It’s only April, but it feels like August inside the Montgomery AIDS Outreach(MAO) clinic: Someone recently climbed on the roof and stole the copperwire from the air-conditioning unit. MAO sits at the end of an all-but-abandonedstrip mall just west of Alabama’s Capitol building, in what’s stillcalled the “black side of town.” The discreet locale suits patientsjust fine: Stigma is so strong in Montgomery that staffers drop AIDSfrom the clinic’s name when answering phones; some have dispensed medsout the backdoor. MAO struggles to get treatment even to patients whowalk through the front door. “For a lot of people, we’re able to patchtogether an amazing amount that works,” says Laurie Dill, MD, one ofMAO’s harried doctors, “but there are a lot of holes.”

Thoseholes are only likely to deepen as long as Alabama—and, indeed, theentire South—fail to confront an ominous reality: The fiercest front inthe domestic war against AIDS is now below the Mason-Dixon line. Sevenof the 10 states with the highest per capita AIDS rates are in theSouth, where 41 percent of all U.S. HIVers live. Many of them areAfrican American: The region has almost twice the number of positiveblack women as the Northeast.

But Alabama has distinguisheditself even among its struggling Southern colleagues. Statewide, twoout of five people who test positive develop AIDS inside 60 days.Nearly half of the state’s diagnosed AIDS cases are among gay andbisexual men, but African-American women accounted for nearly 30percent of new infections in 2004. Three-quarters of all new infecteeswere African American. The number of new HIV or AIDS cases diagnosed inthe state went up 14 percent from 1999 to 2004, a big jump compared tosimilar nationwide statistics from the CDC.

In April, itlooked as though Alabama’s health-care safety net had finally comeapart: Thanks to funding shortages, scores of HIVers were days awayfrom being booted out of Alabama’s severely strapped AIDS DrugAssistance Program (ADAP)—a joint federal and state initiative thatfinances meds for low-income, uninsured people with HIV. An 11th-hourinfusion of emergency funds from the state legislature delayed thecrisis, but no one expects that to last. As of midsummer, Alabama stillhad an ADAP waiting list of at least 200 people, with the list expectedto grow by about 30 people a month. Another 400 people will likely moveout of a special treatment program and onto the waiting list this fall.

Alabamaisn’t the only state in the South with ADAP trouble. Four of thenation’s six longest ADAP waiting lists belong to perennial laggardsAlabama and North Carolina, plus Arkansas and Kentucky. Local activistsacknowledge that the South’s conservative cultural landscapecomplicates the region’s ability to deal with its surging epidemic, butthey also charge that Washington is making their work more difficult.They argue that the system of distributing billions of federal dollarsfor AIDS through the Ryan White CARE Act—which faces congressionalreauthorization this fall—favors large cities in the North and West,imperiling rural Southern HIVers. “We’ve got to figure out how to levelthe playing field here or we’re always going to be struggling,” warnsKathie Hiers, the spunky head of AIDS Alabama. “The status quo is goingto kill Southerners.”

Michelle Lampkin, 48, has beenliving positive in southeastern Alabama for nearly 15 years. She movedfrom upstate New York in the early ’80s, when her sister was stationedat the Army’s Fort Rucker. About 6 years later, Lampkin began sufferingbouts of thrush, but local docs didn’t think to test for HIV. When thefungal infection struck again during a visit back to New York, anemergency-room doctor asked whether she’d ever been tested forHIV. “I said, ‘Hell, no! I’m not a ho. I don’t shoot drugs, and I cancount the men I’ve been with on one hand,’” recalls Lampkin, who hasdated mostly women. She tested positive.

Lampkin, who now lives inDothan, a small town about two hours from Montgomery, kept her statusquiet until a few years ago, when she tried to form a low-key supportgroup. A local health-department staffer heard about her efforts andinvited her to speak at a forum about HIV. “I haven’t shut up since,”she laughs. Her bifocals and shocks of gray hair suggest amild-mannered librarian, but Lampkin has spent the last few yearsharanguing her way into schools and black churches. “They haven’treally been that receptive,” she says, “but they’re starting to openup.” Paying for HIV meds wasn’t an issue for Lampkin until thisFebruary, when an increase in her Social Security disability payments disqualified her from Medicaid. Now she is one of hundreds of people on the state’s ADAP wait list.

