Washington Heights — Three months ago, Ms Cruz's doctor warned her about the abnormal level of T-cells in her blood. They had reached such a low* level that the slender 46-year-old Bronx resident was about to shift from being HIV-positive to having full-blown AIDS. So Cruz made an instantaneous decision—to stop selling her HIV drugs on the black market to support her 20-year cocaine addiction. Now, she realizes, she had been toying with a death sentence.

Homeless and unemployed, the mother of six is one of the nearly 109,000 New Yorkers who are living with HIV or AIDS. Their expensive array of medications has become particularly popular on the black-market in the past couple of years, according to law enforcement sources.

Drug users like Cruz are the main providers of HIV pills such as Atripla or Videx on the street, sources say. But others make the difficult choice to sell their pills not to buy drugs but to pay their rent.

So far, this kind of drug dealing has not been punished harshly by the judicial system. With no prior criminal record, a dealer caught selling $1,000-worth of prescription drugs could be sentenced to one to four years in prison, but most likely would receive probation or a shorter sentence, explains Tom Tapp, chief of the Bronx District Attorney's Arson and Economic Crime Bureau, which prosecutes Medicaid fraud and other abuses related to prescription drugs. For a sale involving a similar amount of money, a dealer selling narcotics such as crack or cocaine could get up to nine years in jail.

But a bill sponsored by New York Sen. Kemp Hannon and passed by the Senate in June could close that gap if approved by the assembly this year.

The bill identified an "exploding black market in non-controlled substance medications," including AIDS medications that are either sold to pharmacies or shipped overseas. Under the bill, first degree "criminal diversion of prescription medications and prescriptions" moves from a C felony (with likely maximum jail time of five to 15 years) to a B felony, for which the maximum is eight to 25 years.

Indeed, law enforcement officials suspect that demand for HIV drugs in foreign countries fuels the trade in HIV medication.

"What I know is anecdotal, I don't have any data," says Tapp. "But they are often sent overseas because medications aren't available, like in Dominican Republic."

The incentive for access to these drugs is acute. According to a 2011 report from the World Health Organization at least 45 percent of the HIV/AIDS population in the Dominican Republic had no access to appropriate treatment in 2009. In Haiti, 47 percent of people needing antiretroviral drugs didn't get them, and in Jamaica some 38 percent did not. In Cuba, fewer than 5 percent of HIV patients went without meds.

Law enforcement experts report that Washington Heights has become the heart of the illegal HIV drug traffic.

Last September, Assemblyman Herman D. Farrell, Jr, City Councilman Ydanis Rodriguez and the Manhattan district attorney, Cyrus R. Vance, Jr. gathered at the 33rd Precinct in Washington Heights to discuss the possible new legislation toughening sanctions on prescription and medication dealers.

A new drug threat

"There's always been a significant drug problem in the area," says Michael Mowatt-Wynn, president of the 33rd Precinct's Community Council for 10 years. Mowatt-Wynn, who also lives in the neighborhood, says Washington Heights has a history of gang and drug problems. The area was one of the first "model blocks," a 1999 city initiative that aimed at reducing illegal drug activity by increasing police presence. The experiment was seen as a success as crime quickly dropped by 20 percent.

But Mowatt-Wynn says that five or six years ago he first started noticing the unusual business inside the 157th Street subway station on the number 1 train.

"We're facing a completely different situation than the usual crack, cocaine, marijuana," says Mowatt-Wynn, who runs the Harlem & the Heights Historical Society.

"On 157th Street at the top of the stairs, there are between two and five Hispanic young men searching the crowds and people coming up the stairs," says Mowatt-Wynn, adding that he was once approached himself by the men.

They're looking for people who could be coming out of the pharmacy with medications, carrying plastic bags. With a simple nod of the head, one of the men will go down the stairs and, in full view of passers-by, exchange the bag for cash. But according to Mowatt-Wynn, the transactions became too obvious, so the buyers now escort the seller to a nearby street corner.

Two major arrests by the Drug Enforcement Administration dismantled two drug rings last year. One was in Brooklyn and involved a bodega owner and a couple who were shipping the HIV medication to the Dominican Republic. The other arrest took place in Yonkers, where DEA agents seized 6,500 bottles of pills worth $4.23 million. According to the DEA, many of the bottles were the kinds of medications used to treat people with HIV.

The police placed cameras at the top of the stairs of the 157th Street subway stop and have been monitoring the deals made there. But according to some, the lack of stricter penalties is hurting local police efforts to target street buyers and sellers in the streets. "The only thing they can go for is Medicaid fraud, but that is if they catch the pharmacist buying," says Mowatt-Wynn.
      
Other court cases earlier this year have shown how difficult it can be to catch these dealers, who are often released right after the verdict with a time-served sentence.

