David Nelson Jr. was just 18 when he received a phone call that changed his life, sending him into a dark spiral: He was HIV positive.

Paralyzed with shock and fear, Nelson, now 30, recalls being forced to grapple with the sudden diagnosis in 2006, during his senior year of high school in Detroit.

"When I first got my results, I just broke down," Nelson said. "I was in the car and I couldn’t leave the parking lot for about two hours. The next day when I showed up at school, I was walking down the hallway, and it felt like all eyes were on me. I felt like everyone knew my status already and that everyone could see HIV written on my forehead. ... And then going to college, I was alone. I went through this dark moment of (contemplating) suicide, partying, drugs and drinking for two years."

While the overall number of people diagnosed with new cases of HIV in Michigan has remained relatively stable since the early 2000s, it has been rising in a key demographic: young African-American gay and bisexual men who have seen a sweeping statewide increase in diagnoses, according to Jennifer Miller, an HIV epidemiology manager for the Michigan Department of Health and Human Services.

Meanwhile other states, including parts of Ohio and Indiana, have seen an uptick in HIV cases fueled by the nationwide opioid crisis.

The number of new HIV diagnoses in Michigan peaked in 1992 at 1,525, before dropping sharply throughout the rest of the decade. Roughly 10 years after the peak, the decline leveled out as the numbers started increasing among black men between the ages of 15 and 29.

If current HIV diagnosis rates persist, according to a new analysis by researchers at the Centers for Disease Control and Prevention (CDC), half of black gay or bisexual men and a quarter of Latino gay or bisexual men nationwide are expected to be diagnosed with HIV in their lifetime, according to a 2016 CDC analysis.

"That is extraordinarily devastating," Leanne Savola, the HIV and STI program director at the Detroit Health Department, said about the CDC's projection. "An entire population of our youth is going to have this disease ... for the rest of their lives because we haven’t done enough to figure out how to halt the transmission. That’s where we really need to focus our programming and ideas more broadly."

Overall, as of Jan. 1, there were 16,218 people in Michigan living with HIV.

Black males make up 40 percent of cases, or 6,559, followed by white males at 30 percent — or 4,812. Black females are at 15 percent, or 2,366; Hispanic males account for 5 percent or 756 cases and white females make up 4 percent or 696.

Detroit has the highest rate — four times the state average, raising concerns among local advocates and organizations who say it feels as if they're battling a silent epidemic that no longer receives public attention.

Detroit makes up a third of the state's HIV cases. About 719 people per 100,000 Detroit residents are living with HIV compared with 163 per 100,000 statewide, according to MDHHS data.

The problem is not confined to Detroit, however:

Almost two out of three people — 64 percent— living with HIV in 2017 resided in Lapeer, Macomb, Monroe, Oakland, St. Clair and Wayne counties. That equals 10,384 metro area residents.

Wayne and Oakland County have the highest rates of persons living with HIV.

In Wayne County, excluding Detroit, there are 190 cases per 100,000 residents. If Detroit is included, the rate rises to 393 per 100,000 residents.

In Oakland County the rate is 166 per 100,000 residents — slightly higher than the state average.

A majority of Michigan residents, 78 percent or 12,650, living with HIV are male. Twenty-one percent, or 3,382, are female and one percent, or 186, are transgender.

Just over half, 51 percent, are 40-59 years old.

In 2002, there were 765 new HIV diagnoses, about 8 new cases per 100,000 residents. Fifteen years later, in 2017, there were 767 people diagnosed with HIV — at again about 8 new cases per 100,000 people.

Nationwide, there were 973,846 people living in the U.S. with HIV at the end of 2015.

New diagnoses declined from 41,984 to 39,782 between 2011 and 2016 — a rate of 12.3 per 100,000 residents.

HIV diagnoses increased 30 percent among African-American gay and bisexual men between ages 25 and 34 from 2011 to 2015, according to a CDC report published in September.

Most experts agree it's hard to pinpoint exactly why Detroit's rate is so much higher than other communities across Michigan, but they believe it could be tied to socioeconomic factors such as poverty, a lack of consistent health care and reliable transportation to get medical care. Others believe there's a direct link to long-standing racial disparities that make it harder for minorities and disadvantaged groups to access care. These groups are also more likely to be stigmatized within their own cultural communities.

