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Countdown to Zero

How the Drug War Accelerated the AIDS Epidemic in Black Communities

When AIDS first appeared on the scene in the 1980s, America was pursuing policies that lead to the mass incarceration of blacks exposed to HIV through intravenous drug use and crack-related sex work.

Henderson, North Carolina. 2006. Kids read the instructions for how to use the condoms given to them by a worker from the Northern Outreach Clinic. Photo by Christopher Anderson/Magnum.

When the Center for Disease Control and Prevention first officially recognized the existence of AIDS in the 1981 publication of its Morbidity and Mortality Weekly Report, it was described as an epidemic among gay white men. A great deal has changed since then. Thanks in part to the devastating impact of mass incarceration as a result of America's war on drugs, HIV/AIDS has become a plague in poor communities of color in the United States.


Men and women of African descent in the US report more new HIV infections annually than any other race/ethnic group. There are more blacks living with HIV and more of them are dying from HIV/AIDS-related deaths than is the case for whites, Hispanics, Asian Americans, or Native Americans. Specifically, blacks in the US represent only about 13 percent of the population, but account for 44 percent of the new adult infections reported annually to the CDC. Blacks comprise a bit less than half of those currently living with the virus in this country. Particularly hard hit are gay, bisexual, and transgender black men, but increasingly, black women are also falling victim to the virus, representing 64 percent of all new infections among women in the US in the year 2010.

The disproportionate impact of HIV/AIDS on black Americans has its roots in poverty and severe disadvantages in the urban communities, where the epidemic has had its most enduring impact. But in my own research that dates back to 1986, I've been increasingly focused on understanding the role that prisons and our national policies of mass incarceration have had in creating a high-risk environment that HIV/AIDS exploits.

In the 1990s, rates of HIV infection among inmates in the nation's prisons and jails was five to seven times that observed among all non-incarcerated American adults. The source of this concentrated pool of infection was the war on drugs that began in earnest under Richard Nixon in the 1970s and sent so many people behind bars that America's incarcerated population grew from fewer than 200,000 inmates in state and federal prisons in 1971 to well over 1.5 million at the end of last year. Roughly half of federal inmates were imprisoned for drug-related offenses and more than half of them were black and Hispanic. In effect, at the moment that HIV was making an unannounced but significant appearance on the American scene, the country was also pursuing a set of policies that resulted in the imprisonment of a population at the greatest risk for exposure to HIV: intravenous drug users, and later, in the 1980s, those caught up in crack cocaine-related sex work.


The cycling of this highly vulnerable population in and out of prisons for the past 40 years has had a powerful impact on rates of HIV infection in the communities to which these men and women returned, and an equally massive impact on the prisons to which many were remanded as recidivists. But, more significantly, the loss of so many adults—particularly men—to their communities dramatically weakened the social infrastructure that is so essential for maintaining the health of the public. This population has often been deprived of the human and social capital necessary to raise children and usher them into successful adult roles.

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In an April New York Times piece entitled "1.5 Million Missing Black Men," graphic statistics are presented describing a national pattern in which major urban areas in the United States report having, on average, 83 black men for every 100 black women not behind bars. (In Ferguson, Missouri, there were just 40 black men for 100 black women.) Mass incarceration and premature mortality among black men account for this significant disparity between black men and women, and it is this incarceration-fueled instability that has helped drive the HIV/AIDS epidemic into the heart of black America. We must address the policies that perpetuate mass incarceration if we hope to prevent the continued onslaught of the HIV/AIDS epidemic.

We've had effective medications for HIV disease since 1996. But the fact is that, as a nation, we still report between 40-50,000 new cases of HIV infection each year, and blacks are disproportionately affected. To end this devastation, we need more than treatment and more than a cure. We need to start to address mass incarceration.

Robert E. Fullilove, MS, EdD is a professor at the Mailman School of Public Health at Columbia University.