For more than 25 years, Robert Scott, MD, 63, has run the only HIV-focused private practice in Oakland, California, a city of some 415,000 people. Unlike many other HIV clinics across the country, which are often bleak and severe, Scott’s sits on a residential drive—in a brown-shingled house with well-trimmed shrubbery and a homey porch. Scott, standing well over 6 feet, swoops through the lobby in a blue medical coat, his stethoscope swaying, warmly greeting the patients who are flipping through magazines near an antique fireplace. Most of them come to Scott through the city’s AIDS organizations and are insured publicly by MediCal or Medicaid. This means the doc gets far less in reimbursements than what private insurance companies pay—a fact that keeps many doctors from choosing the specialty and location Scott did. “This is a poor town,” says Scott. “If you want a big bustling service with the right kind of insurance you go across a tunnel or bridge. But medicine is a service profession, and the communities that need service [here] are minorities.”

The tunnel or bridge to better care leads to the promised land of San Francisco, which sits on the west side of San Francisco Bay, directly across from Oakland. Though a mere eight miles separate the two cities, the gulf between their AIDS epidemics is massive. The juxtaposition perfectly illustrates the disease’s shifting national economic and racial profile—and how economics and race can determine AIDS funding, care and attention. Today San Francisco, home to 744,000 people, and Oakland, in East Bay’s Alameda County, have similar HIV rates. In San Francisco, 2 percent of the population is HIV positive; Oakland’s figure hovers just below 1 percent. San Francisco was ground zero not only for AIDS but also for AIDS activism. Today it has one of the best AIDS support infrastructures in the country. Dave Ellison, media relations manager at the San Francisco AIDS Foundation, says, “A source of pride here is our response to HIV.” Meanwhile, in 1998, Alameda County became the first county in the country to declare AIDS a crisis in the black community. But the subsequent 10 years have not brought the funds or focus that many hoped the declaration would spur. Most Oakland AIDS organizations are underfunded and, unlike those in San Francisco, feel they do not get the community support they need. “In [Oakland’s county] office of AIDS, AIDS is a priority,” says Alvan Quamina, executive director of the AIDS Project of the East Bay. “In the county itself, it is not at all a priority.”

Many members of Oakland’s AIDS com-munity believe that the county health department’s disorganization and underreporting of HIV and AIDS diagnoses have caused a loss of federal funds, which are linked to a region’s reported caseload. “HIV infection competes with other health disparities for the county’s funding dollars,” says Kabir Hipolite, director of the Office of AIDS Administration of the Alameda County Department of Public Health. “However, I believe that the Alameda County Health Department is truly concerned and alarmed by the escalating numbers of HIV infections, particularly in Oakland’s African-American and Latino communities.”

San Francisco is not only larger than Oakland; it is also far whiter and far more affluent. Thirty-six percent of Oakland’s citizens are black while in San Francisco just 7 percent of the population is. In San Francisco more than 60 percent of infections are in white gay men; in Oakland the majority are in African Americans. “San Francisco has held [its] public health system accountable,” says Ed Byrom, director of programs at San Fran’s Black Coalition on AIDS (BCA). “Most positive people [there] are educated and wealthy white men, and they have the power and privilege and sense of entitlement of white men. In Oakland, it is disenfranchised people who are getting sick. How do you expect them to be politically savvy?” Quamina says that Oakland PWAs and advocates have taken action but their actions aren’t taken seriously. “We’ve done rowdy things here like ACT UP used to do in San Francisco,” says Quamina. “But the LGBT community is not as strong here; it doesn’t own businesses and can’t muster votes. If we camp out, it’s like, ‘Oh, it’s just Alvan and all those crazies.’”

These issues are not confined to the Bay Area. Nationally, HIV is increasingly becoming a disease of the poor and of African Americans. While media attention and funds for domestic HIV have dwindled over the past decade, the HIV infection rate has doubled among black people. Although African Americans account for 13 percent of the national population, they constitute 50 percent of the country’s new HIV infections. A 2005 Centers for Disease Control and Prevention (CDC) study reported that 46 percent of black men who have sex with men (MSM) in five major urban areas, including San Francisco, were HIV positive, contrasted with only 21 percent of white MSM. Throughout the U.S., AIDS is the leading cause of death in African-American women ages 25 to 34.

Responding to this racial crisis, the CDC in 2007 announced its Heightened National Response to the HIV/AIDS crisis in African Americans. But the plan has resulted in little on-the-ground impact or concrete commitment. “We’ve been trying for years to get $610 million for the Minority AIDS Initiative, but the president won’t do it,” says U.S. Congresswoman Barbara Lee, who represents Oakland. “I think what is happening with HIV in America is a lot like what is happening abroad in places like Africa in terms of it having a disproportionate impact on communities of color. We are the wealthiest, most powerful nation in the world, and we should not have these disproportionate rates.”

