Bishop Victor Couzens knows people don't expect to hear about some things in church come Sunday morning. Like sex, for example, and condoms and the importance of HIV testing. But the numbers show it's a sermon they need to hear, says Couzens, senior pastor at Forest Park's Inspirational Baptist Church, so he stands in the pulpit and delivers the word.

That's because in the last decade or so, HIV has undergone a huge shift, moving from a gay, white male disease to a largely African-American epidemic.

African-Americans are more likely to contract HIV and to die from its complications, including AIDS, than whites now.

African-American women, in particular, bear the brunt of the disease, making up 61 percent of newly diagnosed female HIV patients in the U.S. African-American men make up 46 percent of all newly diagnosed males with the virus.

In Hamilton County alone, the number of African-American women living with HIV or AIDS more than doubled from 1998 to 2007, from 116 to 267, according to data from the Ohio Department of Health.

HIV is the leading cause of death for African-American women 25 to 34, and for African-American men 35 to 44.

Spreading in silence

The virus has spread in silence, community leaders say, shielded by fear, ignorance and denial.

The virus continues to spread in the African-American community for the same reasons it spreads in every community: Drug users share needles and have unprotected sex. But for some reason, African-Americans aren't heeding the message that condom use can prevent the spread of HIV, experts say.

If African-Americans can talk about sex and HIV in church on Sundays, Couzens says, they can talk about it at home and in school and in clubs the rest of the week.

"People can live with this disease, with the help of medical treatment," he says. "People can live productive lives, but that's only if we open our minds and stop being silent about this monster that's devouring our lives and our community."

In Greater Cincinnati and Northern Kentucky, pastors, health-care workers and community organizations like the NAACP urge African-Americans to get tested for HIV and to learn how to stop its spread.

Cincinnati is a pilot site in a new national effort to increase HIV testing among African-Americans.

To do that, health care advocates are finding innovative approaches to encourage testing.

Nationally, although African-Americans make up 13 percent of the population, they represent nearly two-thirds of the people living with HIV/AIDS.

There are many layers in the debate over why HIV has taken such a stronghold in the African-American community.

"There are so many issues in the black community that I don't even know where to start," says Rose Todd-Stanford, 50, of Finneytown. She learned she was HIV-positive in 1993.

Plenty of stigma, fatalism

Stigma plays a large role.

Regardless of race, male-to-male sex and injection drug use by men are the two most common ways the virus is spread.

In some cases, men infected by the virus while incarcerated spread it after their release to wives or girlfriends, says Liz Presley-Fields, director of the Early Prevention and Intervention Program, a Hamilton County effort aimed at preventing HIV among poor mentally ill or substance-abusing adults.

The Ohio Department of Rehabilitation and Corrections tests incoming prisoners for HIV, but doesn't routinely test them again before they are released, says infection control manager Kevin Runyon.

Incoming prisoners are tested to make sure they get needed treatment, he says. In 2007, 28,178 men and women came into the system. Last year, 28,039 men and women were released from the state's 32 prisons.

Corrections officials know convicts are at risk for contracting the virus while in prison, Runyon says, but there's no legal requirement to test them before they're released.

That could change, though.

At the request of legislators, the department is wrapping up a two-year pilot project in which every inmate being released from one prison is tested for HIV and other sexually transmitted infections, including hepatitis C, chlamydia and gonorrhea. Results should be available in October, he says, and will be sent to legislators for their review.

Inmates can request testing, he says, and inmates caught in behaviors that put them at risk for the virus are referred to a disciplinary committee, which generally orders HIV testing.

There's a huge stigma against homosexuality and bisexuality in the African-American community, so many men likely refuse to use condoms during sex because they don't want to admit they might have been exposed to the virus.

Women, in turn, might be reluctant to demand their male partners use condoms, especially if they're financially dependent on those men, or if they don't know their partners are having sex with other men or women.

"I know so many women who got this disease because they trusted their husbands," says Todd-Stanford.

There's also a degree of apathy surrounding the epidemic, says Mamie Harris, executive director of IV-Charis. The West End faith-based organization provides HIV testing in churches, jails, prisons, homeless shelters, rehabilitation facilities and other places.

"The empathy around HIV is dying," Harris says. "It's been out there a long time, and I think people have become dull of ear and dull in their senses around it. One African-American woman told me, 'Well, after all, you can keep from getting HIV, but you can't keep from getting breast cancer.' Sometimes I get afraid that that's the general consensus, that it's been out there a long time, that it's an STD and that people should know better."

Testing is lacking

Lack of testing for the virus is a critical issue in the spread of HIV, says Eric Washington, STD/HIV program manager for the Cincinnati Health Department. He says people who don't know they have the virus not only aren't getting treated for it; they're also likely spreading it.

Part of the problem is educating people that if they're sexually active, they're at risk for HIV, he says. "We need to come up with a better way to convey the message to the community that they are affected by HIV, and they need to be tested," Washington says.