"Stigma looks very different for black MSMs (men who have sex with men) than it does for heterosexual people of color living with HIV," said Akilah Benton, interim vice president of community research and advocacy at UNIFIED-HIV Health & Beyond in Detroit. "It's almost like you’re dealing with what society has placed on you as this double negative. People of color who are in the LGBT community are oftentimes, including a lot of young people ... ostracized by their family simply because they’re gay."

Nearing rock bottom, Nelson stumbled upon a support group in 2008 — Rec (Real Enough to Change) Boyz — and connected with UNIFIED, when it was formerly known as the Wellness Networks Inc.

“Being with the Rec Boyz is what made me feel more empowered with being positive and being a gay black male,” Nelson said. “It was a group of people understanding the effects of being positive. We were the young gay black boys who were struggling with our identity, struggling with our families, our jobs, just figuring out how to survive as young gay black males.”

Nelson, who is now a Linkage to Care specialist at UNIFIED, said it's important to focus on preventing more cases and helping those who are struggling with their diagnoses. The organization's services are focused on meeting the needs of individuals living with HIV to reduce disparities and link them to care.

"We can have regular, healthy and thriving lives," Nelson said. "Your life doesn’t end with an HIV diagnosis. It's not the end, it's really the beginning. Had I not been positive, I don’t think I’d be doing any of this work."

Benton said the landscape of HIV has changed dramatically with the emergence and advancement of new medications and preventive measures. Since 1981, 13,396 Michigan residents have died of HIV. In 2016, the latest year data is available, 243 people living with HIV in Michigan died.

"You’re not seeing stories on the news of people dying of HIV, like how it was back in the day," Benton said. "I think the conversation has stopped and people think they’re not at risk for HIV and it doesn’t affect them. But it affects everyone, we’re all at risk. We’re grateful for the biomedical advancements but HIV is still here, it’s still impacting and affecting our young people. We're seeing a lot of new diagnoses in our early adolescents, between the ages of 13-24."

Benton said the organization takes a wraparound approach to help individuals who are seeking health care to also get to a point of stability where they're no longer struggling to afford food, housing and other necessary amenities.

"Detroit is a predominantly black city and this is a predominantly black illness that we’re talking about so I think that speaks volumes," Benton said. "I think a lot of factors come into play in terms of why Detroit is struggling with HIV but we’re optimistic. I think having organizations like ours and others around the city, we’ve gotten away from this silo perspective. I think we’re working together now for the common goals that one day we’ll all be out of a job. That’s the goal: Ending HIV."

HIV, short for human immunodeficiency virus, is spread through certain bodily fluids and weakens a person’s immune system by destroying CD4 cells, often called T cells, which are needed to fight disease and infection, according to the CDC.

Left untreated, a person can eventually develop AIDS, also known as HIV Stage 3, which is the most serious stage of HIV infection. People are also more likely to contract various infections or diseases without treatment.

Although major medical advancements have been made, no effective cure exists for HIV but with proper and consistent medical care, it can be controlled.

And a newer medication, pre-exposure prophylaxis or PrEP, has spurred hope that the rate of diagnoses can be greatly lowered. PrEP is a daily pill that prevents an individual from contracting HIV. The PrEP pill contains two medicines that are used in combination with other medicines to treat HIV. These medicines stop HIV from taking hold and spreading throughout the body.

Medicines used to treat HIV are called antiretroviral therapy, commonly known as ART, and can help lower an individual's viral load, which is the amount of HIV in someone's blood, to the point HIV is undetectable — leading to a better prognosis and a lower rate or possibility of transmission, according to MDHHS.

But HIV treatment can be expensive. The most recent published CDC estimate of lifetime HIV treatment costs was more than $400,000.

"It’s very expensive," said Kristina Schmidgall, director of care services at UNIFIED. "But in the past, you’d have to take a variety of pills several times a day and then you had to deal with the side effects of the medication. I remember going into this one woman’s house and her dining table was just covered in pill bottles. We’ve got it now where a lot of individuals are on one pill a day, with low or manageable side effects."

