Before we begin this discussion of HIV prevention, a few questions:

· More than a handful of studies show that any American adult who's made it past seventh grade knows how AIDS is transmitted and how to prevent it. So why do we still need to raise awareness about the disease?

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· How many of us—for real now—wear condoms every time we have sex?

· How can a woman ask a man to wear a condom if that man's her husband and he's her only means of support? Or worse, he's violent, too?

· Or what if her husband's recently returned from prison? Asking him to wear a condom says, "I think you had sex with a man while you were inside, or worse, got raped." After all he's been through, what if that's something he's too ashamed to face?

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· What's up with the down low? Are there really gangs of closeted, black gay men hooking up through the Internet for booty calls—then returning home to their wives or girlfriends? Or is this an E. Lynn Harris plot line—a terrible lie or at minimum, totally overblown?

· If the down low is simply magical realism, how are so many black women getting infected with HIV?

· How many men of color are too scared to tell anyone they have sexual feelings for men or are, in fact, gay? How many loved ones already know their brother-cousin-best friend-hair dresser-choir director is gay, love that person anyway, but don't know how to talk about sexuality?

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· Why are we embarrassed to talk about sex and sexuality with our daughters and sons—even though the kids have seen every BET video and are reading Zane's books under the covers with a flashlight?

These are some of the many questions that come up in discussions of HIV prevention for African Americans. But because of our massive failure to understand the particulars of the epidemic in general, but especially in our community, no one really knows the answers. Or we don't wrestle with the issues and come up with them.

Increasingly, however, as the HIV/AIDS epidemic continues to rage, the appetite to understand what's fueling the spread has grown. At past International AIDS conferences, a session on prevention wouldn't have drawn enough attention to fill a large meeting room. In previous years, treatment totally dominated the conversation.

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But this year the theme of prevention has bubbled to the surface among the tangle of panels and workshops, debates and discussion among the 22,000 attendees in Mexico City. Tuesday's plenary session on the topic was filled to capacity and several other sessions hummed with interest and energy. At the Lancet Series on HIV Prevention, hundreds of people packed into the session room, and many others watched on big-screen televisions in an "overflow" room, while others stood outside, unable to get in.

And it's not just prevention as usual. Throughout the conference, scientists and activists have called for innovative new ways to stanch the spread of HIV throughout the world. The most common methods—teaching people about the disease, distributing condoms and telling them not to have sex—aren't working, at least not well. Last year, 2.7 million people were newly infected, most in sub-Saharan Africa.

"Prevention has not only been marginalized, but in some places it's been suppressed for political, religious or social purposes," said Richard Horton, editor of The Lancet, a British medical magazine that devoted its most recent issue to HIV prevention. "We have to redefine prevention, to create a new dialogue of what we mean by prevention."

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"Combination prevention" is the hot new buzzword. This means, simply, combining various prevention strategies to decrease the spread of HIV. Too often, our prevention framework is one size fits all. Hand out condoms and call it a day. Or, in the United States, fund only prevention programs that teach abstinence to the exclusion of comprehensive sexual health education.

Or the latest magic bullet: circumcision, which has been shown to reduce the spread of HIV from women to men during heterosexual intercourse by 60 percent. Men in Kenya and other African countries have reportedly been lining up to get "cut." But what about the other 40 percent? And what about male to female transmission and male to male—by far the more common forms of transmission in the United States? Circumcision, condom distribution or abstinence education, in isolation, is not and has never been the answer.

"There will never be a single magic bullet to prevent HIV transmission," says Nancy Padian, executive director of the Women's Global Health Imperative in San Francisco. "A combination prevention package is what's most effective."

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In the United States, we have no bullet or package; the federal government has done little to prevent the spread of HIV among African Americans. Since 2001, there has been no real national HIV prevention plan. The previous strategic plan was extended in 2006, but it is anemic at best. What exists has been patchy, piecemeal, one-dimensional and under funded. That neglect has taken its toll. New U.S. statistics released last Saturday show that the number of people infected with HIV every year is 40 percent higher than the federal government has been reporting each year. And the rate of new infections among African Americans is seven times higher than among our white counterparts.

"I am disgusted and frustrated by my government's response to AIDS," said Pernessa Seele, founder and CEO of The Balm in Gilead, a nonprofit organization in Richmond, Va. that mobilizes churches in the fight against AIDS. "In black America, there is no plan."

And though the United States should be applauded for leading the world in global HIV/AIDS funding, it has failed to funnel much money to our national problem. PEPFAR, the $48 billion legislation to fight AIDS and other diseases overseas that now sits on President Bush's desk—triple the amount from 2003—does little for the millions who are newly infected and living with the disease in our own backyard.

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In Mexico City, a group of American HIV/AIDS leaders called for an American PEPFAR, funded to the tune of $1.3 billion—double the current prevention budget—to stop the spread of HIV here.

"Where is our PEPFAR for the United States?" asked Barbara Lee, a member of the U.S. Congress and a co-author of the most recent PEPFAR legislation. "We need a domestic AIDS response that brings new resources to an effort that has been virtually flat funded for years."

As we know, African Americans have a complicated tangle of factors that make us more susceptible to HIV and demand thoughtful, textured and often costly prevention efforts.

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"Prevention can't be about telling people not to have sex," says Ebony Johnson, a Washington D.C. activist who mobilizes women to advocate for better HIV treatment and care. "If you tell people not to have sex, they're not going to listen. How can you tell a married woman not to have sex with her man? That doesn't make any sense; that isn't a strategy."

Other HIV prevention methods have also proven ineffective or incomplete. Dr. Helene Gayle, president and CEO of CARE USA and one of the African-American leaders advocating for more prevention dollars in Mexico City, says: "Black women often cannot insist on things that we use simplistically in our prevention messages like abstinence or use of condom because of fear of violence or other types of emotional and physical abuse from their partners."

What would a comprehensive, combination-prevention package for African Americans look like?

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Comprehensive sexual health education, including abstinence, partner reduction and proper condom usage.

  • Risk reduction for HIV drug users, including needle exchange programs and other harm-reduction strategies.
  • HIV testing and counseling to reduce the number of people who don't know they've been infected.
  • Access to preventive health care for everyone.
  • Human rights and social justice for all, including equal rights for women and lesbian, gays, bisexuals, transgendered people and those living with HIV/AIDS.
  • Treatment and care for people living with HIV and AIDS.

Dazon Dixon Diallo, president and CEO of SisterLove, a women's HIV service organization in Atlanta, has managed to combine several prevention strategies to reduce HIV/AIDS in both her community as well as in a small village in South Africa. At historically black colleges in the Atlanta area, Diallo teaches students about HIV transmission, testing and prevention, but also explains the connection between the disease and sexual health, human rights, stigma and homophobia. Empowered women who understand the struggle for women's equality is related to other kinds of civil rights, she says, make better sexual health choices. They're the ones who can ask difficult questions and demand that their partner get tested and/or wear a condom.

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In South Africa, her organization attacks the problem from several slightly different angles. Several years ago, Diallo formed a partnership with three HIV/AIDS organizations and 66 community members affected by AIDS in South Africa to form the Thembuhlelo Trust Cooperative. Their collective, which owns 668 acres 90 miles east of Johannesburg, grows vegetables and raises chickens and cows. It provides food and hope for a rural area that's been devastated by both HIV/AIDS and poverty. The staff and volunteers of "the farm" also offer HIV education, counseling and testing between chasing chickens and managing their land.

Diallo's cutting-edge work—on both continents—illustrates the importance of combination prevention. In both South Africa and our South, prevention is about not just sexual knowledge.

"When women are poor and economically dependent on men they are vulnerable to HIV," says Diallo. "We realized that if we had even a little bitty piece of land and could feed some chickens and milk some cows, we could feed ourselves and sell whatever we don't need. We could give women and families living with HIV and affected by the disease empowerment and independence and help restore dignity and a sense of self."

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Linda Villarosa is a Brooklyn-based health writer and author of "Body & Soul: The Black Women's Guide to Physical Health and Emotional Well-being."