However, with tax cuts, wartime spending and other financial and debt crises, the nation does not feel as wealthy as it once did. “The state’s broke. The county’s broke. The city’s broke,” says Peggy Bush, director of Oakland’s Vital Life Services, which provides care and serves as a day shelter for positive people with or without homes. “And schools are a bigger priority for them than broke-down people with AIDS.” Oakland not only lost a large proportion of federal funds in the last reauthorization of the Ryan White Care Act; the reauthorization also switched the funding focus from services for people who are positive to funding prevention efforts. “We’ve realized we have to find another source of funding or die,” says Bush. “We’re thinking about starting a barbecue place and using the profits to fund the organization. The economy is [weak] and people don’t give as much, so you have to give them something they want, like good barbecue.”

Oakland resident Carolyn Holmes, 52, who was diagnosed with HIV in 1995, has felt the funding pinch. “I’ve been moving around from place to place and it’s been hard to get [to Vital Life],” says Holmes—who, like every other positive person from Oakland quoted in this story, is African American. “With all the cutbacks we don’t get [subsidized] bus passes every month anymore.”

While Oakland may not have the same AIDS-fighting infrastructure as San Francisco, it does have plenty of individuals dedicated to improving the lives of positive people. And chief among them is Dr. Robert Scott. “He’s the godfather of AIDS in Alameda County,” says Quamina.

Scott set up shop in Oakland in 1977, after finishing a residency at Stanford University—and just prior to the dawn of AIDS. Positive people began showing up at his office, so he began treating them. Seeing that he couldn’t fully serve the growing need within his own practice, he cofounded the AIDS Project of the East Bay, the oldest and largest AIDS organization in Oakland. He reached out to prisons—knowing that in Oakland, a high percentage of the population passes through the criminal justice system—and treated and worked with inmates and the recently released. And because the church, the center of many African-American communities, has often increased the stigma positive people face, he took over the Allen Temple Baptist Church AIDS Ministry in the ’90s.

Scott also sits on various boards and travels the nation giving speeches about HIV. In 2004, he became the first African American licensed to practice medicine in Zimbabwe. He travels there four times a year, bearing antiretrovirals, and sends support to the Mother of Peace orphanage year-round. Scott manages all this while working long hours at his practice, seeing about 4,000 patients, over 400 of whom are HIV positive. He even makes house calls. “If someone doesn’t make it to the office, we go out looking for them. I know the streets where people hang out. And I’ll go to the county jail,” he says. “Last time I went, eight of my patients were there, so I went on a Friday afternoon and saw all eight.”

Scott’s patients depend on his personal touch. Kehn Coleman, 41, was diagnosed in 1993. He moved to Oakland from Toledo, Ohio, in 2003 and at first could not find care in Oakland. “San Francisco was the only place I knew of [that offered care],” says Coleman. “But it was hard to get there because [the trip on public transportation] cost $5. I was at a shelter here in Oakland. And people were very private, and it was hard to get any information.” But eventually he found his way to Scott’s office. “I love it [there],” Coleman adds. “Anyone who will give you a hug is my kind of doctor, and he gave me a hug the first day I met him.”

Like Coleman, many in Oakland don’t know where to find care. “It’s just word of mouth,” says Bruce Lacy, 50, who was diagnosed in 1990 and lives at the East Oakland Community Project. “They should broadcast the information on TV, like they do with ads to join the army.”

But perhaps the largest barrier to getting HIV care in Oakland and to going public to demand improved services is stigma. “For so many of my patients, the patient and I are the only ones who know they are dealing with HIV,” says Scott. “They are so ashamed and fearful.” Kathleen Clanon, MD, who practices HIV care at clinics and Oakland’s Highland Hospital, agrees: “Stigma is the biggest issue, bar none.” At Highland, patients often show up once and then never return; many don’t seek care until they’ve progressed to AIDS. Lacy says that at the East Oakland Community Project, “the word got out that someone’s roommate had HIV and people said they didn’t want to touch the doorknob.”

Compounding Oakland’s HIV challenges, California governor Arnold Schwarzenegger has proposed a 10 percent across-the-board state budget reduction that would slash AIDS services on both sides of the Bay. San Francisco, though still one of the best-funded cities in the nation, now gets nearly a third less federal Ryan White money than it did in the late ’90s. Organizations there must rely more on fund-raisers and private donors. After a recent round of funding cuts, the city had to step in with an emergency grant to keep the San Francisco AIDS Foundation’s rental subsidy program afloat and prevent hundreds of people with HIV from being evicted. And despite the foundation’s comparatively flush coffers, its housing waiting list now has more than 6,000 people. “Some have been waiting for 10 years,” says the San Francisco AIDS Foundation’s Ellison.

But while San Francisco experts discuss how to develop more nuanced approaches to fighting AIDS, Oakland still focuses on the barest fundamentals—basic AIDS awareness, linking people to care and educating the newly diagnosed that HIV is no longer a death sentence. In San Francisco, HIV is a well-accepted fact of city life that citizens and systems must learn to live with and manage. And so organizations like the AIDS Foundation have more leeway to address secondary issues, like self-esteem and marginalization, which continue to fuel new infections even when awareness exists. “The young guys think, ‘If I get infected, I’ll just take a pill.’ There’s a sense of complacency, and scare tactics don’t work,” says Ellison. The foundation’s Black Brothers Esteem project, based in the Tenderloin, a low-income area in San Francisco, aims to build community and leadership among black gay, bisexual and same-gender-loving men. It recently launched an exhibit of photographs—taken by positive members—that will be touring galleries around town.

Another program called Magnet, aimed more at the gay white male population, launched in 2003. Sitting near a prime intersection in the Castro, the city’s historic gay neighborhood, near a giant, billowing rainbow flag, Magnet’s facility has large clear windows, sleek chairs and art on the walls. It looks more like a hip hair salon than a clinic. Postings advertise the group’s art openings and open mikes, and men with strategically placed acupuncture needles sticking out of their bodies flip through magazines with large glossy photos of scantily clad men. The idea is to make sexual health seem like a fun part of life and sex, not an anxiety-provoking chore. “We wanted it to be like a hotel lobby for the neighborhood,” says Steve Gibson, director of Magnet. “And to get out the message that we accept you for who you are. There is so much stress around HIV prevention. Don’t beat yourself up because you had unprotected oral sex. We need to [teach people to] get rid of internalized shame.”

But while Magnet’s large windows proclaim that the people behind them feel no shame or stigma, the Black Coalition on AIDS, located in the southeast corridor of San Francisco, a poor and largely industrial area, faces a different attitude. When BCA sent out a mass mailer with its logo and HIV information, people called in to complain, saying the fliers could cause the neighbors to wonder if they had HIV. “You can’t beat San Francisco when it comes to AIDS [services]. The city is committed. But it’s not all equal and this is a largely forgotten area,” says Byrom from BCA’s headquarters, surrounded by warehouses. There are no hospitals in the area, and public transportation is difficult to access. “Here people are very closeted. There is stigma because there are no services. And there are no services because there is stigma.”

Now the toxic waste and other neighborhood blights are starting to be cleaned up—making way for the coffee shops, condos and other emblems of gentrification. “There is a shrinking African-American population in San Francisco because of the cost of living,” says Andre Robertson, director of programs for education and prevention at BCA. “A lot of [African Americans] are going to the East Bay, and the health disparities will go with them. They have all the issues that plague San Francisco but with fewer resources.”

Dr. Clanon reports that federal and proposed state cuts have forced the HIV clinic at Oakland’s Highland Hospital to cut back on the amount of time that doctors can be present. Also, the state is considering requiring those who get MediCal to reapply quarterly instead of yearly, hoping to disqualify those who are no longer eligible and save money—meaning many people who do not have permanent housing or a place to receive mail regularly may miss a deadline and lose their insurance. “We should be helping people take charge of their health; instead we are spending all our time telling them how to get MediCal back and how to access basic resources,” says Clanon.

While BCA and the AIDS Foundation do have many low-income clients of color, Scott points out that many doctors on the other side of the Bay are dealing with middle-class white men with jobs and health insurance who face different issues than his patients. “You can come up with all the elegant and excellent drug regimens you want, but unless [they] can get housing, proper nutrition and mental-health support, [people] probably aren’t going to stay on them,” he says. “There are lots of graphs of the number of deaths among HIV-positive people dropping. But that’s white people.”

Whatever their limitations, Oakland’s awareness efforts are still far better than those in many American cities, where HIV discussions may rarely occur. Oakland’s Omar Bomani, 48, diagnosed in 1987, arrived from Washington, DC, a year ago. “There’s no place like the Bay Area for services. [You can find] clothing and housing. There is yoga. They take you to the movies every Friday,” he says. And while there are few visible HIV campaigns in Oakland, a new one, Get Screened Oakland, which features the city’s Mayor Ronald Dellums and calls for everyone to get tested, is popping up all over town. Other local leaders including Congresswoman Lee have been tested publicly and have called for others to do the same. Lee has brought in high-profile AIDS events and celebrities like Bono to spotlight the city’s epidemic. “Oakland is really setting the standard on how to break the silence,” says Lee, adding that while San Francisco headed the “silence equals death” charge early in the crisis, other cities, like Oakland, must do so today. And after 20 years moving in and out of shelters and chasing HIV services in cities including DC, Denver and Dallas, Bomani is thankful for the efforts of Scott, Clanon, Bush, Quamina and many more. He says of his life in Oakland: “It’s like heaven.”