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 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.