Police and social workers who work with HIV-infected people in the Bronx said the problem has spread across the Harlem River to their borough.

A detective with the 42nd Precinct in Morrisania says he and his colleagues have heard stories about black market HIV drug deals, but agreed that NYPD narcotic agents were better equipped to investigate such cases. "It's difficult because we don't really know what to look for," he says about the low-profile drug business.

Most of the time, the detective says, cases of HIV medication re-selling come to police attention after computer programs notice individuals who have charged $2,000 or $3,000 worth of HIV medications on their Medicaid cards even though they have not been diagnosed with the virus.

Such cases are transferred to the unit run by Tapp. Often, investigators will find out that these individuals were approached in the streets by men looking to illegally obtain prescription drugs, including HIV medications.

For $50 or $100 they lend their Medicaid cards to "the bad guys," as Tapp calls them, who will forge a fake prescription for HIV medications, using the name inscribed on the Medicaid card. Then the card owner will take the prescription to the pharmacy, get the pills, and hand them in to the forger.

Pharmacists can play a role

Cruz describes a different scenario, where the pharmacist is more of an active player.

Cruz says it often starts with a phone call. The HIV patient calls to let the pharmacist know in advance that it's not really the pills he or she is interested in buying, but something else. Upon arrival at the pharmacy, the pharmacist scans the barcode on the bottle of pills, and then hands over a plastic bag filled with a few hundred dollars, instead of the medication.

The pharmacist can then sell the pills back to drug dealers or ship them directly overseas.

When the spots become too "hot" –meaning the pharmacies are attracting too much attention—Cruz says the patient then moves on to less obvious buyers. "You don't even have to look for him, he's right there outside the pharmacy," she said about a dealer she often went to in the past and who stations himself opposite a small local pharmacy in the South Bronx.
      
The price fluctuates depending on location and dealers, she said, but it's always much below the pills' retail value. Cruz says she could get at least $250 for a bottle of 30 pills, when its real value amounted to more than $1,500.

"It's obviously worth more," says Loni Fernandez, a case manager for two years at Bronx AIDS, who notices that many of her patients did not take their medication. "But when you're dealing with poor people, that's what happens. They'll buy it cheap and sell it for more to people that really want it."

Drug users are well-known targets for street buyers, who sometimes approach them inside the pharmacy where they're buying their medication.

A financial struggle

Case managers and doctors are torn over whether the possible stricter punishments will discourage a dangerous practice or merely punish people who make a bad decision against challenging circumstances.

"They sometimes have to face a difficult choice," says case manager Antionettea Etienne about some of the people selling their HIV treatment. Etienne, also co-chair of the New York City Planning Council, says that often the dilemma boils down to this question: "Should I get my medication, or food for me and my kids?"

"I need my pills!" said two HIV patients at a Bronx AIDS group meeting for women. Roxanne and René, who declined to give their last names, were responding to questions about whether they ever sold their pills for cash. Both admitted that even with a job it's hard to cope financially.

Over the past two decades the cost of living has gone up, but benefits haven't kept pace. A person infected with HIV can get up to $115 a month in public benefits, depending on their occupation, financial situation and needs. If they have full-blown AIDS it's up to $300 plus a maximum of $940 for rent, although once again it varies. All are also eligible for up to $200 of food stamps each month.

These figures have remained about the same for years, says Fernandez. The financial support poor patients receive is often insufficient to cover everyday expenses such as transportation, food, rent and other bills, she explains.

"We know when something's wrong," says Julie Peña, who works at CitiWide, a needle exchange program based in the South Bronx. Peña carried out interviews for Bronx Works on the black-market of HIV drugs in 2004. According to her, the study was never published but she remembers that he black market for AIDS medication was already fairly common at the time.

Each month, case managers look at their patients' T-cells levels and viral load, which respectively indicate the state of the immune system and measure the spread of the infection. "So we see the participants and ask them why the numbers are changing," says Peña. "Most of the time they'll tell you the truth, that they're not taking their meds."

Selling HIV meds can be harmful to both seller and recipient. If a patient doesn't take his or her medications meticulously, the risks of becoming resistant to the treatment and developing colds and pneumonia become higher. Different cases of HIV have different biological characteristics, so the cocktails of drugs vary. And all treatments don't fit all viruses.

Cruz made plenty of trips to the hospital too, when bad colds turned into pneumonia. But what worried her most was the way she'd look if she kept on not taking her HIV treatment. "If you keep on getting high and you mess up with your immune system, you look even more messed up," she said. "I wanna look pretty when I die."

* CORRECTION: The original version of this article referred to Ms. Cruz's T-cells getting "high" enough for her to be on the verge of full-blown AIDS. In fact, it's a decrease in T-cells that indicates the onset of AIDS.