leaving children without parents and often killing multiple relatives. It is the leading cause of death among adults 35 to 44 years of age, surpassing homicide, and has had a corrosive effect on neighborhoods already beset by poverty, crime and homelessness.
At last count, Baltimore's rate of new AIDS diagnoses was nearly three times the nation's, 21 percent higher than New York's and almost double San Francisco's - two cities that people more commonly associate with the epidemic.
In certain parts of the city, the impact is even more striking. In ZIP code 21217, which includes Sandtown-Winchester and the Pennsylvania Avenue corridor, the percentage of people living with HIV/AIDS is 15 times the national average.
Public health authorities have been slow to address the connection between AIDS and what some experts call "survival sex," in part because the people involved are elusive and their role hard to quantify. Most of the women have been addicted to drugs and, in some cases, ensnared in prostitution since childhood. Many are homeless, wandering from one abandoned building to another.
The prevalence of crack
A key part of the sex trade, epidemiologists say, is crack cocaine. The drug produces an intense high followed quickly by a crushing depression that can be relieved only by smoking more. Crack, which has been a major presence in Baltimore since the early 1990s, drives many female addicts into a relentless cycle of drug-seeking and prostitution.
"They have a lot of partners to sustain their habits," said Dr. Jacques Normand, chief of the AIDS program at the National Institute on Drug Abuse. "There is no question in this country that there's a substantial epidemiological relationship between crack and HIV transmission. It all comes down to the trading of sex and drugs."
Terry Brown, vice president of Baltimore Behavioral Health, daily sees the link between drug use and prostitution among the women who enter his drug treatment center. "I would say that if we have a woman who is a substance abuser, is unemployed and has no income, the way she supports her habit is the sex trade," said Brown, who is co-chairman of the city's Commission on HIV/AIDS Prevention and Treatment.
In a months-long examination, The Sun interviewed physicians, advocates, social workers, addiction counselors and public health experts to learn how the sex trade contributes to the greater epidemic. The best understanding, however, comes from the stories shared by nearly 20 women who have fed their addictions this way.
Many of the women were initiated into prostitution around puberty. Several told of childhoods in which fathers or relatives forced them to have sex with men to support their own drug habits. Soon the girls were getting high to numb their shame.
As women selling sex for drugs, many have been routinely exposed to beatings, robberies and sexually transmitted diseases, including HIV.
"They're holding on for dear life," said Sidney Ford, who runs a drop-in center on West Pratt Street called You Are Never Alone. "They feel they're doing all they can to keep that grasp on what little bit of life they see is left for them."
In Baltimore, the neighborhoods most afflicted by HIV/AIDS flank downtown, sweeping past Johns Hopkins Hospital on the east and curving from Druid Hill Park past Carroll Park on the west. They are the same ones heavy with drug dealers, jobless residents and prostitutes.
About dusk one day, a stream of young people traipsed north from Pigtown to Sandtown in search of drugs. Hours later, their purchases completed, they hurried home along streets where prostitutes struck solitary poses. The women wore blank expressions and shabby clothes as they awaited passers-by and motorists.
The women were black and white, teenage to middle age.
Sgt. Sean Mahoney, who patrols the Western District, observes this ragged commerce night after night. Along Wilkens Avenue and Washington Boulevard, he addresses many of the women by name and knows their stories.
"They've been treated like crap all their lives by their parents, by their men," said Mahoney. "Drugs are an escape."
Drug use and prostitution have long been a part of Sharon Williams' life. She failed as a Fells Point waitress because of her addiction but became an attraction on west-side streets where, in her heyday, "I was one of the prettiest girls in the neighborhood."
Back then, men approached her for sex as she walked along Ramsay and Carey streets wearing hot pants. On a typical day, she said, she had four "johns." With a touch of pride, she said she made to afford her own place to live.
But she lost that a long time ago. This summer, she was finding refuge in an abandoned Formstone-faced rowhouse just north of Carroll Park. To get there, she walked up an alley and scaled a low stone wall to enter a kitchen with empty cabinets and ankle-deep trash.
Up a flight of stairs were two bedrooms. The one where she slept had two bare mattresses and a mural of a toucan in a tree that someone had defaced by painting an obscenity. Strewn about were empty malt liquor bottles, frayed insulation and dirty clothes. On the torn edge of a drop ceiling, she had stashed her needle and tools.
Soon, she was feeling the effects of a heroin injection. Her head dropped to her chest, straight brown hair cascading over her face. Suddenly, she cried out to no one in particular, "How many times?"
She scratched her head and rubbed her eyes with puffy hands that are common among people whose veins have collapsed from shooting drugs. Minutes later, she rose and stooped over a chair. Holding onto the armrests for support, she murmured incoherently before calling out, "Oh, my God. I'm still here. Still here, all right."
That she's still here at 45 is remarkable.
Williams spent most of her childhood in foster care but ran away at 15. By 17, she began dancing on The Block, the stretch of bars and strip joints on East Baltimore Street. She has been addicted to heroin and cocaine for more than 25 years, she said, and has been prostituting herself about that long.
The men she cared about were users, too.
On her arms are the tattooed names of long-ago boyfriends. On her left arm is written Richard, a strip-club doorman who died when he slammed his sports car into a tractor-trailer while high on cocaine, she said. On her right arm is Buddy, her first love, who died of a heroin overdose.
"I'm beginning to feel like the black widow," Williams said, going on to describe how her fiance, Paul, used drugs and died of AIDS in 2003. AIDS later claimed his brother too.
Like many people with multiple risk factors, Williams can only speculate how she contracted the virus. Paul may have given it to her. In her family, there was precedent for this. She said her elder sister died of AIDS in 1995, having caught the virus from a drug-using boyfriend.
Then again, she said she might have gotten it from a fellow drug user who stuck a needle into her cooker, a large bottle cap that she had used to dissolve heroin into an injectable liquid.
Williams said she doesn't always tell customers about her HIV status. One man, she said, was so enraged after she belatedly told him that "he put his car in reverse and tried to run me over."
Among women who trade sex, studies find infection rates as high as 30 percent in locales around the nation. Such studies haven't been done in Baltimore, though several nonprofit groups that serve this population report rates that are similar or higher.
In general, the odds of an infected woman spreading the virus to a man through sex are lower than the odds of a man transmitting HIV to a woman. For female-to-male transmission, the risk might be as low as one in 1,000 for a single act of intercourse.
But the risk rises steeply if certain conditions are met. A woman with a genital sore is more contagious. An uncircumcised man is more susceptible. A woman who has gone untreated might have more virus to shed.
The risk, studies have shown, can rise as high as one in four, depending on which conditions are met.
"The likelihood they will infect someone keeps going up because of the probabilities," said Dr. Thomas Quinn, infectious disease professor at the Johns Hopkins Bloomberg School of Public Health. "If the odds are one out of 10 and someone has sex with 10 people, then one is going to get infected."
Many of those who trade sex for drugs have sexually transmitted infections such as syphilis, gonorrhea and chlamydia, which boost their susceptibility to HIV - and the potential to pass it along. People who have lesions caused by these infections are three to six times more likely to spread the virus in a single act of sex, according to experts.
"Their primary focus is on getting high," said Dr. Jonathan Zenilman, chief of infectious diseases at Johns Hopkins' Bayview Medical Center. "They may ignore symptoms of STIs, ulcerations. They are chronically ill, a lot of them."