Across metro Detroit, however, a troubling trend has emerged: There are a substantial number of people who aren't obtaining care.

In the tri-county area, among communities with at least 10 cases, the highest rate of unmet need, or people not receiving care, is in Washington Township and Lake Orion, where the percentage of people not in care was 50 percent and 41 percent, respectively, last year.

In Detroit, the overall rate of individuals not receiving care was 20 percent last year.

But in some ZIP codes, it ranged from 25-39 percent: On Detroit's east side, it was ZIP codes 48205, 48211, 48213 and 48215; in southwest Detroit 48209, and in Midtown 48201.

MDHHS also found that people living in Michigan with HIV who are consistently not in care are more likely to be in one of the following demographic groups:

Young people 20 to 29: 23 percent not in care.

Foreign-born persons: 32 percent not in care.

Hispanic males: 25 percent not in care

People who inject drugs: 23 percent not in care.

"I think the biggest challenge is the social and structural barriers for certain populations to actually access things like treatment," said Henry Ford Health System Dr. Maureen Connolly, who also works at the Ruth Ellis Center's Health & Wellness Center in Highland Park. "That’s really going to be the bigger challenge. It’s a lot easier to prescribe the medication than to address the ways racism has impacted someone’s ability to access health care. That’s a much more complicated process."

The Ruth Ellis Center provides short- and long-term safe spaces and support services for LGBTQ runaway or homeless youths.

According to the CDC, limited access to quality health care, lower income and educational levels and higher rates of unemployment and incarceration may place some African-American gay and bisexual men at a higher risk for HIV.

Two years ago, the organization launched the Ruth Ellis Health & Wellness Center, which Connolly said provides a host of primary care services including basic checkups, STD testing, transition care for transgender youths and much more. Connolly said she's treating 28 patients right now.

Connolly said she believes when speaking about the high rate of diagnoses among young gay or bisexual black men that people incorrectly assume they contracted HIV through risky behaviors. Connolly said the higher prevalence of HIV within the African-American community makes it easier for the transmission to spread among young men who have sex with men.

"Young African-American men are more likely to have a partner who's living with HIV than, for example, their white counterparts in the suburbs or Ferndale or Royal Oak," she said.

Connolly said experts who are working within the community believe that in the same way that racial segregation has long impacted schools and housing, it also impacts public health.

"We really need to be thinking about how to make health services available for communities who have been historically excluded," Connolly said. "If you look at PrEP data. ... It hasn’t reached communities of color yet and these racial disparities are disheartening and really a call to action for those of us in public health."

In March, a new CDC analysis revealed that only a small percentage of Americans who would benefit from PrEP have actually been prescribed it. In the first detailed analysis of its kind, CDC researchers found that while two-thirds of people who could potentially benefit from PrEP are African-American or Latino, they account for the smallest percentage of prescriptions to date, according to the CDC.

According to the research, about 500,000 African-Americans and nearly 300,000 Latinos across the nation could have potentially benefited from PrEP, yet only 7,000 prescriptions were filled at retail pharmacies or mail order services for African-Americans. Only 7,600 for Latinos were filled during a similar time period from September 2015 and August 2016.

The gap between how many people could potentially benefit from PrEP and how many received it was smaller among whites, yet still considerable. Of approximately 300,000 whites who could potentially have benefited from PrEP, only 42,000 prescriptions were filled at retail pharmacies or mail order services, the research found.

Many private insurance companies cover the cost of PrEP, as does Michigan's Medicaid program.

Benton said many of the individuals treated at UNIFIED face issues such as joblessness or housing that may be a higher priority for them instead of treatment.

"If I don’t have a place to sleep, is it my priority to go to the doctor and get my health checked out or is it my priority to find a place to sleep?" Benton said. "Addressing the whole person is important and that's what our team does."

Although only a small percentage of the HIV diagnoses are accounted for by the transgender population, Connolly said a large number of the patients seen at Ruth Ellis are transgender women — another population for which care can be scarce.

"For transgender or gender-conforming individuals, accessing medical care can be really difficult," Connolly said. "You're walking into a traditional clinic space not knowing how you’re going to be treated, how a security guard may treat you or how you may be treated when you walk up to the front desk. I know this firsthand that medical institutions aren’t really set up well yet in Michigan to address the needs of the transgender community."