Lampkinis a fighter: She has personally given hospice care to three positive siblings and nursed her partner—who also has HIV—through cervicalcancer. But she’s visibly shaken by her uncertain treatment future. “It’s stressing me out,” she says, “and I don’t appreciate it.”

Congressformed ADAP in 1990, just before Lampkin tested positive. Envisioned asan emergency response at a time when HIVers were dying quickly, theprogram has become more overwhelmed every year since 1996, whencombination
therapy began saving lives. Since 9/11, Washington hasn’t funneled enough money into the program to manage its growing caseload, sparking a nationwide wait-list crisis. Alabama hasn’t let a new person into its ADAP since June 2004.

Asthey saw all too clearly this spring, HIVers already enrolled in theprogram aren’t necessarily out of harm’s way either. In April, thestate legislature passed an emergency spending bill two days before thehealth department would have had to start knocking people out of ADAP.More trouble is just around the corner. Last summer, President Bushgave a $20 million emergency grant to the 10 states that had waitinglists at the time. That allocation allowed Alabama to create a drug-purchasing program for 392 people on its list. But if Washingtondoesn’t pump millions more into the whole ADAP program through RyanWhite or renew its emergency appropriation—and all signs suggest that’sa long shot—the state will have to find several million additional dollars or stop treating those 392 patients. “We don’t know what the hell is going to happen to those people,” AIDS
Alabama’s Hiers scoffs.

Non-Southernersmight reflexively blame Alabama’s unwillingness to fund HIV care on itspolitical and religious conservatism. But Democratic staterepresentative Laura Hall, 62, whose son died 13 years ago fromHIV-related complications, counters that another Southern phobia—fearof raising taxes—is the real source of the state’s AIDS-funding woes.“We won’t raise property taxes. We won’t raise any kind of taxes. Youmention taxes around here and you just sound”—the grandmotherly Hallwaves her hands around, miming a lunatic. “Democrats and Republicansboth feel if they talk about taxes they’ve signed their death warrant.”ADAP isn’t the only government program withering in the South’s antitaxheat. “The health department lost whole programs,” says Alabama’s beleaguered HIV program director Jane Cheeks.

ButCheeks adds that Alabama’s legislature isn’t entirely at fault. She andHiers point out that Washington’s formula for handing out Ryan WhiteCARE Act money is weighted toward large metropolitan areas that havebeen designated AIDS epicenters. North Carolina’s caseload is higherthan Connecticut’s, for instance, but its ADAP gets half as muchfederal funding, because Connecticut has New Haven. Well-funded statescan also claim expansive ADAPs: Missouri’s offers hundreds of drugs,from HIV-specific ones to asthma meds; Alabama’s offers 32, limited to anti-retrovirals and drugs for opportunistic infections.

Urbanand Southern activists don’t want to fight one another in the upcomingRyan White reauthorization debate, particularly given the likelihoodthat the Republican-led Congress will want to put a conservative stampon the program—and that congressional leaders plan to aggressively cutmost domestic spending, including Medicaid. Nonetheless, Southernstates have formed the Southern AIDS Coalition (SAC) and dispatchedlobbyists to Washington to plead the region’s case to lawmakers. SAClobbyists are wielding a manifesto that calls for a range of reforms,including standardized qualifications and benefits for state ADAPs.Such standards would ensure that hard-hit states like Alabama receiveadequate funding.

The so-called CAEAR Coalition spearheads thelobbying for the nation’s 51 designated AIDS epicenters and is aninfluential voice on Capitol Hill. At press time, it had not taken aposition on SAC’s proposals. Jacqueline Muther, a CAEAR Coalition boardmember from Atlanta, says the group focuses on hiking the overall AIDSbudget numbers, so there’s enough to serve everyone. Still, the fear ofa hostile Congress has created undeniable tension between increasinglyvocal Southern advocates and those from big cities. “Everybody’slooking after their folks, and you can’t fault them for that,” saysMuther, adding that unless there’s more money on the table, “it’s kindof like the case of Solomon: You can’t win.”

Meanwhile, HIVerson ADAP wait lists, like Michelle Lampkin, resort to desperate measuresto get meds. Lampkin, her girlfriend—and the couple’s 15-year-old HIVpositive son—all take Sustiva, so Lampkin skims from their supplies. Sofar, no one in her family has missed a dose. But when POZ met her inApril, Lampkin had eight days of Truvada—the other med she’s on—andabout two weeks’ worth of Sustiva left.