For years, Williams devoted herself to her addictions and little else. Last spring, she estimated that she had been spending $20 to $30 a day for heroin, and $100 to $200 for crack. She raised some of the money by "tricking" and some by securing drugs for others. She has a criminal record that includes convictions for drug possession, burglary and prostitution.
She took HIV medications in the late 1990s in a prison health program supervised by Johns Hopkins Hospital but drifted out of therapy after her release, according to records at the University of Maryland's Evelyn Jordan Center, where she is an occasional patient She gave doctors there permission to discuss her medical history.
In April, after failing to show up for two medical appointments on the same day, she confessed that she was busy "using." Doctors had no opportunity to examine her until June, when she went to the University of Maryland Medical Center emergency room after a beating. There, doctors treated her wounds but also discovered a sexually transmitted disease.
"The fact that she has gonorrhea means she's having unprotected sex and [potentially] spreading HIV as well," said Dr. Ronald Reisler, her doctor at the center.
It was the latest in a string of infections that included syphilis. She also has hepatitis C, which is spread by dirty needles. Last year, a blood test indicated that her HIV infection had worsened, compromising her immune system.
"The problem is, she doesn't come to clinic, doesn't take medicines," he said. "If she continues on this path, I would expect her life expectancy to be short."
During the summer, Williams was back at the emergency room with a painful abscess in her calf at the spot where she had repeatedly injected heroin. As it turned out, her trip to the hospital was fortunate.
Doctors not only treated her abscess but also referred her to a methadone program that she has begun to view as a springboard to stability and legitimate employment. She attends daily support groups and sees a counselor who is helping her organize her life. For now, she is living with a sister near Hollins Market, though Williams occasionally ends up homeless after disagreements.
Weeks into treatment, she reports that she hasn't been tempted by heroin but did smoke crack when friends lit up a pipe. Afterward, Williams said, she was "miserable" with regret.
The link between crack, risky sex and the virus has not been well-studied in Baltimore. But in Miami, which has the nation's highest AIDS rate, a study among female crack addicts provides some insight.
There, the drug of choice is overwhelmingly crack, in contrast to Baltimore, where heroin and crack addiction are intertwined. But the Miami experience shows the role that crack can play in motivating prostitutes to seek one customer after another, said Dr. Toya Brewer of the University of Miami.
Brewer set out to measure sexual risk-taking among female crack addicts. A majority had at least one paying customer. Three-quarters who were HIV-negative engaged in unprotected sex. Among those who were positive, 56 percent had unprotected sex - a smaller percentage, but a majority nonetheless.
Sex-trading addicts draw customers from inside and outside their social circles. "They can be linked to people who are not in their group who in turn spread HIV in the larger community," Brewer said. "Some of them are exposing others; the rest are exposing themselves."
While prostitution can result in sexual transmission of HIV, it does not show up in federal statistics that characterize the epidemic. "Intravenous drug use is considered a recognizable risk factor, whereas having sex for crack does not fit into one of the defined categories," Brewer said.
In Baltimore, scientists hope to learn more about the link between prostitution and AIDS from a study of sexual transmission in neighborhoods with severe poverty and high rates of HIV infection. The survey is part of a larger national look at heterosexual transmission being overseen by the Centers for Disease Control and Prevention.
The researchers, with the Maryland AIDS Administration and the Johns Hopkins University, have begun recruiting 750 adults who will submit to HIV blood tests and recount their sexual and drug histories. The survey, among other things, asks specific questions about the trading of sex for money, drugs or other favors.
"Rather than being filtered through a physician's report, we're getting a better picture of the mixture of risk behaviors that need to be addressed," said epidemiologist Colin Flynn of the AIDS administration. "We'll use this to guide our prevention programs."
Prostitution, which has a long history in Baltimore, increased noticeably with the arrival of crack in the 1990s. Public health authorities believe that it triggered a syphilis outbreak, which they eventually quelled by offering testing and antibiotics in the worst drug neighborhoods.
But reducing prostitution was far more difficult. Dr. Peter L. Beilenson, then the city health commissioner, said he is convinced that the sex-for-drugs trade was one of the main forces driving the HIV epidemic during his 13-year tenure.
"They're not an easy group to reach," he said. "They're not all in the Route 40 corridor or even in hotel rooms, where some of the prostitution occurs."
The city sex trade ripples beyond the neighborhoods where it is concentrated. Just as people drive into the city for drugs, men from outlying areas cruise the streets for sex, running the risk of becoming infected and passing the virus to their spouses or other partners.
How many women sell sex in Baltimore remains unknown, although advocates for them contend that there could be thousands. About 700 visit two drop-in centers, and 1,000 prostitution cases are filed annually in District Court. That number probably includes multiple cases for some women, according to a prosecutor. On the other hand, many go undetected.
Some women don't work the streets at all, trading sex instead with male drug dealers and acquaintances. Some accept as little as $5 but say they are frequently offered more for sex without a condom. The women are engaged in a relentless if dangerous struggle - not only for drugs but also for the necessities of life.
"It could be for money, food or clothing," said Dr. Susan Sherman, a Johns Hopkins epidemiologist who refers to their work "survival sex." "It could be for cigarettes, drugs, anything."
You Are Never Alone
Sidney Ford left her job as a hospital social worker a decade ago after she read of two prostitutes who had been chained and tortured in a basement. "I started going to the brothels, saw the vulnerabilities, women who early in adolescence were raped by their fathers, boyfriends," she said. For some, sexual abuse began when they were even younger than that.
Ford founded You Are Never Alone to break the pattern that this kind of abuse established. She placed the center in a Carrollton Ridge neighborhood that is well-known for drug activity and the sex trade associated with it.
Outside is a constant flow of men and women, black and white, many with unsightly needle tracks on their arms and necks. Young men wearing the colors of local gangs can be seen stuffing bills into barely open fists. Other men amble by, pushing shopping carts filled with scavenged aluminum and copper that can be turned into cash.
Merchants trace the neighborhood's decline to the arrival of crack over a dozen years ago. Craig Strohmer, who operates a nearby hardware store that has been in his family for more than 100 years, recalled the exodus of middle-class families that coincided with the proliferation of corner drug dealers. Landlords abandoned their properties. Mom and pop stores closed.
At her center, Ford sometimes has to shoo away dealers and addicts who congregate nervously in the backyard of an adjacent rowhouse.
She hopes to help the women inside avoid drugs or find inspiration to shake them. A realist, she said many of her clients won't do so until they are ready, and she displays enormous patience with those who struggle.
"They're not in a state emotionally or physically or intellectually to be able to plan, to think about a future," said Ford.
Ford tries to create an environment in which women feel safe and can at least begin to envision something better. Some come for the basics. They shower, eat lunch, engage in banter and assemble outfits from piles of donated clothing.
Many go beyond that. They might meet with Ford to discuss the emotional wreckage left by years of childhood abuse. They may consult a nurse practitioner from Healthcare for the Homeless about routine medical problems or get a referral to free HIV treatment. About a third of the women have the virus, Ford said. Many have never been in treatment.
Eventually, women may decide to attend weekly support groups in which they learn skills as basic as how to say no. Ford and Tim Bridges, the assistant director, help them navigate the bureaucratic labyrinth that keeps many from getting drug treatment or public assistance. Bridges also assists some who are fresh out of prison.