Bre' Campbell, the executive director and co-founder of the Trans Sistas of Color Project – Detroit, said she works directly with transgender women who seek HIV care.

Campbell said living with HIV has empowered her to help others retain care and build a community network of support.

"One of the biggest things that’s been a driver for me is making sure the girls feel loved," Campbell said. "I'm really happy to be in this place where I can do this now."

Campbell agrees that transphobia makes it harder for people to feel comfortable coming forward to seek health care or other needs.

"I think that’s the root of if it," Campbell said. "As someone who is living with HIV, I will be honest and say that it doesn’t really matter to me if people know. If you have HIV, I want you to just live your best life. I knew that if I didn't own my HIV status and kind of embrace it and control that narrative, that other people would try to. It's not anything that you can use as ammunition against me."

Nationwide, African-American women also are disproportionately impacted by HIV compared with women of other races or ethnicities, according to the CDC.

In Michigan, the majority of females living with HIV — 70 percent — are black.

"I think (black) women are slipping through cracks and we think HIV has this face and demographic and it really doesn’t," Benton said.

Eastpointe resident LaDawn Tate found out she was HIV positive in May 2011 during a routine OB/GYN appointment. It was the first time her doctor ever offered an HIV test.

"My first reaction was, 'How could I help the next person?' " Tate, 36, said. "I’m sure a lot of people don’t go to the doctor and ask for an HIV test. ... HIV is still a hush-hush topic because sex is a taboo topic and both really need to be discussed."

Tate said while a lot of preventive measures are focused on gay men, more attention needs to be paid to demographics that aren't typically seen "as the face of HIV."

Tate, who is now also a Linkage to Care Specialist at UNIFIED, said she and her partner were both tested on the same day.

"I found out he was also positive," Tate said. "Years later after we broke up, I found out he was also having sex with men but he was down low. I’ve run across a lot of other women who have said the same thing, that they were married or I’ve been with this guy for so long, how could this have happened? That’s what I mean when I say we shouldn’t just focus on specific demographics. In this day and age, it doesn’t have a face. If you’re having unprotected sex, you’re at risk."

Andre Johnson, president and CEO of the Detroit Recovery Project, said his organization was recently awarded a more than $2 million five-year federal grant to specifically target adult women who are living with HIV or at risk of contracting it in Detroit.

"I don’t think we have enough resources on the ground," Johnson said.

Michigan's HIV funding has dropped since 2013, when more than $23 million was allocated. About $19.4 million was allocated for fiscal year 2017.

MDHHS spokeswoman Lynn Sutfin said the amount includes what the state spends on people living with HIV for clinical services, nonmedical services such as case management, insurance and medication-related needs.

The figures, which don't include the cost of individuals living with HIV who are enrolled in Medicaid, have gone down partly because of the recent Medicaid expansion, Sutfin said.

Stacia Cottrell-Scott, 54, remembers nearly every detail of when she was diagnosed with HIV in 1995.

Cottrell-Scott said at the time, her life was spiraling out of control, and she used drugs to cope with the pain and stress in her life, and resorted to prostitution to make ends meet.

"I didn't have a reaction at that moment," she recalled. "The only thing on my mind and my only goal was to finish getting high. But eventually, I became very bitter and so angry. I questioned God. I questioned myself. ... But I had to grow up."

So Cottrell-Scott said she worked to turn her life around and now volunteers at the Detroit Recovery Project to help others. Cottrell-Scott's viral loads are now undetectable.

"I didn't want to die in the streets," said Cottrell-Scott, who is nearing her 11th year of sobriety. "It's still an ongoing learning thing where I have days where I don’t want to get out my bed or want to knock my medicine cabinet off the wall. But now, I'm living my life like it's golden and I have a second chance. My advice to everyone is: Know your status and love yourself."

Kat Stafford is the Detroit government watchdog reporter for the Free Press, covering city issues and the community. Contact Kat Stafford: kstafford@freepress.com or 313-223-4759.

Kristi Tanner is a member of the Free Press Investigations team. Contact Kristi Tanner: ktanner@freepress.com.

How to get help

To find places near you that offer confidential HIV testing: