Back in 1989, Carole, then 42, started suffering from a strange assortment of ailments that her doctors couldn’t account for: chronic yeast infections, swollen lymph nodes, inflammatory pelvic infections, painful numbing in her feet and drastic weight loss. At the time, Carole had just quit her job as a marketing executive and was taking classes to become a radiologist. One night as she lay in bed studying for a test on the immune system, she noticed that the symptoms associated with AIDS matched her own. She says, "I pointed to the section in my textbook and said to my husband, ‘Hey, do you think there’s any chance I could have this?’ That was my way of asking him, politely, ‘Is there anything I need to know about what you’ve done?’ And he turned to me and said, ‘Of course not!’"
She wouldn’t learn the truth until almost four years later, in 1993, when a rheumatoid arthritis doctor, unable to find any other explanation for Carole’s collection of symptoms, finally asked if there were any chance she could be at risk for HIV. As Carole remembers it, she laughed and said, "Gee, I don’t think so. But go ahead, test me, and let’s eliminate that possibility." When she brought the results home, her husband broke down. He had cheated on her with another man, he admitted, and he hadn’t used condoms.
Men who have sex with both men and women — sometimes referred to as men on the down low — "are a significant bridge for HIV transmission to women," says CDC researcher Linda Valleroy, who conducted a 2003 study on the subject. About one in 10 men who have sex with men have also had sex with women in the past year, often without condoms. Furthermore, experts estimate that two-thirds of women involved with actively bisexual men don’t know it.
Today, Carole and her husband are still together. He’s asymptomatic; she has full-blown AIDS. "People ask me how I could forgive him," she says. "I have to tell you: Initially, I was pretty goddamn mad at him. I had a rocker in my bedroom, and I used to sit in it and think, hmm, should I kill him?" But Carole loves her husband, raised two children with him, and sees no point in ditching their comfortable life together. He also promised he wouldn’t have sex with anyone else, and she believes he hasn’t. Plus, she admits, she needs his financial support: Her medication alone runs $1,000 a month. No longer able to work full time, she couldn’t afford the expensive treatment without her husband’s income and insurance. "He never set out to give me this disease," she says. "I can forgive the infidelity. What hurt me the most was that he didn’t protect me."
Whether married, dating, or single, midlife women who are sexually active in the age of AIDS are caught in a perfect epidemiological storm. Their very biology makes women twice as likely as men to contract the virus from heterosexual sex: The vagina has a much larger area of exposed skin and tissue than the penis. Infected semen contains a far higher concentration of the virus than do vaginal secretions, and semen transmits HIV eight times more efficiently. Yet physicians, by their own admission in numerous interviews for this story, often don’t consider HIV when they examine women past their reproductive years and may be unlikely to offer a routine test. Even classic symptoms of the virus — chronic yeast infections, extreme fatigue, night sweats — are sometimes mistaken for menopause or other signs of aging. "It is amazing how badly we doctors do this," says Cu-Uvin, who directs a clinic in Providence, Rhode Island, that provides special services for menopausal women with HIV. "We seem to think there is an age when women stop having sex. You see a 54-year-old woman, and you will blame everything else for her symptoms before you think of HIV."