Recently, Sharon Williams bounded into the center carrying a purse stuffed with prescriptions for a stomach ailment and other ills being addressed at the Evelyn Jordan Center. Perhaps, she said, she will one day begin treatment for hepatitis C and, finally, HIV.
None of that will happen if she doesn't learn to manage the details of daily living. Fishing through her purse, she located a scrap of paper that may represent the first steps toward accomplishing that.
It contained a "to do" list that her methadone counselor suggested that she update on a daily basis. On it were tasks such as obtaining proof of her divorce, documentation that she would need to obtain from a government records office to qualify for Medicaid.
She had no idea whom to call or where to go but seemed energized by the task.
"I've started writing goals," Williams said. "I make four goals on a piece of paper. Even if I do one and write 'completed,' it makes me feel good."
An epidemic's unseen cause
Jonathan Bor
Baltimore Sun
11/4/07
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Part Two
Second of two parts - Angela Jackson strides down Pennsylvania Avenue with pamphlets under her arm, unfazed by the line of dealers hawking drugs beneath blinking police cameras. "James Brown, James Brown!" cries one young man, applying the late soul star's name to his heroin capsules. "Ray Charles, Ray Charles!" cries another.
Places like this are utterly familiar to Jackson, who once supported a heroin addiction by selling sex to men eager to step into an alley or vacant building. Today, she spots someone who's trolling for customers as she once did.
"Hey, miss, you have a minute?" Jackson says to an emaciated woman with hollow eyes. "We're giving information about HIV and condoms." But the woman drifts by, vanishing into an alley.
"I was just like her," says Jackson, 44, who left a life of prostitution nine years ago, found housing and began treatment for HIV. "There's hope for everybody."
There aren't enough hopeful stories like Angela Jackson's. Often homeless and desperate for their next fix, women who exchange sex for drugs are an elusive group for public-health authorities. Many are caught in an incessant rhythm of tricking and drug use rooted in the sexual abuse they suffered as children.
Despite millions of dollars spent on HIV/AIDS programs, the city until recently has taken only a piecemeal approach to helping these women break the cycle. Baltimore's health commissioner, Dr. Joshua Sharfstein, asserted recently that the city lacks a coherent strategy for curbing HIV infections. He vowed to sharpen the focus.
The renewed focus comes at an important juncture in the history of the city's HIV epidemic. With additional people catching the virus each year and better treatments prolonging life, the number of infected residents has more than doubled over the past decade - reaching nearly 16,000 last year.
Women who trade sex for drugs play a central role in spreading the virus, contributing to Baltimore's ranking as the city with the second-highest rate of AIDS diagnoses in the United States. They are "core transmitters," experts agree, because as a group they have high infection rates and large numbers of partners.
Prostitution may be the direct or indirect cause of 20 percent to 40 percent of new infections, estimated Dr. William Blattner, director of epidemiology at the University of Maryland's Institute of Human Virology.
"I think there are certain taboos to even admit that it exists," said Blattner, also co-chairman of the Baltimore City Commission on HIV/AIDS.
"Part of it also is that this is a culture that's very marginalized and hard to wrap your arms around. These people don't pay taxes, don't get counted in the census. It's a forgotten group. It's also one that doesn't raise a lot of voter sympathy," Blattner said.
Women like Jackson who shared their stories with The Sun described a nomadic existence that made it difficult to even contemplate entering treatment for HIV, let alone sticking with it. Those sleeping in vacant buildings lack refrigerators to store medications, addresses to leave at a doctor's office and the confidence of knowing where they're going to stay the night - and the night after that. Advocates say housing is one of this group's greatest needs.
Sharfstein acknowledged that more can be done to stem the spread of HIV among the women and their customers. "There are pieces of different things addressing the problem," he said. "But I think we need to address whether a more systematic approach is indicated."
City's initiative
Recently, he announced the department's first efforts in that direction. Twice a week as the sun rises, the city will dispatch a van staffed with outreach workers just as women start seeking customers to feed their addictions.
On Tuesdays, the van will appear at Monroe and Ramsay streets in West Baltimore, and Thursdays at an east-side location also known for prostitution.
"My primary focus is the women exchanging sex for drugs and money," said Chris Serio-Chapman, director of harm reduction for the city Health Department. "We were missing an entire portion of the day when a lot of these women are awake, outside, providing services to their johns."
The genesis of the idea occurred several months ago, Serio-Chapman said, as she reflected on the absence of programs aimed directly at this population. The city's needle-exchange and testing vans attracted some women engaged in sex work, she said, but didn't offer the concentrated services that the women required.
Sharfstein said that finding $70,000 for a one-year pilot program was "an easy call" because of Serio-Chapman's interest as well as The Sun's inquiries about how the city was addressing the problem.
The department's initiative will start in January. The Health Department and Power Inside, a nonprofit group in East Baltimore, will offer not only HIV testing and clean drug needles, but also counseling and referrals to medical care and housing assistance.
Women can also receive wound care products and ointment to soothe the dry, bleeding lips common to people who smoke crack cocaine.
The program is an extension of the city's needle-exchange program but with several differences.
It will specifically target women engaged in the sex trade rather than the broad population of drug users. It will be staffed only by women in an effort to be non-threatening. And rather than waiting for people to come to them, outreach workers will fan out into the neighborhoods to draw them in.
More than willpower
No such program existed for Jackson, who needed more than her uncommon willpower to leave drugs and prostitution behind. It came in the form of a caring social worker who ventured to the street in Southwest Baltimore where Jackson worked, offering help at a time when she had bottomed out and was receptive to change.
She traces her history of substance abuse to age 8 when her parents would awaken her late at night to sing for guests and she'd help herself to drinks at the living room bar. Soon, she discovered that alcohol could numb her revulsion at being molested by an adult relative who sometimes entered her room at night. Later, she used heroin and cocaine to help her cope with abusive boyfriends.
By her mid-teens, she had run away from home and dropped out of school. Several years later, she tested positive for the AIDS virus in a hospital where, she said, the stigma ran so high that she was forced to await the results in a storage room. Looking back, she figures she caught the virus from an infected boyfriend with whom she was intimate and shared needles.
It was the mid-1980s, a decade before the advent of effective treatments. Sure that she had received a death sentence, she slit her wrists in a failed suicide attempt and began meting out a kind of sexual justice against men whom she thought had wronged her.
"I started sleeping around with everybody," she said. "It got to be revenge sex where I didn't care. I was just going to sex it up and drug it up."
She engaged in a ritual called "body crashing" that involved injecting heroin in one arm and cocaine in the other while inhaling on a crack pipe. To pay for her drugs, she entertained men in alleys and cars. Some beat her to get their money back.
Nine years ago, Jackson had an epiphany. She awoke at a customer's house and looked down to discover that both forearms had "blown up like Popeye," infected in the places where she had repeatedly injected heroin. At an emergency room, a doctor told her she might lose both arms to amputation if she didn't stop.
"So I quit," said Jackson.
Jackson's story is unusual in many respects. She quit without entering a program and, by her account, didn't relapse, as many recovering addicts do. She also possesses determination and charisma despite a history that might have snuffed out those qualities.
Strength came, too, from the social worker she met one morning on Patapsco Avenue. In the pre-dawn blackness, the woman pulled up alongside her and rolled down her window.
'There's help if you want help," Williams recalled her saying. Sidney Ford handed her a card for the drop-in center, You Are Never Alone, that she had just opened on West Pratt Street. Stop by for food and counseling, she said.
