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 crackA 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.
Increases in riskBut 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 AloneSidney 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."