Journal of Community Health

, Volume 42, Issue 5, pp 844–853 | Cite as

State of HIV in the US Deep South

  • Susan ReifEmail author
  • Donna Safley
  • Carolyn McAllaster
  • Elena Wilson
  • Kathryn Whetten
Original Paper


The Southern United States has been disproportionately affected by HIV diagnoses and mortality. To inform efforts to effectively address HIV in the South, this manuscript synthesizes recent data on HIV epidemiology, care financing, and current research literature on factors that predispose this region to experience a greater impact of HIV. The manuscript focuses on a specific Southern region, the Deep South, which has been particularly affected by HIV. Epidemiologic data from the Centers from Disease Control and Prevention indicate that the Deep South had the highest HIV diagnosis rate and the highest number of individuals diagnosed with HIV (18,087) in 2014. The percentage of new HIV diagnoses that were female has decreased over time (2008–2014) while increasing among minority MSM. The Deep South also had the highest death rates with HIV as an underlying cause of any US region in 2014. Despite higher diagnosis and death rates, the Deep South received less federal government and private foundation funding per person living with HIV than the US overall. Factors that have been identified as contributors to the disproportionate effects of HIV in the Deep South include pervasive HIV-related stigma, poverty, higher levels of sexually transmitted infections, racial inequality and bias, and laws that further HIV-related stigma and fear. Interventions that address and abate the contributors to the spread of HIV disease and the poorer HIV-related outcomes in the Deep South are warranted. Funding inequalities by region must also be examined and addressed to reduce the regional disparities in HIV incidence and mortality.