Jackson said this rare expression of concern cemented her resolve to quit prostitution as well as drugs. Yet she spent the next three years homeless, unable to find housing or employment because of a criminal record that included drug, prostitution and burglary convictions.
She had given up custody of her daughters to relatives. She took to sleeping in abandoned buildings where she washed her clothes in toilet tanks. She remained untreated for HIV.
Eventually, a nonprofit organization helped her qualify for a subsidized apartment under a federal program, Housing Options for People with AIDS.
That was her breakthrough. It gave her stability to find a job as an AIDS educator and enter treatment for HIV at the University of Maryland's Evelyn Jordan Center. Medication has driven the virus to an undetectable level and restored her immune system, said Dr. David Wolde-Ruphael.
Jackson gave permission for her doctor to speak about her health. "She's doing wonderfully," he said. "She's strong."
AIDS, however, has continued to stalk her family. The disease claimed two relatives just four days apart last year, shaking up Jackson's aunt, Wilhemina Harrington, who lost her brother and her son.
"I feel like I'm walking around here with a scream about to come out of me," said Harrington.
Her son, Kevin Hudgin, 49, had lost touch with his family during his final months. After he died in a Forest Park apartment, his body went unclaimed at the state anatomy board. Relatives got word of his death from someone on the street who asked when the funeral would be.
Jackson's family retrieved her cousin's body only one day before it was due to be cremated. His ashes had been destined for a cemetery where the state buries unclaimed remains, including those of numerous people who died of AIDS.
While the death rate has declined, AIDS remains a lethal force in poor neighborhoods where many infected people don't get into care until they are gravely ill. It has claimed over 9,000 lives and is the leading cause of death among adults 35-44.
The disease has left a tragic imprint on families throughout the city. Mayor Sheila Dixon knows this, having lost a brother, Phillip Dixon, and sister-in-law, Juanita Dixon, to AIDS early in the epidemic. In 2002, as City Council president, she was a leading force behind the city's declaration of a "state of emergency" and creation of a commission on HIV/AIDS.
Earlier this year, the city launched a safe-sex media campaign aimed at young people. Still, Dixon said in a recent interview that too few individuals are getting the message that "irresponsible sex" is perpetuating the epidemic.
"I don't think we've done the best job we've needed to," Dixon said.
Programs to help
Federal, state and local governments spend $6 million to prevent HIV in Baltimore. The federal government spends $20 million for treatment under the Ryan White program, named after an Indiana youth who fought discrimination before dying in 1990 of the disease. Much of the money is distributed by the Maryland AIDS Administration.
Through Medicaid, the state directs more than $110 million annually toward the care of city residents with HIV/AIDS, with a portion of the funds devoted to treatment of other illnesses. Taxpayers spend millions more on medications for indigent patients. Treatment means prevention, too, since patients with less virus aren't as likely to infect others.
Even so, Sharfstein recently told the AIDS commission that Baltimore lacks a comprehensive prevention strategy for HIV, in part because no one has fully assessed the services performed by the patchwork of organizations receiving public money. As a first step toward solving this, the department plans to map which neighborhoods and risk groups are being served and which are left out.
"As amazing as our medical institutions are," he said, "we're not going to treat our way out of HIV in Baltimore."
Some argue that little can be done to reach untreated people until they are provided decent housing. A research study in New York found that needle-sharing and unprotected sex were less common among people who had even a relative's couch to sleep on than among the homeless. It was least common among those with stable places to live.
Dr. David Holtgrave, a social scientist at the Johns Hopkins Bloomberg School of Public Health, estimated that providing housing to homeless people with HIV infection would save society money if just one case of transmission were averted for every 19 people housed.
The calculation is based on an average housing subsidy of about $10,000 per year, and a lifetime cost of $221,000 to treat one person for HIV infection. His analysis appeared recently in the journal AIDS and Behavior.
He is now concluding a related study to determine whether housing people with HIV infection leads to better health outcomes and a reduced risk of transmission. The research involves over 600 people in Baltimore, Chicago and Los Angeles.
Five hundred patients and their families are now living in subsidized housing through the federal program that helped Jackson, according to Mary Lee Bradyhouse, who administers it through the city Health Department. Those given a slot must have a case manager, but addiction is not a barrier. Nonetheless, landlords are free to evict tenants for illegal activity.
Funding for the program has been flat in recent years despite rising numbers of people living with HIV/AIDS. Some 600 people are on the waiting list for vacancies, which open when someone occupying a unit gets evicted, moves out or dies.
The effort to house people with HIV infection takes place amid a wider housing shortage. A recent report by the Abell Foundation contends that the city has focused on demolishing derelict properties rather than providing housing, citing a 42 percent drop in occupied public housing units over the past 15 years.
Advocates who extend services to prostitutes say anyone hoping to address their needs must be persistent and act quickly when the women are ready to be helped.
At Ford's program on West Pratt Street, many show up for years before they are ready to seek drug treatment or attend a clinic offering free treatment for HIV infection. Eventually, some simply get tired of living the way they have.
"There's a certain purposefulness that people who are ready for recovery have," Ford said. "There are no superficial concerns. It's all they want to talk about."
Outreach workers with the East Baltimore nonprofit Power Inside approach women again and again before they agree to step inside the group's office. Some are desperate for their next hit on a crack pipe, a need that may arise every couple of hours. Others may agree only if they are guaranteed a ride back to the corner where they work.
"So we're dealing with the narrowest possible window," said Jacqueline Robarge, director of Power Inside. "It's kind of crazy to think that we can widen that stage just enough to have the conversations we know lead to behavior change. But we do."
In these intervals, outreach workers try to find room in drug treatment centers or shelters that are often full.
"If they're not housed, what prevention can you be doing?" said Robarge.
Housing is the key
Once Angela Jackson obtained a place to live, she was able to regain custody of her two daughters. With another on the way, she had enough room for her reunited family. All are healthy. Treatments have greatly reduced the chance of a mother's transmitting the virus to her baby.
Now, she rises at 5:30 each morning to take her medications and ride out the shakiness she initially feels. Within an hour, she's ready to help daughters, Matika, 14, and Shamya, 7, get ready for school.
Jackson has found happiness.
Last year, she married. She dresses fashionably and wears a curly wig that hides thinning hair, a possible side effect of medication. She works as a peer counselor for Light, Health and Wellness, a nonprofit that serves women and children affected by HIV.
She calmly walks past drug dealers who congregate in the courtyard of her West Baltimore apartment and speaks of "tricking" as something that happened long ago.
"Housing gives you a sense of responsibility and dignity and respect," said Jackson. "It makes you want to strive to do the right thing. Makes you feel worthy to be treated like a person. It covers so much. You're no longer putting yourself in harm's way."
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The years have worn away at Sharon Williams, whose deeply lined face, reddened eyes and pained expressions tell of poor health, nights in abandoned buildings and customers like the man who kicked her down a flight of stairs, breaking two ribs and puncturing a lung.
Yet she remained a prostitute to support herself and her habits. Not even the discovery 12 years ago that she had been infected with HIV changed that. She also counts herself among the many addicted women who, despite knowing the risks, have given in to customers who refuse to wear condoms.
"They'll do anything for a high," Williams said. "If they want money enough, they'll agree to it. I've slipped up once in a while."
