HIV antiretroviral medications fetch a hefty price on the black market, causing poorer Washington Heights residents to sell the drugs that could ward off the worst symptoms of AIDS. (Graphic by Sarah McNaughton.)

Many Washington Heights residents are choosing money over their own health. What once were the miracle drugs that changed an HIV-positive diagnosis from a death sentence into a treatable problem are now among the most desirable medications on the black market.

The trade resembles the usual illegal deals that take place across New York City, but the drugs flow upstream: people with desirable prescriptions sell their medications to buyers, who then either ship the drugs directly to family members abroad or sell it to pharmacists for resales overseas.

Street sales have been particularly noticeable near uptown subway stations for more than six years, according to Dr. Michael Mowatt-Wynn, the president of Precinct 33’s Community Council. Prescription painkillers are prevalent, but the most popular drugs aren’t addictive and don’t produce any kind of high: HIV antiretroviral medications.

Mowatt-Wynn remembers the first time he saw a deal take place.

“I was exiting the subway on the 1 train line, and I always noticed there were young gentlemen just wandering around, scoping out the passengers who were walking up the stairs,” he says. “Others would stop at the first level of the subway, stand with bags in their hands, pull out bottles of drugs, and the young gentlemen would inspect the bottles.”

Drug treatments for HIV dates to the 1990s, and although they remainl expensive, many health clinics and AIDS advocacy groups offer medications at no cost or at sharply reduced prices.

“HIV is no longer a death note,” Mowatt-Wynn says. “It’s a controllable disease someone can live with, like diabetes.”

But that doesn’t mean everyone has access to the medication. The waiting lists for treatment are lengthy. More than 107,000 New Yorkers are living with HIV, and thousands more are unaware they’ve been infected, according to the New York City Department of Health and Mental Hygiene. New York City’s AIDS rate is almost three times the U.S. average, and the infection continues to spread.

And those who do have access to the medication don’t always make healthy choices. Pablo Colón* is the senior HIV counseling and treatment specialist at East Harlem’s Iris House, a service and advocacy program for women, families and communities affected by HIV/AIDS. Colón himself received an HIV diagnosis in 1990, and has witnessed the poorest recipients of HIV medication make the harrowing decision to forgo their physical health in the name of their families’ financial well-being.

“A lot of us are tired, a lot of us are poor,” Colón says. “There are a lot of us who are homeless, a lot of us who have children who are hungry. A lot of us live on the edge. The same reasons that you go out and sell your body is the same reason they sell their medication.”

Although the price depends on the strength of the black market, some HIV medications can fetch around $500 a bottle, Mowatt-Wynn says, an alluring sum to those who are infected but also desperately need money.

“I saw a mother with children in tow, no more than 5 or 6 years old,” Mowatt-Wynn says. “She was selling her HIV medicine, saying she needed to get food for her children. So she was basically selling herself. It’s a form of medical prostitution — that’s what we call it.”

In other countries, HIV medication is expensive and uncommon, making it a lucrative product for the black market. Buyers stand around the more popular uptown subway stations as if it’s a full-time job. From 9  to 5  Monday through Friday, they’re buying prescription medication from people who will use the proceeds to buy food, pay bills or fuel an addiction. Pharmacists then buy and repackage the drugs so they’ll sell for higher prices and ship them to countries with high demand, like the Dominican Republic and Mexico, Colon says.

He also knows people on the other side of the deal — the buyers — who purchase medication in order to send it directly to  infected family members abroad. But people overseas who use medication without a prescription are taking huge risks, he says.

“It’s not only dangerous to buy someone else’s prescription, but you don’t know the effects you’re going to have from those prescriptions,” he says. “Because you and I are on the same medication doesn’t mean we take the same dose.”

Colón remembers when an acquaintance purchased and sent medication to a pregnant HIV-positive family member in the Dominican Republic. She took the medication regularly, but her infected baby only lived a few days. Colón believes the medication actually harmed the woman and baby, and says only a personalized prescription is safe.

