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 initiativeRecently, 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 willpowerNo 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," Jackson 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 helpFederal, 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 keyOnce 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."
firstname.lastname@example.org Captions on photographs accompanying this story misidentified Matika Jackson's age. The Sun regrets the errors.