The sale of sex for drug money is an important but largely overlooked reason why Baltimore has the nation's second-highest rate of AIDS diagnoses, trailing only Miami. By the end of last year, almost 16,000 city residents were living with HIV or AIDS.
Women desperate for their next fix and men willing to risk their health for cheap sex are partners in an epidemic that shows no signs of ending. Experts consider prostitutes to be "core transmitters" because of their high infection rates and large numbers of partners.
Therapeutic advances have prolonged life while education has lowered the overall HIV infection rate. Still, the death toll from AIDS continues to mount, reaching almost 9,800 in Baltimore since the epidemic began in the early 1980s. The disease has devastated families, leaving children without parents and often killing multiple relatives. It is the leading cause of death among adults 35 to 44 years of age, surpassing homicide, and has had a corrosive effect on neighborhoods already beset by poverty, crime and homelessness.
At last count, Baltimore's rate of new AIDS diagnoses was nearly three times the nation's, 21 percent higher than New York's and almost double San Francisco's - two cities that people more commonly associate with the epidemic.
In certain parts of the city, the impact is even more striking. In ZIP code 21217, which includes Sandtown-Winchester and the Pennsylvania Avenue corridor, the percentage of people living with HIV/AIDS is 15 times the national average.
Public health authorities have been slow to address the connection between AIDS and what some experts call "survival sex," in part because the people involved are elusive and their role hard to quantify. Most of the women have been addicted to drugs and, in some cases, ensnared in prostitution since childhood. Many are homeless, wandering from one abandoned building to another.
The prevalence of crack
A key part of the sex trade, epidemiologists say, is crack cocaine. The drug produces an intense high followed quickly by a crushing depression that can be relieved only by smoking more. Crack, which has been a major presence in Baltimore since the early 1990s, drives many female addicts into a relentless cycle of drug-seeking and prostitution.
"They have a lot of partners to sustain their habits," said Dr. Jacques Normand, chief of the AIDS program at the National Institute on Drug Abuse. "There is no question in this country that there's a substantial epidemiological relationship between crack and HIV transmission. It all comes down to the trading of sex and drugs."
Terry Brown, vice president of Baltimore Behavioral Health, daily sees the link between drug use and prostitution among the women who enter his drug treatment center. "I would say that if we have a woman who is a substance abuser, is unemployed and has no income, the way she supports her habit is the sex trade," said Brown, who is co-chairman of the city's Commission on HIV/AIDS Prevention and Treatment.
In a months-long examination, The Sun interviewed physicians, advocates, social workers, addiction counselors and public health experts to learn how the sex trade contributes to the greater epidemic. The best understanding, however, comes from the stories shared by nearly 20 women who have fed their addictions this way.
Many of the women were initiated into prostitution around puberty. Several told of childhoods in which fathers or relatives forced them to have sex with men to support their own drug habits. Soon the girls were getting high to numb their shame.
As women selling sex for drugs, many have been routinely exposed to beatings, robberies and sexually transmitted diseases, including HIV.
"They're holding on for dear life," said Sidney Ford, who runs a drop-in center on West Pratt Street called You Are Never Alone. "They feel they're doing all they can to keep that grasp on what little bit of life they see is left for them."
In Baltimore, the neighborhoods most afflicted by HIV/AIDS flank downtown, sweeping past Johns Hopkins Hospital on the east and curving from Druid Hill Park past Carroll Park on the west. They are the same ones heavy with drug dealers, jobless residents and prostitutes.
About dusk one day, a stream of young people traipsed north from Pigtown to Sandtown in search of drugs. Hours later, their purchases completed, they hurried home along streets where prostitutes struck solitary poses. The women wore blank expressions and shabby clothes as they awaited passers-by and motorists.
The women were black and white, teenage to middle age.
Sgt. Sean Mahoney, who patrols the Western District, observes this ragged commerce night after night. Along Wilkens Avenue and Washington Boulevard, he addresses many of the women by name and knows their stories.
"They've been treated like crap all their lives by their parents, by their men," said Mahoney. "Drugs are an escape."
Drug use and prostitution have long been a part of Sharon Williams' life. She failed as a Fells Point waitress because of her addiction but became an attraction on west-side streets where, in her heyday, "I was one of the prettiest girls in the neighborhood."
Back then, men approached her for sex as she walked along Ramsay and Carey streets wearing hot pants. On a typical day, she said, she had four "johns." With a touch of pride, she said she made to afford her own place to live.
But she lost that a long time ago. This summer, she was finding refuge in an abandoned Formstone-faced rowhouse just north of Carroll Park. To get there, she walked up an alley and scaled a low stone wall to enter a kitchen with empty cabinets and ankle-deep trash.
Up a flight of stairs were two bedrooms. The one where she slept had two bare mattresses and a mural of a toucan in a tree that someone had defaced by painting an obscenity. Strewn about were empty malt liquor bottles, frayed insulation and dirty clothes. On the torn edge of a drop ceiling, she had stashed her needle and tools.
Soon, she was feeling the effects of a heroin injection. Her head dropped to her chest, straight brown hair cascading over her face. Suddenly, she cried out to no one in particular, "How many times?"
She scratched her head and rubbed her eyes with puffy hands that are common among people whose veins have collapsed from shooting drugs. Minutes later, she rose and stooped over a chair. Holding onto the armrests for support, she murmured incoherently before calling out, "Oh, my God. I'm still here. Still here, all right."
That she's still here at 45 is remarkable.
Williams spent most of her childhood in foster care but ran away at 15. By 17, she began dancing on The Block, the stretch of bars and strip joints on East Baltimore Street. She has been addicted to heroin and cocaine for more than 25 years, she said, and has been prostituting herself about that long.
The men she cared about were users, too.
On her arms are the tattooed names of long-ago boyfriends. On her left arm is written Richard, a strip-club doorman who died when he slammed his sports car into a tractor-trailer while high on cocaine, she said. On her right arm is Buddy, her first love, who died of a heroin overdose.
"I'm beginning to feel like the black widow," Williams said, going on to describe how her fiance, Paul, used drugs and died of AIDS in 2003. AIDS later claimed his brother too.
Like many people with multiple risk factors, Williams can only speculate how she contracted the virus. Paul may have given it to her. In her family, there was precedent for this. She said her elder sister died of AIDS in 1995, having caught the virus from a drug-using boyfriend.
Then again, she said she might have gotten it from a fellow drug user who stuck a needle into her cooker, a large bottle cap that she had used to dissolve heroin into an injectable liquid.
Williams said she doesn't always tell customers about her HIV status. One man, she said, was so enraged after she belatedly told him that "he put his car in reverse and tried to run me over."
Among women who trade sex, studies find infection rates as high as 30 percent in locales around the nation. Such studies haven't been done in Baltimore, though several nonprofit groups that serve this population report rates that are similar or higher.
In general, the odds of an infected woman spreading the virus to a man through sex are lower than the odds of a man transmitting HIV to a woman. For female-to-male transmission, the risk might be as low as one in 1,000 for a single act of intercourse.
But the risk rises steeply if certain conditions are met. A woman with a genital sore is more contagious. An uncircumcised man is more susceptible. A woman who has gone untreated might have more virus to shed.
The risk, studies have shown, can rise as high as one in four, depending on which conditions are met.
"The likelihood they will infect someone keeps going up because of the probabilities," said Dr. Thomas Quinn, infectious disease professor at the Johns Hopkins Bloomberg School of Public Health. "If the odds are one out of 10 and someone has sex with 10 people, then one is going to get infected."