The people who stop taking their medication in order to sell it risk even more. Colón says people who do not follow the prescribed regimen can grow resistant to medication and develop serious infections.

As with most black market items, some scam their way into a sale. HIV-negative men and women can obtain medications from corrupt doctors or pharmacists simply to sell on the streets. Many people abuse the system, Colón says.

“It’s unfortunate for those people who really need the medication, who can’t get medication because there’s a waiting list longer than their arms,” he says.

Precinct 33 Commander Brian Mullen told Mowatt-Wynn and the rest of the council during a public safety meeting that the trend of everyday people selling their prescription medications represents one of the precinct’s longest ongoing investigations. The council and precinct have instituted new policies to try to reduce the drug trade, placing cameras on lampposts at the most popular subway stations and stationing patrol officers nearby. It’s a start, Mowatt-Wynn says, but many sales continue right in front of the cameras, and enforcement has been challenging given the precinct’s limited resources.

Colón hasn’t seen much of an improvement from where he’s sitting, either. “What’s out there is real, and it’s a mess,” he says. “And that’s the reason the numbers continue to rise.”

*Pablo Colón died a few days following this interview.

b condoms currently sell two products online: the Classic and the Platinum. (Photo by Paul Smith)

The image of a marching band jitters across the screen to a hip-hop soundtrack. Black and white footage of Morehouse College is interspersed with shots of trendy young African-Americans watching a football game. The dancing photos stop and a slogan appears: “b healthy. b proud.”

The YouTube clip, directed by George Twopointoh – noted for his work with singer Janelle Monáe – documents a recent college tour sponsored by b condoms, a Harlem startup.

The b condoms elevator pitch takes some explaining. As the self-proclaimed “only minority-owned socially responsible condom company in the world,” b manufactures contraceptives and reinvested 20 percent of its first-year profits in HIV/AIDS community programs. “It would be easy if it was just a condom company and I was only dealing with retailers and working on profit margins,” says co-founder Elkhair Balla. “It’s bigger than that.”

Since its inception last year, b has begun selling to major institutions, including Harvard University, and local health organizations. The company has hosted panel discussions at high schools, encouraging teenagers to get tested. Yet the ambitious project had humble beginnings. Its headquarters are on Adam Clayton Powell Boulevard between a hair salon and a hat boutique.

Balla and co-founder Jason Panda, dressed in dapper pinstriped shirts fastened with cufflinks, are sitting around the conference table in their office on a recent Friday afternoon. They’re planning to start selling in stores early next year and are researching retailers. “We want to make sure we pick the right partner that will represent a socially-responsible brand and highlight our message,” Balla says.

B currently sells products only online, with three packs of Classic condoms costing $15 or $18 for Platinum XL, wrapped in metallic packaging. “We’re priced at the same level as competitors,” says Balla, “and in some cases a little higher. Part of it is psyche. You don’t want to be known as the discount condom.”

They argue that their social cause distinguishes their brand in a competitive market. “Trojan, Durex, LifeStyles,” said Panda, tapping figures into his iPhone calculator, “they don’t fund campaigns on the scale we do.”

In fact, UK manufacturer Durex donated over 200,000 condoms to the International AIDS Conference; Sir Richard’s, a Colorado company, donates one condom to a developing country for every one purchased.

But Panda says, “There hasn’t really been a condom company to bring all the collective pieces together under one umbrella.” The pieces he has in mind combine educational outreach with strategic marketing. “We fund a lot of prevention and awareness initiatives,” he says.

Before life as a social entrepreneur, Panda was a disillusioned attorney specializing in pharmaceutical patent law and “top-shelf miserable” despite a six-figure salary. “I wanted to do something more community-focused, something bigger than arguing about the difference between ‘and’ and ‘or’ in a patent,” he said.

He sought inspiration from his mother, who runs a Massachusetts treatment facility for drug addicts and alcoholics. “Nonprofits can buy boxes of thousands of condoms,” he said, “but why isn’t any of that money reinvested into communities to create change at a grass roots level? That simple concept sparked something.”

