Editor's note: This week, CNN Health's team is taking a close look at the HIV/AIDS epidemic in the Southeast with a series leading up to World AIDS Day on December 1. Learn more about the problem and our upcoming stories here.
Atlanta (CNN) -- Her blue-green eyes are as clear as her name would suggest, but her wants and needs are muddy as she walks with aching joints on the streets of Atlanta, trying to resist the urge to get high.
Like many people living with HIV/AIDS in downtown Atlanta, she's less concerned with her disease than about where she's going to sleep, what she's going to eat and how she's going to stay clean. It's been a few days since she's had cocaine or alcohol, and she wants to keep that up. But when you're living on the streets, surrounded by dealers and users, it's hard to say no to a source of good feelings you've known for decades.
"What am I gonna do if I don't use? Who am I gonna be, if I'm not gonna be an addict?" Crystal, 46, asks one crisp day in October, her icy hands hoping to find gloves later. "I've been an addict all my life, which just leaves you with a lot of empty time, a lot of space in your life; that seems like a dangerous thing to me. People get in trouble when they don't know what to do, or where to go."
Crystal -- CNN is not using her last name -- is stuck in a cycle of addiction, drugs, homelessness and disease. She got HIV by selling sex to buy more drugs, a risk factor that isn't the only predominant way of contracting the virus, but something Dr. Wendy Armstrong sees commonly at Grady Health Care System's Ponce De Leon Center, one of the largest HIV/AIDS treatment facilities in the United States.
More than 40,000 people in Georgia have HIV or AIDS; 67% of them live in the 28-county metropolitan area that includes Atlanta, according to a 2010 report by the Georgia Department of Community Health's HIV/AIDS Epidemiology Unit. The epidemic is concentrated in Fulton County, which includes the city's downtown, as well as DeKalb, Gwinnett and Clayton counties, said Paula Frew, a researcher at Emory University School of Medicine.
Male-to-male sexual contact is the most common mode of transmission among men, but for women living with the disease in the metro area, some 27% are "high-risk heterosexual," meaning they've had sexual contact with someone with known risk for HIV.
High rates of poverty, sex trafficking, food insecurity and continued stigma attached to the disease all help make Atlanta a center of the Southeast epidemic. And it feeds on itself: When there's already a high prevalence of HIV, the chance that any single sexual encounter will lead to transmission of the virus is greater.
"We see a whole lot of homeless people at our clinic. It's very, very, very common that patients are unstably housed," said Armstrong, an associate professor of infectious disease at Emory University School of Medicine, and an investigator at the Emory Center for AIDS Research.
But because Crystal doesn't have noticeable symptoms from her disease, she, like many others with HIV in the United States, doesn't see that as her priority. Her story highlights how addiction can lead to a path of risky behaviors that feed on one another, and can result in a chronic life-threatening illness that affects more than 1.1 million people in the United States.
Making sense of a diagnosis
Crystal was once going to visit the Ponce clinic but missed her scheduled time, and says she can't get another appointment.
Staff can see only patients whose CD4 count (a measure of white blood cells available to fight infection) has ever dipped below 200; in other words, those who have full-blown AIDS, Armstrong said. To Crystal's knowledge, she has not reached that point. The clinic is currently seeing 5,100 patients already, Jacqueline Muther, interim administrator at the Grady Infectious Disease program says.
Crystal also met with a counselor from a different AIDS organization but was put off when given a list of shelters to call herself.
"Sometimes, people have tried to help her, and she wants it on her terms only," said a close friend who has known Crystal for more than three years but did not want to be identified in this article. "You can't really do it that way."
Desperate for drug money, Crystal used to sell sex to support her addiction. She thinks she got HIV from a man who offered her money and told her he was HIV-positive. And she didn't care.
"The addiction takes over your mind and your thinking and perpetuates itself," she said. "The money he was giving me was more powerful than the consideration of the chance that I would become HIV-positive. That's the mind of the addict."
Crystal got her first diagnosis while in jail about two years ago. Her recollections of why she was arrested at various times are fuzzy, but Fulton County has a record of her charged with possession of cocaine in November 2009. Crystal says she does remember that the nurse who delivered her HIV diagnosis results smiled, as if she were taking perverse pleasure in it. Crystal didn't react.
"Did you hear me? You're positive," the nurse said. Crystal began to cry.
She went with her close friend to get confirmation at the health department in January 2010. Crystal was initially upset to learn that the result was positive, but her friend reassured her that people can live a long time with HIV. After learning about the disease more, she felt better about dealing with it.
"The way I was living my life, I was living to die anyway. I was very promiscuous. I was buying drugs on the street when you have no idea what's in them. Now I'm much more careful," she said in August 2011. But by November, her attitude had become more one of denial -- she insists that she's not sick; she feels the pain of arthritis in her joints, but no symptoms she relates directly to HIV.