Finding new places for testing is also important.

In some cases, he says, people don't have access to a doctor's office to get tested, and many are reluctant to go to a health department clinic for testing because they're afraid someone they know will see them.

At the Center for Closing the Health Gap's April health fair, HIV testing was set up on the upper floor of the Duke Energy Convention Center, says Dwight Tillery.

Signs pointed people up the escalators to the testing site. Of the 4,000 or so people who attended the expo, about 100 got tested.

"No one wanted to be seen going up those escalators to get tested," says Tillery, executive director and CEO of the Center for Closing the Health Gap.

Cincinnati is a pilot site in the Black AIDS Institute's "Test One Million" campaign, which aims to increase the number of African-Americans being tested.

Many agencies, including Harris' group, AIDS service organizations and churches, are involved in the effort.

For years, African-American church leaders were reluctant to take on HIV as it spread into their community.

No one wanted to be seen as condoning homosexuality or drug use.

That view has changed as the virus' impact on the African-American community becomes clearer.

Several churches in Cincinnati, including Couzens', and Corinthian Baptist Church in Avondale, have invited IV-Charis and other organizations to conduct tests at the churches after Sunday services.

Church testing starts

At one church, Harris's group tested 20 people; at another, 37 stayed to be tested.

That was unheard of a few years ago.

"The position that the church is taking is that this is a crisis, and until the church gets involved, like we did with the civil rights movement, the community is not going to change our habits," Couzens says. "My position and my stance is that anybody and everybody is at risk, and unless you know you're HIV-negative, you're positive. Unless you know you don't have it, you should live like you do."

Bishop E. Lynn Brown, presiding bishop, Second Episcopal District, and pastor of Christian Methodist Episcopal Church in Bond Hill, was one of 10 church leaders at a recent national convention who underwent testing. "We all stood up and took that test," he says. "We hoped it would be an incentive for our members to do the same."

Advocates are finding other venues for HIV testing.

Barbara Laing, a case manager for HIV/AIDS with the Northern Kentucky Health Department, works with others in her department to offer HIV testing in people's homes.

"African-Americans will not traditionally come out and test," Laing says. "The ones who do come to the health department or to the doctor's office are not at risk."

So Laing and her colleagues go the people who need testing. Clients get a group of friends together, and Laing goes to the house and gives a presentation on HIV risks and prevention. Anyone who wants to can get an HIV test.

Workers with Stop AIDS Cincinnati, the Cincinnati Health Department and the Early Prevention and Intervention Program take condoms, prevention information and quick HIV tests to bars and clubs. Workers reach out to homeless people and prostitutes to encourage them to get tested.

Adam Reilly, an HIV risk reduction specialist with Stop AIDS Cincinnati, heads to gay bars around Cincinnati a few nights a week. He makes sure the men's rooms are well-stocked with condoms. He discreetly hands out information on risks and testing sites to patrons.

"It seems like, among the African-American population, there's a much lower rate of condom use. They don't use the condoms we supply," he says. "The condoms we're handing out, they don't want to take because they think they're not going to fit, which is not the case."

A frican-American men who sleep with other men often keep their behavior secret, or on the down-low, which increases the risk of spreading HIV.

Victoria Straughn, chairwoman of the Cincinnati NAACP's health committee, wants the African-American community to get fired up about HIV testing and prevention.

But she and others aren't quite sure how to make that happen.

Young people feel safe

Younger African-Americans may feel safe from the disease because newer treatments let HIV patients live longer and more productive lives.

Older folks may not realize they're at risk.

Given the community's other challenges, including poverty, education and crime, HIV might be just one more problem to solve.

"I think a lot of people feel like it's one more thing we can be blamed for," Harris says.

On June 9, the Ohio Commission on Minority Health will hold a press conference in Columbus highlighting the "Test 1 Million" initiative.

Harris will be among the speakers, along with Phill Wilson, executive director of the Black AIDS Institute in Los Angeles. Members of the Ohio Legislative Black Caucus will also be present.

Straughn says it's time for the community to take ownership of the epidemic.

"I often revert back to the white gay community and their actions early in the epidemic," she says. "I have often praised and commended them for having first said, 'Yes, we own it. Yes, we have high risk behaviors.' They not only took ownership, but they created a prevention campaign by them and for them.

"We need desperately to do the same thing, and it is something that we are going to have to own, we're going to have to accept it, and we have to develop our own plan of action to save ourselves."

Former NBA great Magic Johnson was one of the first African-Americans to go public with his HIV diagnosis in 1991, but too few "ordinary" people are willing to risk backlash by revealing their HIV status, Straughn says.

"We don't hear real-life stories today of people who live next door with the disease. It's almost invisible. And it's going to stay invisible until we have courageous men and women and young people who will stand up and say, 'This is real. You don't have to be an IV drug user. You don't have to be promiscuous," she says.