If the South and Alabama are the new front in the AIDS war,then Montgomery is the trenches. The impoverished capital city has thestate’s highest per capita rate of diagnosed AIDS cases: just under 400cases per 100,000 people. With the exception of a handful of its ownsatellite clinics, MAO is the only clinic serving the entiresoutheastern portion of the state. “We hear about [AIDS organizations]in New York and Los Angeles that have all this stuff, like massagetherapists,” says MAO executive director James Waid, chuckling throughhis slow drawl and looking like he thinks it may be an urban legend,“but we’re just trying to keep our food bank open.”

MAO’s problemshardly end there. Because so many of the clinic’s patients don’t gettested until they develop serious health problems—and are months awayfrom life-threatening immunosuppression—“time is a significantproblem,” says MAO doc Dill. “Our methods for getting medicinesfor uninsured patients take time.” MAO treats its largely uninsuredpatients by applying to pharmaceutical companies’ charity programs.Social workers spend the bulk of their hours filling out paperwork toget meds instead of providing the kind of supportive care they’retrained to give. In serious cases, Dill and MAO’s two other docs areforced to use samples or borrow meds left on the shelf by someone inADAP who hasn’t shown up. The latter strategy won’t be available forlong. The health department recently decided to kick anyone out of ADAPwho fails to pick up their meds for three months.

The ADAPcrisis has handicapped MAO’s support services in another way. Thelegislature’s emergency appropriation in April was actually less thanhalf what was needed, so the state health department is taking anotherhalf a million from AIDS support services to make up the difference.“The irony is, yeah, we’ve got your $10,000 worth of drugs for theyear, but we can’t help you with the $15 cab fare to get here and pickthem up when your car is broken down,” Dill says. “Those sorts ofthings impact our most vulnerable patients’ ability to be adherent.”

Keepingpatients adherent is a major concern in the climate of fear aroundAIDS. “When you don’t have any support and you’re depressed about it,it’s a lot harder to be successful with treatment. No one’s theresaying, ‘Did you take your medicines? How are you feeling today?’” Dillsays.

Longtime staffer Barbara Harper adds that MAO had torelocate its satellite clinic in Tuskegee because clients in the smalltown regularly felt uncomfortable with its central location. “Patientssaid, ‘Oh, Sister Judy works near there,’” she recalls, “or ‘Elderso-and-so used to work by there. I’m not going there.’” Indeed, theblack church looms large throughout the region. Almost two-thirds ofthe HIVers in AIDS Alabama’s survey said they pray at least six times amonth. Yet sexuality and drug use remain taboo topics in many Southernchurches. Harper, who does outreach work in her Pentecostal church,says local congregations are slowly opening up to the sorts ofuncomfortable conversations HIV forces, but they are not yet proactive.“Nobody says, ‘Baby, let me pray with you.’”

MAO client TracyHilton just found a new church after leaving prison about a month ago.He tested positive the first time he got locked up, in 1993, but hewalked out of the prison doctor’s office and promptly blocked out theidea. “[HIV] never crossed my mind,” he shrugs. “Nobody talks aboutit.” Alabama is the only state in the country that segregates positiveprisoners. The segregation reinforced Hilton’s awareness of stigmaassociated with the virus and simultaneously gave him a pass on payingmuch attention to dealing with his own infection, since everyone aroundhim was positive. It wasn’t until his last bid that Hilton started todeal with his health.

A handsome 38-year-old, Hilton’s returnfrom prison hasn’t gone unnoticed by potential suitors. He hasn’t hadsex yet, but women are showing interest in him. “I talked to one,” hebashfully boasts about coming out as positive. “She appreciated myhonesty.” Most of his fellow ex-inmates aren’t taking that sort of risk.

“There’sa lot of work still to be done in our community,” Rep. Hall says ofblack Alabama. “I lived through that fear, so I guess I want to thinkthat 13 years later we wouldn’t have to deal with that. But it is sooverbearing.” The future may depend on HIVer heroes like Hilton andLampkin, who seem to understand that, with or without more help fromWashington, they hold the key to  combating the rising tide of HIVin their state. Hilton is gearing up for the kind of public speakingthat Lampkin’s doing—and he’ll start by disclosing soon to his twoyoung children. When asked whether he has told the congregants at hisnew church, Hilton flashes a nervous smile. “Not yet,” he says. “butI’m looking forward to the chance.”