After recruiting Balla, a Sudanese former investment banker and friend from Morehouse College, Panda began ordering samples for manufacture in Malaysia, from the same factory that produces condoms for the U.N. The packaged condoms are shipped in batches, often by the thousands, to a warehouse in the Bronx.

A year ago, Panda sat in his Harlem apartment making cold calls with Balla. “We’d get somebody on the phone, put our little suits on and get our couple of samples,” Panda recalls. Both 32, they christened themselves Subway Salesmen, riding the train from Brooklyn to the Bronx, pitching their new products.

They struck up an early partnership with the National Black Leadership Commission on AIDS, a nonprofit working with religious leaders to raise awareness of sexually transmitted disease among African-Americans.

Harlem Coordinator Leatrice Wactor, who has shared an office with b condoms since summer, invites Panda and Balla to speak in churches. “It’s refreshing to see two black heterosexual men discuss HIV,” she says. Young African-Americans, she thinks, “feel more comfortable talking about condom use” with their peers.

For Balla, the firm’s marketing director, rebranding the condom is crucial. The name b was his idea. “You can be anything you want to be so long as you do it in a safe, responsible way,” he says. “Our slogan is ‘b cool. b safe. b yourself.’” He adds, “You don’t have to sell sex. Sex sells itself.”

Financially, Balla says he has “no concern” over the venture, which he and Panda have self-funded with a third investor, Ashanti Johnson. He wouldn’t disclose the initial investment, but says that the company is already profitable and paying five salaries.

Last month, Balla celebrated the company’s anniversary with a World AIDS Day cocktail reception at Nectar on Frederick Douglas Boulevard. Panda was off speaking at a Georgia health care conference. Balla paced about the candlelit wine bar, taking pictures of the hors d’oeuvres platter on his iPhone. “I’ve got to tweet stuff,” he said, sharing the images with b’s 1500 Twitter followers.

Elkhair Balla, co-founder, at b condoms' World AIDS Day reception in Harlem. (Photo by Paul Smith)

Peter Kim, part of the crowd, responded to an ad on ideaslist.org and joined the team as a summer intern. Now, at 24, he’s strategic partnership director. “Students like the packaging,” he said, “but in addition, our socially responsible message really resonates with them.”

Kim finds the prospect of working for a startup exciting, even if his job provokes various reactions from friends. “A lot of people confuse it with condominiums,” he said, shaking his head. “I say, ‘It’s a different kind of high rise.’”

Harlem United CEO Patrick McGovern and Program Coordinator Jennifer Rodriguez (Photo by: Sam Petulla)

Mary sits calmly. Her jeans are clean and well-made, her hands compact — never fidgeting — and she’s telling anecdotes about all the men she’s dated. She has lots of advice for what to look for in a man, and she can tell you how to leave a man and confidently move on, independently, for yourself. The night before, she broke up with her boyfriend. She’s alert, can take a joke, and holds her ground, and she has lived with HIV for 16 years.

Mary, just by appearances, could be misperceived as uninfected. She goes shopping, meets friends for lunch — she’s even about to go to a recently opened “HIV Only” club downtown, where she can dance and meet other singles. “I haven’t experienced the things people experience,” she says. “I have never been to a hospital.”

She lives in Harlem, a neighborhood sometimes called the United States’ HIV/AIDS epicenter and bellwether. Local HIV/AIDS organizations constantly scramble to anticipate trends and statistics. In the ’90s, the focus was on needle-users and the MSM (men who have sex with men) community. Then there were the rumors. Sixteen years ago, when Mary became infected, she “thought that only gays could get it,” she said. Even today, some residents uptown believe HIV can be transmitted through doorknobs and house flies.

As HIV’s reputation has changed from an unknown virus to a treatable medical condition, Harlem United, Harlem’s leading HIV/AIDS organization, has radically revamped how it fights HIV. In the last two years, instead of targeting groups – even those experiencing startling rises in new infections — Harlem United has taken a more encompassing approach that could reach the whole community.