Many of those who trade sex for drugs have sexually transmitted infections such as syphilis, gonorrhea and chlamydia, which boost their susceptibility to HIV - and the potential to pass it along. People who have lesions caused by these infections are three to six times more likely to spread the virus in a single act of sex, according to experts.
"Their primary focus is on getting high," said Dr. Jonathan Zenilman, chief of infectious diseases at Johns Hopkins' Bayview Medical Center. "They may ignore symptoms of STIs, ulcerations. They are chronically ill, a lot of them."
For years, Williams devoted herself to her addictions and little else. Last spring, she estimated that she had been spending $20 to $30 a day for heroin, and $100 to $200 for crack. She raised some of the money by "tricking" and some by securing drugs for others. She has a criminal record that includes convictions for drug possession, burglary and prostitution.
She took HIV medications in the late 1990s in a prison health program supervised by Johns Hopkins Hospital but drifted out of therapy after her release, according to records at the University of Maryland's Evelyn Jordan Center, where she is an occasional patient She gave doctors there permission to discuss her medical history.
In April, after failing to show up for two medical appointments on the same day, she confessed that she was busy "using." Doctors had no opportunity to examine her until June, when she went to the University of Maryland Medical Center emergency room after a beating. There, doctors treated her wounds but also discovered a sexually transmitted disease.
"The fact that she has gonorrhea means she's having unprotected sex and [potentially] spreading HIV as well," said Dr. Ronald Reisler, her doctor at the center.
It was the latest in a string of infections that included syphilis. She also has hepatitis C, which is spread by dirty needles. Last year, a blood test indicated that her HIV infection had worsened, compromising her immune system.
"The problem is, she doesn't come to clinic, doesn't take medicines," he said. "If she continues on this path, I would expect her life expectancy to be short."
During the summer, Williams was back at the emergency room with a painful abscess in her calf at the spot where she had repeatedly injected heroin. As it turned out, her trip to the hospital was fortunate.
Doctors not only treated her abscess but also referred her to a methadone program that she has begun to view as a springboard to stability and legitimate employment. She attends daily support groups and sees a counselor who is helping her organize her life. For now, she is living with a sister near Hollins Market, though Williams occasionally ends up homeless after disagreements.
Weeks into treatment, she reports that she hasn't been tempted by heroin but did smoke crack when friends lit up a pipe. Afterward, Williams said, she was "miserable" with regret.
The link between crack, risky sex and the virus has not been well-studied in Baltimore. But in Miami, which has the nation's highest AIDS rate, a study among female crack addicts provides some insight.
There, the drug of choice is overwhelmingly crack, in contrast to Baltimore, where heroin and crack addiction are intertwined. But the Miami experience shows the role that crack can play in motivating prostitutes to seek one customer after another, said Dr. Toya Brewer of the University of Miami.
Brewer set out to measure sexual risk-taking among female crack addicts. A majority had at least one paying customer. Three-quarters who were HIV-negative engaged in unprotected sex. Among those who were positive, 56 percent had unprotected sex - a smaller percentage, but a majority nonetheless.
Sex-trading addicts draw customers from inside and outside their social circles. "They can be linked to people who are not in their group who in turn spread HIV in the larger community," Brewer said. "Some of them are exposing others; the rest are exposing themselves."
While prostitution can result in sexual transmission of HIV, it does not show up in federal statistics that characterize the epidemic. "Intravenous drug use is considered a recognizable risk factor, whereas having sex for crack does not fit into one of the defined categories," Brewer said.
In Baltimore, scientists hope to learn more about the link between prostitution and AIDS from a study of sexual transmission in neighborhoods with severe poverty and high rates of HIV infection. The survey is part of a larger national look at heterosexual transmission being overseen by the Centers for Disease Control and Prevention.
The researchers, with the Maryland AIDS Administration and the Johns Hopkins University, have begun recruiting 750 adults who will submit to HIV blood tests and recount their sexual and drug histories. The survey, among other things, asks specific questions about the trading of sex for money, drugs or other favors.
"Rather than being filtered through a physician's report, we're getting a better picture of the mixture of risk behaviors that need to be addressed," said epidemiologist Colin Flynn of the AIDS administration. "We'll use this to guide our prevention programs."
Prostitution, which has a long history in Baltimore, increased noticeably with the arrival of crack in the 1990s. Public health authorities believe that it triggered a syphilis outbreak, which they eventually quelled by offering testing and antibiotics in the worst drug neighborhoods.
But reducing prostitution was far more difficult. Dr. Peter L. Beilenson, then the city health commissioner, said he is convinced that the sex-for-drugs trade was one of the main forces driving the HIV epidemic during his 13-year tenure.
"They're not an easy group to reach," he said. "They're not all in the Route 40 corridor or even in hotel rooms, where some of the prostitution occurs."
The city sex trade ripples beyond the neighborhoods where it is concentrated. Just as people drive into the city for drugs, men from outlying areas cruise the streets for sex, running the risk of becoming infected and passing the virus to their spouses or other partners.
How many women sell sex in Baltimore remains unknown, although advocates for them contend that there could be thousands. About 700 visit two drop-in centers, and 1,000 prostitution cases are filed annually in District Court. That number probably includes multiple cases for some women, according to a prosecutor. On the other hand, many go undetected.
Some women don't work the streets at all, trading sex instead with male drug dealers and acquaintances. Some accept as little as $5 but say they are frequently offered more for sex without a condom. The women are engaged in a relentless if dangerous struggle - not only for drugs but also for the necessities of life.
"It could be for money, food or clothing," said Dr. Susan Sherman, a Johns Hopkins epidemiologist who refers to their work "survival sex." "It could be for cigarettes, drugs, anything."
You Are Never Alone
Sidney Ford left her job as a hospital social worker a decade ago after she read of two prostitutes who had been chained and tortured in a basement. "I started going to the brothels, saw the vulnerabilities, women who early in adolescence were raped by their fathers, boyfriends," she said. For some, sexual abuse began when they were even younger than that.
Ford founded You Are Never Alone to break the pattern that this kind of abuse established. She placed the center in a Carrollton Ridge neighborhood that is well-known for drug activity and the sex trade associated with it.
Outside is a constant flow of men and women, black and white, many with unsightly needle tracks on their arms and necks. Young men wearing the colors of local gangs can be seen stuffing bills into barely open fists. Other men amble by, pushing shopping carts filled with scavenged aluminum and copper that can be turned into cash.
Merchants trace the neighborhood's decline to the arrival of crack over a dozen years ago. Craig Strohmer, who operates a nearby hardware store that has been in his family for more than 100 years, recalled the exodus of middle-class families that coincided with the proliferation of corner drug dealers. Landlords abandoned their properties. Mom and pop stores closed.
At her center, Ford sometimes has to shoo away dealers and addicts who congregate nervously in the backyard of an adjacent rowhouse.
She hopes to help the women inside avoid drugs or find inspiration to shake them. A realist, she said many of her clients won't do so until they are ready, and she displays enormous patience with those who struggle.
"They're not in a state emotionally or physically or intellectually to be able to plan, to think about a future," said Ford.
Ford tries to create an environment in which women feel safe and can at least begin to envision something better. Some come for the basics. They shower, eat lunch, engage in banter and assemble outfits from piles of donated clothing.
Many go beyond that. They might meet with Ford to discuss the emotional wreckage left by years of childhood abuse. They may consult a nurse practitioner from Healthcare for the Homeless about routine medical problems or get a referral to free HIV treatment. About a third of the women have the virus, Ford said. Many have never been in treatment.
Eventually, women may decide to attend weekly support groups in which they learn skills as basic as how to say no. Ford and Tim Bridges, the assistant director, help them navigate the bureaucratic labyrinth that keeps many from getting drug treatment or public assistance. Bridges also assists some who are fresh out of prison.
Recently, Sharon Williams bounded into the center carrying a purse stuffed with prescriptions for a stomach ailment and other ills being addressed at the Evelyn Jordan Center. Perhaps, she said, she will one day begin treatment for hepatitis C and, finally, HIV.
None of that will happen if she doesn't learn to manage the details of daily living. Fishing through her purse, she located a scrap of paper that may represent the first steps toward accomplishing that.
It contained a "to do" list that her methadone counselor suggested that she update on a daily basis. On it were tasks such as obtaining proof of her divorce, documentation that she would need to obtain from a government records office to qualify for Medicaid.
She had no idea whom to call or where to go but seemed energized by the task.
"I've started writing goals," Williams said. "I make four goals on a piece of paper. Even if I do one and write 'completed,' it makes me feel good."
An epidemic's unseen cause
Jonathan Bor
Baltimore Sun
11/4/07
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Part Two
Second of two parts - Angela Jackson strides down Pennsylvania Avenue with pamphlets under her arm, unfazed by the line of dealers hawking drugs beneath blinking police cameras. "James Brown, James Brown!" cries one young man, applying the late soul star's name to his heroin capsules. "Ray Charles, Ray Charles!" cries another.
Places like this are utterly familiar to Jackson, who once supported a heroin addiction by selling sex to men eager to step into an alley or vacant building. Today, she spots someone who's trolling for customers as she once did.
"Hey, miss, you have a minute?" Jackson says to an emaciated woman with hollow eyes. "We're giving information about HIV and condoms." But the woman drifts by, vanishing into an alley.
"I was just like her," says Jackson, 44, who left a life of prostitution nine years ago, found housing and began treatment for HIV. "There's hope for everybody."
There aren't enough hopeful stories like Angela Jackson's. Often homeless and desperate for their next fix, women who exchange sex for drugs are an elusive group for public-health authorities. Many are caught in an incessant rhythm of tricking and drug use rooted in the sexual abuse they suffered as children.
Despite millions of dollars spent on HIV/AIDS programs, the city until recently has taken only a piecemeal approach to helping these women break the cycle. Baltimore's health commissioner, Dr. Joshua Sharfstein, asserted recently that the city lacks a coherent strategy for curbing HIV infections. He vowed to sharpen the focus.
The renewed focus comes at an important juncture in the history of the city's HIV epidemic. With additional people catching the virus each year and better treatments prolonging life, the number of infected residents has more than doubled over the past decade - reaching nearly 16,000 last year.
Women who trade sex for drugs play a central role in spreading the virus, contributing to Baltimore's ranking as the city with the second-highest rate of AIDS diagnoses in the United States. They are "core transmitters," experts agree, because as a group they have high infection rates and large numbers of partners.
Prostitution may be the direct or indirect cause of 20 percent to 40 percent of new infections, estimated Dr. William Blattner, director of epidemiology at the University of Maryland's Institute of Human Virology.
"I think there are certain taboos to even admit that it exists," said Blattner, also co-chairman of the Baltimore City Commission on HIV/AIDS.
"Part of it also is that this is a culture that's very marginalized and hard to wrap your arms around. These people don't pay taxes, don't get counted in the census. It's a forgotten group. It's also one that doesn't raise a lot of voter sympathy," Blattner said.
Women like Jackson who shared their stories with The Sun described a nomadic existence that made it difficult to even contemplate entering treatment for HIV, let alone sticking with it. Those sleeping in vacant buildings lack refrigerators to store medications, addresses to leave at a doctor's office and the confidence of knowing where they're going to stay the night - and the night after that. Advocates say housing is one of this group's greatest needs.
Sharfstein acknowledged that more can be done to stem the spread of HIV among the women and their customers. "There are pieces of different things addressing the problem," he said. "But I think we need to address whether a more systematic approach is indicated."
City's initiative
Recently, he announced the department's first efforts in that direction. Twice a week as the sun rises, the city will dispatch a van staffed with outreach workers just as women start seeking customers to feed their addictions.
On Tuesdays, the van will appear at Monroe and Ramsay streets in West Baltimore, and Thursdays at an east-side location also known for prostitution.
"My primary focus is the women exchanging sex for drugs and money," said Chris Serio-Chapman, director of harm reduction for the city Health Department. "We were missing an entire portion of the day when a lot of these women are awake, outside, providing services to their johns."
The genesis of the idea occurred several months ago, Serio-Chapman said, as she reflected on the absence of programs aimed directly at this population. The city's needle-exchange and testing vans attracted some women engaged in sex work, she said, but didn't offer the concentrated services that the women required.
Sharfstein said that finding $70,000 for a one-year pilot program was "an easy call" because of Serio-Chapman's interest as well as The Sun's inquiries about how the city was addressing the problem.
The department's initiative will start in January. The Health Department and Power Inside, a nonprofit group in East Baltimore, will offer not only HIV testing and clean drug needles, but also counseling and referrals to medical care and housing assistance.
Women can also receive wound care products and ointment to soothe the dry, bleeding lips common to people who smoke crack cocaine.
The program is an extension of the city's needle-exchange program but with several differences.
It will specifically target women engaged in the sex trade rather than the broad population of drug users. It will be staffed only by women in an effort to be non-threatening. And rather than waiting for people to come to them, outreach workers will fan out into the neighborhoods to draw them in.
More than willpower
No such program existed for Jackson, who needed more than her uncommon willpower to leave drugs and prostitution behind. It came in the form of a caring social worker who ventured to the street in Southwest Baltimore where Jackson worked, offering help at a time when she had bottomed out and was receptive to change.
She traces her history of substance abuse to age 8 when her parents would awaken her late at night to sing for guests and she'd help herself to drinks at the living room bar. Soon, she discovered that alcohol could numb her revulsion at being molested by an adult relative who sometimes entered her room at night. Later, she used heroin and cocaine to help her cope with abusive boyfriends.
By her mid-teens, she had run away from home and dropped out of school. Several years later, she tested positive for the AIDS virus in a hospital where, she said, the stigma ran so high that she was forced to await the results in a storage room. Looking back, she figures she caught the virus from an infected boyfriend with whom she was intimate and shared needles.
It was the mid-1980s, a decade before the advent of effective treatments. Sure that she had received a death sentence, she slit her wrists in a failed suicide attempt and began meting out a kind of sexual justice against men whom she thought had wronged her.
"I started sleeping around with everybody," she said. "It got to be revenge sex where I didn't care. I was just going to sex it up and drug it up."
She engaged in a ritual called "body crashing" that involved injecting heroin in one arm and cocaine in the other while inhaling on a crack pipe. To pay for her drugs, she entertained men in alleys and cars. Some beat her to get their money back.
Nine years ago, Jackson had an epiphany. She awoke at a customer's house and looked down to discover that both forearms had "blown up like Popeye," infected in the places where she had repeatedly injected heroin. At an emergency room, a doctor told her she might lose both arms to amputation if she didn't stop.
