HIV and the South

Key Terms

 

What is the Deep South?

The Deep South is a cultural and geographical subregion of the American South, differentiated from the “Old South” as being the post-colonial expansion of the southern states. The core states of the Deep South are: Alabama, Georgia, Louisiana, Mississippi, Florida, Tennessee, and South Carolina.

 

What is considered rural?

A geographical area located outside of towns and cities. Typically rural areas have a low population density and small settlements.

 

What is the Black Belt?

The Black Belt is a region of the southern United States. It is an area known for prairies and dark fertile soil, located in central Alabama and northeast Mississippi. As this is where cotton was developed, large portions of African-Americans reside here. 

Who is affected in Southern Rural Areas?

 

Black youths (ages 13 to 24) accounted for 34% of all new HIV infections among African Americans. Among black men who have sex with men (MSM), this age group accounted for 45% of new infections.

 

Black women accounted for nearly two-thirds (64%) of new HIV infections among women.

 

The rate of new HIV infections was

about 8 times higher for black/African  

Americans than for whites, and 3 times

higher for Hispanics/Latinos.

 

In 2018, there were many new cases (27%) of

Hispanic/Latinos diagnosed with HIV

in the US, and many lived in the Deep South.

Reasons for Disparities in the South vs. Urban Areas:

 

Poverty: A study released by the Centers for Disease Control and Prevention (CDC) revealed that 40 percent of those infected have an annual household income of $10,000 or less, and don’t have access to cars, others have no running water.

Stigma: None of the southern states with the highest rates of HIV infection require public schools to provide LGBT-inclusive information in their health classes.

  • Most Deep South states have abstinence-based sex education in public schools, which has shown to not be effective in preventing STI’s

  • Deep South States lack the sexual education requirements that would help educate the residents about HIV transmission

  • Not required to provide any medically accurate information about HIV

  • Lack of proper healthcare:

Since the Supreme Court ruled that states could choose whether to expand Medicaid, Alabama, like most of the Black Belt states, decided not to.

  • Cuts to Medicaid would disproportionately hit rural hospitals, which largely depend on funding from the program

  • States in the south have the least expansive Medicaid programs and the strictest eligibility requirements to quality for assistance, which prevents people living with HIV/AIDS from getting care

  • People living with HIV have to reach disability status before they quality for aid

  • According to research conducted by the Morehouse School of Medicine in Atlanta, HIV/AIDS patients rely on Medicaid for their health insurance

 

Persistent Anti-Gay Attitudes: Others see HIV/AIDS as a punishment from God, so having HIV/AIDS creates a stigma and barrier for compassion and treatment.

Ways to Prevent HIV/AIDS in the Deep South:

 

  1. Adopt new advances in HIV prevention, such as antigen/antibody combination HIV tests that can detect the earliest stages of infection.

  2. Education! Education! Start from the South, destigmatize, especially start with the “No promo homo”.

  3. All CDC-supported health departments and CBOs must formally partner with medical care providers:

    • Link newly diagnosed individuals to appropriate care

    • Provide behavioral interventions and other support to help people with HIV reduce transmission risk, stay in care, and adhere to treatment

    • Identify and re-engage people who have been diagnosed with HIV but have fallen out of care

Federal Funding Disparities:

The South has more people with HIV/AIDS than San Francisco and New York City combined, and South Carolina has the highest rate of rural people living with HIV/AIDS in the country. Yet South Carolina, which is 6th in the nation for people with AIDS, ranks 19th in the country for federal funding – receiving $7.9 million, in contrast to New York’s $80 million and California’s $70 million.

 

The South Carolina Rural Health Research Center reports that 91 percent of metropolitan rural counties and 98 percent of remote rural counties lack a Ryan White medical provider.

Louisiana Highlights

Birmingham, Alabama

Tennessee

Documentary

If you want to learn more about HIV/AIDS in the Deep South, our partner organization, HEROES LA, did a documentary. Please click here to go to their website and learn more about it. 

deepsouth is a documentary about the rural American South and the people who inhabit its most quiet corners. Beneath layers of history, poverty--and now soaring HIV infections--four Americans redefine traditional Southern values to create their own solutions to survive.

HEROES's own Monica Johnson and Tamela King try tirelessly to unite reluctant participants at their annual HIV retreat in rural Louisiana. 

Report

HEROES LA also did a report on the disparity of the HIV/AIDS epidemic between metropolitan and rural areas in Louisiana. If you are interested in learning more about it, please click here.

More Information

In the decades since the first AIDS cases were reported in Los Angeles and New York City in 1981, the epicenter of the nation’s HIV epidemic has shifted from urban centers along the coasts to the 16 states and District of Columbia that make up the South The South now experiences the greatest burden of HIV and deaths of any U.S. region, and lags behind in providing quality HIV prevention services and care. Closing these gaps is essential to the health of people in the region and to our nation’s long-term success in ending the HIV epidemic.

