Q: To what extent is the HIV/AIDS epidemic among African-Americans a unique public health phenomenon? Or is it part of the larger problem of health disparities in America - one of many diseases and conditions that hit harder among people who don't have access to routine care?

That's an interesting question, and I would say there are elements of both. My own view is that AIDS is now a disease of poverty, not unlike tuberculosis or diabetes, and it affects poor populations in much greater numbers: those who are less likely to have health insurance, for example - and blacks are more than twice as likely as whites, as a percentage of their respective populations, not to be insured.

Q: Can you talk about that a little more? How has the epidemic changed?

I remember attending the international AIDS conference in 1996, and everyone thought it might be one of the last times we'd need to meet. There was this tremendous hope in the air. The new protease inhibitors, combined with other antiretroviral treatments, were showing great promise. People were living longer. We were hearing projections that HIV might be eliminated, or at least under control, in our lifetimes.

But underlying all of that progress was the fact that we were principally focused at that point on a patient population that was largely gay, white and male - college-educated, professional, highly organized, politically active. They had excellent access to care and the financial resources to take advantage of these treatments. They were connected to the research community. They were getting screened for HIV in ever-increasing numbers.

Q: So when did African-Americans become so statistically prominent?

Well, I think those numbers were always there. We always knew that this disease was extremely opportunistic, and that certain populations were more vulnerable. If you had access to routine screening and the antiretroviral medications, your prognosis was going to be good. And, obviously, that turned out to be true - more so than a lot of us would have dared to hope after witnessing the despair of the '80s.

But on the other side of the coin, the disease continued to spread among the poor, and that's been true all over the world. Remember, without access to screening, a person - especially a young person -- can walk around out there for a very long time before they're going to exhibit any symptoms. They can be infected for years and not know it.

Q: Isn't that the concern now? That there are 'reservoir populations' who are unknowingly spreading the disease within their communities?

Yes, and they're continuing to have sex, and partying, and doing all of the other things that people do, and they feel just fine. But they're doing those things in communities that don't have adequate medical facilities or screening programs. So it creates ideal conditions for the virus to spread. We're talking about places where people might go years without ever seeing a doctor or dentist.

Q: That certainly appears to be a factor in the case of African-American women, correct?

Black women - particularly poor, black women -- are one of the fastest growing populations of people living with HIV-AIDS. They're more than 20 times as likely to become infected as white women - but many don't typically fall into the established high-risk categories.

Q: Meaning?

They're not becoming infected in huge numbers from IV drug use, for example. And men who have sex with men are still the number one risk group. What poor black women are doing is having sex within their own community - communities that often don't have adequate care and treatment clinics to detect the virus, communities in which the virus is more prevalent, and where your sexual partner is less likely to know if he's infected. By 'sex,' of course, I mean unprotected sex, which is like taking your life in your hands in some places.

Q: So it becomes cyclical?

Somewhat. Let us not forget that this is a stigmatizing disease, because it's sexually transmitted. Everybody knows somebody who has diabetes or hypertension, right? Even in poor populations, there's information out there on where to get tested, how to get treatment, what to do next. But HIV is different. We face this constant uphill climb in public health against the idea that this is somehow a 'shameful condition' - that even getting tested is somehow admitting you did something wrong.

Q: Which brings us back to health disparities.

I've spent most of my professional life dealing with this disease, and it's the only one really that's been so heavily politicized at every level. It's an illness like any other, but it has multiple constituencies and advocacy groups who often don't speak with one voice. So our social policy on how to address it has always being pulled one way, then another.

For those of us in public health, it comes down to how to increase prevention and screening; how to increase capacity in underserved communities. And we're doing it -- that's HRSA's job! -- with 7,000 primary care clinics all over the country, and 2,100 Ryan White sites, all of them dedicated to providing services in affected populations and communities as far as our budgets will take us. I administer $2.1 billion, and almost every dime of it goes to helping people cope with this disease.

HIV doesn't care what color you are, or what your sexual preference may be, or what religion you may subscribe to. It's a disease, a public health problem, and that affects us all.