"Someone else says there's a virus in my blood," she says, her Southern twang broadening when she speaks passionately.
" 'Positive' is being happy and open-minded and open to things happening in my life. 'Positive' is continuing to go forward and do the right thing. Do the next good thing, continue to live, that's what being positive is to me."
The majority of patients at Atlanta's Grady Memorial Hospital who get a diagnosis of HIV as an inpatient progress to AIDS within one year because they are tested so late in the course of the disease, Armstrong said. More than half already have AIDS, she said. Generally, how fast that progression from HIV to AIDS occurs varies from person to person.
According to Armstrong, current recommendations suggest that everyone with a count of CD4 cells (an important part of the immune system) below 500 should get treatment; below 200 means the person has AIDS. But that's not the whole story of how HIV harms the body; just having a chronic disease with viral implications increases the risk of cardiovascular disease and bone disease, Armstrong said.
A very small number of people with the disease are "elite controllers," who appear to control the virus because of special properties in their immune system, and may have lived several decades without progressing to AIDS, taking no HIV medications. But they represent only about 3% of people with HIV according to the International HIV Controllers Study.
Crystal does not have full-blown AIDS, according her and her close friend, and does not know her CD4 count.
"I'm not living in this diagnosis," she said in early November, while staying with a friend downtown. "I'm not going to let this control my life, make my choices for me, make my decisions."
Her close friend, who describes Crystal as "bright and very attractive," desperately wants to get Crystal off drugs and off the streets permanently, and is trying to help her.
"We have to love people where they are, even if they can never get into recovery. The fact that she's not successful won't stop me from loving her and just hugging her and helping her," the close friend said.
A past in broken fragments
Jail in autumn 2009 gave Crystal a diagnosis. Jail in October 2011 gave her 10 days to think about her 8-year-old daughter, whom she hasn't seen since the girl was 3 months old. During the incarceration, she slept well and ate well, and she returned to the streets with renewed optimism.
"I want one day to be someone that I would let my daughter see," she said. "I'd like to be someone that my family would claim. My mother would say, 'Yes, that's my daughter.' My sister might say, 'Yes, that's my sister.' "
Her memory is imperfect. There are periods of her life that she believes are still in her brain somewhere, but that her memory can't access. "It's all there," she says, "like on a tape recorder. I just don't have access to all of it." Head injuries, alcohol and drugs have all clouded some of her thinking about the past.
Growing up in Jacksonville, Florida, Crystal began smoking marijuana at age 15; it gave her the immediate gratification she was looking for. She would smoke pot every day and drink on the weekends. Drugs, she believed, were the "in thing."
"It made me feel good," she said. "As a child, I didn't grow up learning how to feel good about myself."
From beer keg parties, she moved on to heavier drugs: acid, powdered cocaine, speed. She could get a gram of powdered cocaine for $50 and supported her addiction by working.
Cocaine, both powdered and crack, is an independent risk factor for HIV transmission because of the associated behaviors and social disorganization that it creates, said Dr. Vincent Marconi, associate professor in the division of infectious diseases at Emory University School of Medicine.
Crystal's mother was a busy woman, in Crystal's memory. She was a high school graduate but did not attend college, and worked extensively in accounting, Crystal's remembers. She said her father worked in the printing business, and also bought a tavern and worked graveyard shifts, sleeping in the day and working in the evening.
"We went without nothing. We built a pool in the backyard. We had things, dogs, clothes. I had everything I needed," Crystal said.
She says she graduated from high school in 1983. There is a record of her being arrested in Florida for possession of marijuana in April 1985.
But Crystal has barely any memory of 1983, '84 and '85, the years leading up to a major car wreck.
"When I woke up in the hospital, I was a child again inside my head and I had to grow up again," she said. "I would do something and realize: This is a mistake."
She moved to Atlanta about three months before the accident. She learned that, one week before, she'd brought her car -- a 1975 Ford Capri, an ugly orange "bubble" hatchback with stick shift -- from Florida. Driving on Interstate 75 close to Windy Hill Road, where her mother's office was, she was in an accident with a truck on September 10, 1985.
Left with a severe head injury, Crystal spent three months in the hospital, including six weeks in a coma. She said her jaw was broken for nine years, and it took 10 years for the reconstructive surgery that would repair her face. She had bone graft surgery three times.
She tried to hold various jobs -- she was a cashier and an ice cream truck driver, among other things -- but never developed concrete skills. And she moved around the Atlanta area -- Midtown, Chamblee, Roswell Road.
Into the early 2000s, she continued using drugs and was arrested several times on drug-related charges in the Atlanta area. She had been on and off the streets when she found out that she was pregnant. The child's father was from Mexico, she said; Crystal isn't sure if he's still in the country.
She moved in with her mother in Gwinnett County. At that time, she stopped using crack but still drank a little, occasionally. But she also failed to report for to DeKalb County court when required and was jailed overnight while about seven months pregnant.
She went into labor on her own birthday in 2002 and gave birth the next day.
What happened next, Crystal doesn't want to talk about. She was still making "bad choices" and had an "altercation" with her mother, resulting in her mother taking legal action against her. Her mother mentioned the 1985 car accident in the petition, stating that the head injury, combined with substance abuse, has given Crystal problems with judgment and memory. She also wrote that while on alcohol or drugs, Crystal can get violent and abusive.
In July 2002, the Gwinnett County Superior Court gave her mother temporary custody over Crystal's infant daughter. The court also issued a six-month protective order barring Crystal from approaching her mother within 100 yards or having any contact.
"My mother doesn't want anything to do with me. She doesn't claim me," Crystal says, tears spilling over from her eyes. "That's my mother!"
Crystal would spend much of the next year in confinement. In August 2002, the State Court of Gwinnett County ordered her to serve six months at the Gwinnett County Correctional Institute, minus the approximate month she'd already served. But because of a probation violation in DeKalb County, she would then spend October 2002 to May 2003 in jail there.
A handwritten letter with loopy "f"s and "g"s, which she wrote from jail in DeKalb County, remains in her file in Gwinnett County. Crystal writes, "I am going nuts worrying about my baby and am doing all I know to do." She wrote that she had tried to inquire about the welfare of her daughter, but hadn't heard anything from the Division of Family and Children Services in Gwinnett and DeKalb.
"I stopped smoking 'crack' because I wanted this baby more than I wanted a 'hit,'" she wrote. "I believe I have changed my life."
As far as she knows, her mother is still taking care of her daughter.
"Until I can be the mother she deserves, I'm not going to be in and out of her life. I see that a lot on the streets: mothers having more children to get bigger checks," Crystal says. "I love my daughter. I loved her enough to walk away. God willing, we will be restored. I pray constantly that she will have no hard feelings."
She left jail in 2003 without a permanent place to live.
On the streets
Crystal has tried a few shelters, but she didn't like all the rules that went along with staying at them: She doesn't want to have to talk to a counselor. She doesn't like having a bedtime and getting in line for food. One shelter wouldn't let her keep her possessions underneath her bed. Another dismissed her because, according to Crystal, a woman said she snored too loudly.
All the while, she's had HIV in her body for about two years, at least, and said she hasn't felt sick as a result.
"If they're feeling somewhat OK -- they might be a little bit sick -- they don't look at the long-term plan in their life," Marconi said of people living with HIV/AIDS in situations like Crystal's. "They might be focused on, 'What do I need to do to eat today? What do I need to do to get access to drugs today?' "
Sometimes, an unstable housing situation prevents people from getting HIV medications because some drugs need to be refrigerated, and "you don't want to start them on HIV meds if they're going to take them incorrectly," said Lane Tatman, a triage nurse at the Ponce De Leon Center.
Crystal's hideaway used to be under a bridge behind the building that used to house the Atlanta Journal-Constitution newspaper, by the CSX train tracks. She lived there with her friend Frank, who used to drink constantly and panhandle in front of the AJC. Crystal hasn't seen him in a while, because a church group took him to a program where he stopped drinking.
Despite her generally upbeat attitude, life on the streets has not treated her well. Besides numerous arrests, Crystal said she has been physically and sexually assaulted multiple times.
"Every day I see the scars on my body. I totaled three cars. A guy cut my throat once," Crystal said.
"I wouldn't have been in those places if I hadn't been out trying to hustle some money or some dope."
Barbara Heath, a specialist at Recovery Consultants of Atlanta who first met Crystal about two years ago, remembers her showing up at the county health department bleeding with two black eyes; she had been "beaten to a pulp."
"She's very willful and stubborn. She'll get into arguments with people," a close friend of Crystal's said. "That's how I think she gets beat up a lot. She's very combative."
That stubbornness prevents her from accepting the help that many people close to her want to offer.
Heath had tried to get her into a recovery program, which would require a weeklong detox and work with a treatment team. The paperwork was all filled out when Crystal backed out.
"I don't know what else it would take. The only thing I can do is just be here when she calls. Just be a friend or someone she can talk to," Heath said.
Crystal has a few personal mottoes that she'll often repeat during a conversation. One of them is: "Bad choices lead to more bad choices." Another is: "If you don't want a haircut, don't hang out in the barbershop."
Eight years ago, few people would sell anything smaller than a $10 rock of cocaine, the size of a small pebble. Some addicts cut that in half. Today, there are dealers who sell $1 hits -- it's "not enough to make you crazy, but gosh, I could have bought a cup of coffee with that dollar," Crystal said.