 

Southern states today account for an estimated 51% of new HIV cases annually,22 Centers for Disease Control and Prevention. Estimated HIV incidence and prevalence in the United States, 2010–2016.  Published February 2019. even though just 38% of the U.S. population lives in the region. In 2017, the South also had a greater proportion of new HIV diagnoses (52%) than all other regions combined. Diagnosis rates for people in the South are higher than for Americans overall. Eight of the 10 states with the highest rates of new HIV diagnoses are in the South, 4 as are nine of the 10 metropolitan statistical areas with the highest rates  Like the rest of the country, the majority of HIV diagnoses in the South occur in urban areas. However, the South has a higher proportion of new diagnoses (24%) in suburban and rural areas compared with other regions in the U.S., which poses unique challenges to HIV prevention efforts.6 6The impact of HIV in the South also varies by race. African Americans are disproportionately impacted in every risk group (see chart below), accounting for 53% of new HIV diagnoses in the region in 2017. Black gay, bisexual, and other men who have sex with men (MSM) account for six out of every 10 new HIV diagnoses among African Americans in the South. Among MSM, the number of new diagnoses in black MSM is nearly twice that of white and Hispanic/Latino MSM. While the number of new HIV diagnoses is similar among the latter two groups, new diagnoses among Hispanic/Latino MSM in the south have increased 27% since 2012, while new diagnoses among white MSM in the South have decreased 9% in the same period. Among women, black women are also disproportionately impacted, accounting for 67% of new HIV diagnoses among all women in the South

 

Fewer people with HIV in the South are aware that they have HIV compared with other regions in the U.S.9 99. Consequently, fewer people with HIV in the South receive timely medical care or treatment, which is important because taking HIV medicine as prescribed can make the amount of virus in the body very low (called viral suppression or undetectable). People with HIV who stay undetectable can live long, healthy lives and have effectively no risk of transmitting HIV to an HIV-negative sexual partner. Mortality in the South is high—in some southern states, people with HIV have death rates that are three times higher than people with HIV in other states. Although death rates have declined since 2012, the South still accounted for nearly half (47%) of the 15,807 people diagnosed with HIV in the U.S. who died in 2016.1018. There has been limited uptake in the South of pre-exposure prophylaxis (PrEP), a daily pill that is highly effective in preventing HIV. PrEP is underutilized across the nation – with less than a quarter of the 1.1 million Americans who could benefit from PrEP using it – and Southerners accounted for only 27% of PrEP users in 2016, even though the region has more than half of new annual HIV cases. Predominantly in non-urban areas of the South, the nation’s opioid crisis has increased risk for acquiring HIV and hepatitis C (HCV). According to a 2016 estimate, nearly seven in 10 (68%) counties vulnerable to an HIV or HCV outbreak among people who inject drugs are in the South.

 

The heavy burden of HIV in the South, especially in those states considered the “Deep South, is driven in part by socioeconomic factors like poverty and unemployment. The South has the highest poverty rate and lowest median household income compared to other regions of the U.S. Both factors are associated with poorer health outcomes and may contribute to a higher concentration of HIV and other chronic diseases like diabetes in the region.17 17 Reif S, et al, 844-853. People in the South face several access barriers that can prevent them from receiving adequate HIV and other health care services. Nearly half of all Americans without health insurance live in the South.1Medicaid is the largest source of coverage for people with HIV in the U.S., but nine of 16 states in the South have not expanded Medicaid. In rural areas, people with or at risk for HIV face challenges in accessing consistent HIV prevention and treatment services, like lack of public transportation, longer travel time to receive care, and reduced availability of medical and social services compared to non-rural areas.21. These places may also experience health care provider shortages and have fewer providers with expertise in treating HIV.22 22 Cultural factors may also play a key role in driving the southern HIV epidemic. HIV stigma is pervasive in the South and is often associated with stigma around sexual orientation, substance abuse disorder, poverty, and sex work, and may limit people’s willingness to disclose their HIV status or seek testing, care, or prevention services.2323 Reif S, et al, 844-853. Stigma has been associated with lower or delayed access to care due to perceived discrimination from healthcare providers


Southern states generally lag behind other regions in key prevention and care outcomes like knowledge of HIV status, linkage to care and viral suppression. One factor may be failure to apply key technologies. For example, southern states have not yet widely adopted new HIV prevention advances, such as antigen/antibody combination HIV tests. These new tests can detect HIV in its early stages, when it is most easily transmitted.2 Being able to diagnose HIV early is critical to ensure people with HIV get treatment to protect their health and prevent transmitting HIV to their partners.

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