Harlem United maintains an extensive network. It runs two clinics and multiple housing facilities, and partners with smaller organizations focused more on local populations’ needs. It offers services from art therapy to health care for the homeless and runs the only entirely bilingual Spanish HIV/AIDS clinic in the United States.

In the last few years, HIV has spread in Harlem in various, often troubling, directions. In 2006, the average Harlem resident was six times more likely to receive a new HIV diagnosis than an average American, according to statistics released in 2008 by the Centers for Disease Control and Prevention. Most new infections were among Harlem’s Latinos, who were more than 12 times as likely to receive new HIV diagnoses than other New York City Latinos. In fact, “over the past five years, new HIV infections, and concurrent HIV/AIDS diagnoses have fallen among all race categories, except for Hispanic women,” according to New York City Department of Health evaluation coordinator Chris Williams, commenting on the 2006 statistics.  Health professionals believe that trends like these will eventually spread countrywide.

Harlem United, carefully monitoring the CDC and the NYC health department statistics and compiling its own, decided to retain its existing Latino support and testing programs, rather than launch new ones.

Instead, its Blocks Project, begun in January 2008, sets a broader goal of testing everyone in the area — from women discouraged by a partner to the unsuspecting elderly. For the organization, it’s a new way of thinking about HIV/AIDS testing.

Soraya Elcock, Harlem United’s vice president for policy and public affairs, sits in her office, surrounded by mementos from 20 years in HIV/AIDS work and explains the shift.

Although organizations have changed, one thing hasn’t. People still contract HIV in the same ways: through risky sex, intravenous drug use, or long-term partners who become infected.

“It’s not about whether you’re at risk. What is needed is a neighborhood taking care of its basic health,” Elcock says. Unlike programs that target specific groups, she explains the blocks project treats HIV as a basic community health problem, along with hepatitis C, diabetes and hypertension. That means it’s a treated as a disease no more spectacular than any other and no more applicable to one group than another. Women in particular, “respond to something targeting to a larger community health awareness,” Elcock says.

“You have to create a hothouse effect — or you miss all the small groups,” she explains. Targeting a group — like Latinos or small African immigrant populations — tells a sub-community: There’s a problem among people like you. That breeds fear, Elcock says, which can discourage testing by making people clam up in denial or driving them to disregard the risk.

In taking this approach, the Blocks Project also targets an elusive but crucial body of people: infected people unaware they carry HIV.  Harlem United consider them the most hazardous group.  Last year the rate of HIV transmissions originating from people unaware of their infection was 54 to 70 percent, Elcock points out.

“A lot of them don’t believe they are at risk,” she says. As a result, merely encouraging people to be tested for HIV has had limited success. But Harlem United says the Blocks Project, with its enlarged approach, led to 75 percent more testing its first year.

Since kicking off the Blocks Project’s 2008, it has gone through continual revision based on what has worked and hasn’t.

Jennifer Rodriguez, a Harlem United community outreach coordinator, explained that at first, “Harlem United would have meetings with tenant association presidents. We ask them what would be the best way,” she says. Then Harlem United’s outreach staff would head out to the large buildings in teams. “We would have messages that we would put on every door,” Rodriguez says. “They might say Tuesday or Thursday come to this corner,” where testing vans would be available.

But, “the whole ‘come-to-my-van’ approach doesn’t work,” Rodriguez says.  So this year’s strategies were totally different. “In the last month or two we started getting a more intense outreach focus. We’ll have a five-minute conversation like, ‘Oh, why won’t you use a condom?’” she says. “Now it’s not so concerned with tenants. It’s more zones. It’s wider.”

As Mary sits and talks about her experiences with relationships, she suggests that even as more effective HIV treatments have become widely available, the old rumors and stigmas about HIV still pervade uptown.  Although she feels well, facing the disease’s stigma can be the hardest part. She describes an incident she had one night at a bingo game, when she overheard some players talking.

“The older ladies would gather and say, ‘I don’t want him to get HIV out there,’” she says, referring to married women whose husbands may be having affairs. “I used to go out there and say: This could happen to anybody. Because you don’t know what your husband does when he walks out that door.”