"Drug addicts make choices that are irrational. I like to get high. You forget, or it doesn't matter. I know what's going to happen when I start using drugs: You make bad choices, you make tradeoffs, you spend money that you don't really have to spend just to get that euphoria."
One event that gives Crystal's day structure is a recovery meeting in the basement of the Catholic Shrine of the Immaculate Conception, where she's been going several times a week. She's been going to groups like this through Church of the Common Ground, a spiritual organization for homeless people, for years.
The format uses the framework of Alcoholics Anonymous -- reading the 12 steps, introducing yourself when you speak, having a sponsor. Some meetings are called "Double Trouble," dealing with addiction in addition to other mental illnesses.
A year ago, Crystal spoke about using alcohol and drugs when she feels bored, since there's nothing positive or healthy to do, recalls Darrell Stapleton, who has attended the Double Trouble meeting several times. Stapleton connected with that instantly -- he had been doing the same thing.
At a recent meeting, Stapleton -- dressed in a pressed white shirt and jeans, and now living in Stone Mountain -- celebrated one year of being clean. Crystal and dozens of others in recovery applauded as he stood up to accept a white poker chip symbolizing his sobriety.
Stapleton pocketed his chip, but usually someone with a record of being clean for a year or more will pass the token on to someone who's just starting out.
"I would say that he should have given it to Crystal," says Gail Herrschaft, a recovering drug addict who's been clean for 15 years. She is the director of Double Trouble In Recovery, and led the meeting that day.
Herrschaft and Crystal share a keen understanding of drug addiction.
"You'll prostitute. You'll do anything. Rob, steal, anything," Herrschaft says.
"Lie, cheat," Crystal adds.
"Lie, cheat, exactly," Herrschaft echoes. "Anything to get dope. It's like, it's a driving force. I've got to get another one. Gotta get another one. Once you start, it's like, 'OK, I'll do one and then I'll go pay my bills.' Well, that doesn't happen. The next morning, you wake up and you say --"
"'What have I done?' " Crystal finishes.
"'I don't have any food for the kids, I can't pay the rent,'" Herrschaft adds. "It's a vicious cycle. And that's when you start doing things that you said you'd never do."
From shooting dope with dirty needles, Herrschaft contracted HIV 19 years ago. After finding out her diagnosis, she smoked and drank in Georgia and four surrounding states because she thought she was going to die.
"I was like, let me just get super high and just tear everything up and --"
"Go out with a bang," Crystal finishes.
Herrschaft turned her life around after an intervention from her children. She also learned that she had hepatitis C, and stopped drinking. Today, she's in good health and sees her doctors regularly.
Crystal later said she had asked her own mother and sister to go to codependency meetings for families to see how they could help her, but they weren't interested.
The last time she spoke to them by phone, they were still angry.
CNN could not reach them for comment.
She walks with her left shoulder higher than the right, her hips and knees and other joints aching with arthritis. But she doesn't hesitate to bend over and pick up a stray resealable plastic bag, swiftly depositing it in the black garbage bag she's clutching. For her, nothing is trash.
She eats at various food lines. She used to sit at Woodruff Park all day long, but police have cracked down on that. But she'll still pick up a book at the outdoor reading room, or go to the library down the street. Her tastes are varied: historical romance, nonfiction, James Patterson, Patricia Cornwell. In August, she checked out "Dead Reckoning," the 11th book in the Sookie Stackhouse series.
Or she'll read her Bible in her "cat hole," a place where she stashes her stuff so no one takes it. Other homeless people have gone through her things and stolen them. But she shrugs it off; she's thin and 5-foot-8, so it's easy to find clothes at church giveaways.
On the street, it's hard to say who's really a friend.
"They think they know me, but they only know what they see out on the streets. This is a role. Everybody's playing a role," Crystal says. "This is not who I am. This is not who I grew up to be. This is Crystal on the streets. Crystal in survival mode."
She speaks of a man who can drink three six-packs of beer in a day, and will swing at her when he doesn't have alcohol. The rational choice is to walk away and sleep alone, Crystal says.
But options become scarce as Atlanta's leaves turn from green to red and then fall off with the coming of winter. These days, she's staying with a friend downtown, she says, when it's raining and she can't stay on the street. And despite her dedication to the recovery meetings, she said recently that's she's not finding recovery there.
"I don't know that I need treatment. I just need to act on the knowledge that I have. But if I sleep outside and I'm cold and I'm miserable and I'm dirty in the morning, if you don't got nothing, you don't got nothing to lose," she said.
Besides reuniting with her daughter one day, Crystal hopes that people will learn from her story through this article, and not go down the same path of addiction. She has been public about her diagnosis at church, and doesn't want anyone else to have to live through hearing the words "you're HIV-positive."
"If I can use my bad experiences to prevent someone else from bad experiences, maybe it wasn't such a bad lesson for me to learn," she said.