"So I quit," said Jackson.
Jackson's story is unusual in many respects. She quit without entering a program and, by her account, didn't relapse, as many recovering addicts do. She also possesses determination and charisma despite a history that might have snuffed out those qualities.
Strength came, too, from the social worker she met one morning on Patapsco Avenue. In the pre-dawn blackness, the woman pulled up alongside her and rolled down her window.
'There's help if you want help," Williams recalled her saying. Sidney Ford handed her a card for the drop-in center, You Are Never Alone, that she had just opened on West Pratt Street. Stop by for food and counseling, she said.
Jackson said this rare expression of concern cemented her resolve to quit prostitution as well as drugs. Yet she spent the next three years homeless, unable to find housing or employment because of a criminal record that included drug, prostitution and burglary convictions.
She had given up custody of her daughters to relatives. She took to sleeping in abandoned buildings where she washed her clothes in toilet tanks. She remained untreated for HIV.
Eventually, a nonprofit organization helped her qualify for a subsidized apartment under a federal program, Housing Options for People with AIDS.
That was her breakthrough. It gave her stability to find a job as an AIDS educator and enter treatment for HIV at the University of Maryland's Evelyn Jordan Center. Medication has driven the virus to an undetectable level and restored her immune system, said Dr. David Wolde-Ruphael.
Jackson gave permission for her doctor to speak about her health. "She's doing wonderfully," he said. "She's strong."
AIDS, however, has continued to stalk her family. The disease claimed two relatives just four days apart last year, shaking up Jackson's aunt, Wilhemina Harrington, who lost her brother and her son.
"I feel like I'm walking around here with a scream about to come out of me," said Harrington.
Her son, Kevin Hudgin, 49, had lost touch with his family during his final months. After he died in a Forest Park apartment, his body went unclaimed at the state anatomy board. Relatives got word of his death from someone on the street who asked when the funeral would be.
Jackson's family retrieved her cousin's body only one day before it was due to be cremated. His ashes had been destined for a cemetery where the state buries unclaimed remains, including those of numerous people who died of AIDS.
While the death rate has declined, AIDS remains a lethal force in poor neighborhoods where many infected people don't get into care until they are gravely ill. It has claimed over 9,000 lives and is the leading cause of death among adults 35-44.
The disease has left a tragic imprint on families throughout the city. Mayor Sheila Dixon knows this, having lost a brother, Phillip Dixon, and sister-in-law, Juanita Dixon, to AIDS early in the epidemic. In 2002, as City Council president, she was a leading force behind the city's declaration of a "state of emergency" and creation of a commission on HIV/AIDS.
Earlier this year, the city launched a safe-sex media campaign aimed at young people. Still, Dixon said in a recent interview that too few individuals are getting the message that "irresponsible sex" is perpetuating the epidemic.
"I don't think we've done the best job we've needed to," Dixon said.
Programs to help
Federal, state and local governments spend $6 million to prevent HIV in Baltimore. The federal government spends $20 million for treatment under the Ryan White program, named after an Indiana youth who fought discrimination before dying in 1990 of the disease. Much of the money is distributed by the Maryland AIDS Administration.
Through Medicaid, the state directs more than $110 million annually toward the care of city residents with HIV/AIDS, with a portion of the funds devoted to treatment of other illnesses. Taxpayers spend millions more on medications for indigent patients. Treatment means prevention, too, since patients with less virus aren't as likely to infect others.
Even so, Sharfstein recently told the AIDS commission that Baltimore lacks a comprehensive prevention strategy for HIV, in part because no one has fully assessed the services performed by the patchwork of organizations receiving public money. As a first step toward solving this, the department plans to map which neighborhoods and risk groups are being served and which are left out.
"As amazing as our medical institutions are," he said, "we're not going to treat our way out of HIV in Baltimore."
Some argue that little can be done to reach untreated people until they are provided decent housing. A research study in New York found that needle-sharing and unprotected sex were less common among people who had even a relative's couch to sleep on than among the homeless. It was least common among those with stable places to live.
Dr. David Holtgrave, a social scientist at the Johns Hopkins Bloomberg School of Public Health, estimated that providing housing to homeless people with HIV infection would save society money if just one case of transmission were averted for every 19 people housed.
The calculation is based on an average housing subsidy of about $10,000 per year, and a lifetime cost of $221,000 to treat one person for HIV infection. His analysis appeared recently in the journal AIDS and Behavior.
He is now concluding a related study to determine whether housing people with HIV infection leads to better health outcomes and a reduced risk of transmission. The research involves over 600 people in Baltimore, Chicago and Los Angeles.
Five hundred patients and their families are now living in subsidized housing through the federal program that helped Jackson, according to Mary Lee Bradyhouse, who administers it through the city Health Department. Those given a slot must have a case manager, but addiction is not a barrier. Nonetheless, landlords are free to evict tenants for illegal activity.
Funding for the program has been flat in recent years despite rising numbers of people living with HIV/AIDS. Some 600 people are on the waiting list for vacancies, which open when someone occupying a unit gets evicted, moves out or dies.
The effort to house people with HIV infection takes place amid a wider housing shortage. A recent report by the Abell Foundation contends that the city has focused on demolishing derelict properties rather than providing housing, citing a 42 percent drop in occupied public housing units over the past 15 years.
Advocates who extend services to prostitutes say anyone hoping to address their needs must be persistent and act quickly when the women are ready to be helped.
At Ford's program on West Pratt Street, many show up for years before they are ready to seek drug treatment or attend a clinic offering free treatment for HIV infection. Eventually, some simply get tired of living the way they have.
"There's a certain purposefulness that people who are ready for recovery have," Ford said. "There are no superficial concerns. It's all they want to talk about."
Outreach workers with the East Baltimore nonprofit Power Inside approach women again and again before they agree to step inside the group's office. Some are desperate for their next hit on a crack pipe, a need that may arise every couple of hours. Others may agree only if they are guaranteed a ride back to the corner where they work.
"So we're dealing with the narrowest possible window," said Jacqueline Robarge, director of Power Inside. "It's kind of crazy to think that we can widen that stage just enough to have the conversations we know lead to behavior change. But we do."
In these intervals, outreach workers try to find room in drug treatment centers or shelters that are often full.
"If they're not housed, what prevention can you be doing?" said Robarge.
Housing is the key
Once Angela Jackson obtained a place to live, she was able to regain custody of her two daughters. With another on the way, she had enough room for her reunited family. All are healthy. Treatments have greatly reduced the chance of a mother's transmitting the virus to her baby.
Now, she rises at 5:30 each morning to take her medications and ride out the shakiness she initially feels. Within an hour, she's ready to help daughters, Matika, 14, and Shamya, 7, get ready for school.
Jackson has found happiness.
Last year, she married. She dresses fashionably and wears a curly wig that hides thinning hair, a possible side effect of medication. She works as a peer counselor for Light, Health and Wellness, a nonprofit that serves women and children affected by HIV.
She calmly walks past drug dealers who congregate in the courtyard of her West Baltimore apartment and speaks of "tricking" as something that happened long ago.
"Housing gives you a sense of responsibility and dignity and respect," said Jackson. "It makes you want to strive to do the right thing. Makes you feel worthy to be treated like a person. It covers so much. You're no longer putting yourself in harm's way."
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