The double, triple, fourfle and fiffle whammy . . .

In the United States, something like 36% of all HIV infections are attributable, directly or indirectly (through sex with an infected person) to injection drug use (IDU). Estimates vary widely but depending on the city, the prevalence of HIV among injection drug users ranges from 5% to 40%. People with addictions who do not inject drugs also have about twice the HIV prevalence as people without addictive disorders, and people who enter alcoholism treatment have rates from 5% to more than 10%. People living with HIV have been estimated to have a prevalence of substance abuse disorders as high as 44%, with lifetime rates as high as 60%.

Rates of other mental illness diagnoses among people with HIV vary tremendously, but it appears that something like 1/3 to 1/2 meet the criteria for at least one mental disorder, which is considerably above the population prevalence of less than 25%. Substance abuse treatment programs typically find that more than 50% of their clients have other mental disorders, while mental health providers typically find that from 20-50% of their clients have substance abuse disorders. (I am indebted to a review by Klinkenberg, et al in AIDS Care 2004; 16:suppl, for a convenient summary, but these basic facts are well known by everyone who works in the field of HIV.)

Then, of course, a high percentage of people living with HIV are gay, and/or African-American or Latino.

Abe Feingold, in Mental HealthAIDS, discusses stigma. HIV/AIDS itself is a stigmatizing condition. Feingold quotes a report from the Health Resources and Services Administration. "HIV-related stigma refers to all the unfavorable attitudes, beliefs and polcies directed toward people perceived to have HIV/AIDS. . . Patterns of prejudice which include devaluing, discounting, discrediting, and discriminating against these groups of people, play into and strengthen existing social inequalities -- especially of gender, sexuality, and race -- that are at the root of HIV-related stigma." Feingold tells us that "Research has demonstrated that HIV-related stigma and discriminatory practices can negatively affect condom use, HIV-test seeking behavior, willingness to disclose HIV-positive serostatus, the pursuit of HIV-related health care, and the solicitation of social support."

A few months ago I got annoyed with the executives where I work because we needed to relocate and they weren't coming up with a new place. The vacancy rate for commercial real estate around here is huge, and landlords are begging for tenants. But it when they find out that we're serving homeless, HIV positive mentally ill drug addicts, they seem to find a reason not to rent to us.

I once interviewed a woman who concealed her HIV status from her own children. When she went to the drugstore, she'd immediately pour the pills out of the bottle and into a plastic bag so they couldn't see the label. She kept them under the bed and took them in secret. I interviewed a man who was diagnosed in the hospital after he was admitted for pneumonia. The nurse (unconscionably) told his mother that he had tested HIV positive, and she didn't speak to him for six months. I interviewed another woman who refused to accept treatment while she was in jail because the other prisoners know what HIV medications look like.

Many people I have interviewed have been ostracized by their families, have lost most of their friends. One guy is allowed to visit his brother's house when they have family get togethers, but they make him sit out on the porch, use plastic utensils and paper plates, and they won't let him hold the baby. Some people almost never leave the house. It's different in the mostly middle class, mostly white urban gay community, but African American, Haitian and Latino people living with HIV, and people of all ethnicities in small towns and suburbs, still face denunciation from the pulpit, shame and shunning in their communities.

Moral condemnation is the enemy of public health, and the opposite of compassion.