HIV AIDS South Stigma 



This research was commissioned by the HIV/AIDS Policy Clinic at Duke University through a Ford Foundation Grant (1115–1373).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    US Census Bureau. (2016). United States population growth by region. Accessed September 2016.
  2. 2.
    United Health Foundation. (2015). Annual report. In: America’s Health Rankings. Accessed September 2016.
  3. 3.
  4. 4.
    U.S. Census Bureau. Census regions and divisions of the United States. Accessed November 2011.
  5. 5.
    Reif, S., Safley, D., Wilson, E., & Whetten, K. (2016). HIV/AIDS in the U.S. Deep South: Trends from 2008 to 2013. HIV/AIDS in the U.S. Deep South: Trends from 2008 to 2013.Google Scholar
  6. 6.
    NCHHSTP Atlas. (2014). Accessed Jul 2016.
  7. 7.
    Institute of Medicine. (2004). Measuring what matters: Allocation, planning, and quality assessment for the Ryan white CARE Act. Washington, DC: National Academies Press.Google Scholar
  8. 8.
    Government Accountability Office. (2005). Ryan White Care Act: Factors that impact HIV and AIDS funding and client coverage.
  9. 9.
    Reif, S., Whetten, K., Wilson, E., et al. (2014). HIV/AIDS in Southern USA: A disproportionate epidemic. AIDS Care, 26(3), 351–359.CrossRefGoogle Scholar
  10. 10.
    Office of National AIDS Policy. (2015). National HIV/AIDS Strategy for the United States, Updated to 2020. Accessed September 2016.
  11. 11.
    Office of National AIDS Policy. (2015). National HIV/AIDS strategy for the United States.Google Scholar
  12. 12.
    Centers for Disease Control and Prevention. (2016). Underlying cause of death 1999–2014 on CDC Wonder Online Database. 2016.
  13. 13.
    Kaiser Family Foundation. (2016). State health facts. Accessed September 2016.
  14. 14.
    Centers for Disease Control and Prevention. (2015). Underlying cause of death 1999–2014 on CDC Wonder Online Database. 2015.
  15. 15.
    Kaiser Family Foundation. (2015). State Health Facts: Total federal HIV/AIDS grant funding by agency. Accessed 2015.
  16. 16.
    Kaiser Family Foundation. (2011). Medicaid and HIV: A national analysis. Accessed October 2011.
  17. 17.
    Garfield, R., & Damico, A. (2016). The coverage gap: Uninsured poor adults in states that do not expand Medicaid.
  18. 18.
    Wasserheit, J. (1992). Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sexually Transmitted Diseases, 19(2), 61–77.CrossRefPubMedGoogle Scholar
  19. 19.
    Cohen, M. (2012). Classical sexually transmitted disease drive the spread of HIV-1: Back to the future. Journal of Infectious Diseases, 206(1), 1–2.CrossRefPubMedGoogle Scholar
  20. 20.
  21. 21.
    Haan, M., Kaplan, G., & Camacho, T. (1998). Poverty and health prospective evidence from the Almeda County study. American Journal of Epidemiology, 125(6), 989–998.CrossRefGoogle Scholar
  22. 22.
    Conroy, K., Sandel, M., & Zuckerman, B. (2010). Poverty grown up: how childhood socioeconomic status impacts adult health. Journal of Developmental and Behavioral Pediatrics, 31(2), 154–160.CrossRefPubMedGoogle Scholar
  23. 23.
    Ahnquist, J., Wamala, S., & Lindstrom, M. (2012). Social determinants of health: A question of social or economic capital? Interaction effects of socioeconomic factors on health outcomes. Social Science and Medicine, 74(4), 930–939.CrossRefPubMedGoogle Scholar
  24. 24.
    Pellowski, J., Kalichman, S., Matthews, K., & Adler, N. (2013). A pandemic of the poor: Social disadvantage and the US HIV epidemic. American Psychologist, 68(4), 197–209.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Kaiser Family Foundation. (2016). State health facts: Percent of adults who have ever been told by a doctor that they have hypertension, 2013.,%22sort%22:%22desc%22%7D.
  26. 26.
    Kaiser Family Foundation. (2016). State Health Facts: Percent of adults who have ever been told by a doctor that they have diabetes, 2014.,%22sort%22:%22desc%22%7D.
  27. 27.
    Reif, S., Whetten, K., Wilson, L., & Gong, W. (2011). HIV/AIDS epidemic in the South reaches crisis proportions in the last decade. Durham. Accessed July 2012.
  28. 28.
  29. 29.
    Kaiser Family Foundation. (2016). State Health Facts: Health insurance coverage of the total population.,%22sort%22:%22desc%22%7D.
  30. 30.
    Heiman, H., & Artiga, S. (2016). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. 2015.
  31. 31.
    Napravnik, S., Eron, J., McKaig, R., et al. (2007). Factors associated with fewer visits for HIV primary care at a tertiary care center in the Southeastern US. AIDS Care, 18(Supp 1), 45–50.Google Scholar
  32. 32.
    Centers for Diseases Control and Prevention. (2016). Leading causes of death by age, black females, 2013.
  33. 33.
    Centers for Diseases Control and Prevention. (2016). Leading causes of death by age, black males, 2013.
  34. 34.
    National Poverty Center Poverty in the United States. (2011). Accessed November 2011.
  35. 35.
    Mays, V., Cochran, S., & Barnes, N. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology. 58, 201–225.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    CERD Working Group on Health and Environment Health Unequal Health Outcomes in the United States. (2008). Accessed November 2011.
  37. 37.
    Williams, D., Priest, N., & Erson, N. (2016). Understanding associations among race, socioeconomic status, and health: Patterns and prospects. Health Psychology, 35(4), 407–411.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Fullilove, R. (2006). African Americans, recommendations for confronting the epidemic in Black America health disparities and HIV/AIDS. National Minority Council. Accessed November 2011.
  39. 39.
    Whetten, K., Leserman, J., Whetten, R., et al. (2006). Exploring lack of trust in care providers and the government as a barrier to health service use. American Journal of Public Health, 96(4), 716–721.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Adimora, A., Ramirez, C., Schoenbach, V., & Cohen, M. (2014). Policies and politics that promote HIV infection in Southern United States. AIDS (London, England), 28(10), 1393–1397.CrossRefGoogle Scholar
  41. 41.
    Adimora, A., Schoenback, V., & Doherty, I. (2006). HIV and African Americans in the Southern United States: Sexual networks and social context. Sexually Transmitted Diseases, 33(7), 39–45.CrossRefGoogle Scholar
  42. 42.
    Khan, M., Wohl, D., Weir, S., et al. (2008). Incarcertaion and risky sexual partnerships in a southern US city. Journal of Urban Health, 85(1), 100–113.CrossRefPubMedGoogle Scholar
  43. 43.
    Kalichman, S., Eaton, L., Kalichman, M., et al. (2016). Race-based medical mistrust, medication beliefs and HIV treatment adherence: Test of a mediation model in peope living with HIV. Psychology and Health, 39(6), 383–395.CrossRefGoogle Scholar
  44. 44.
    Maulsby, C., Millett, G., Lindsey, K., et al. (2014). HIV among black men who have sex with men in the United States: A review of the literature. AIDS and Behavior, 18(1), 10–25.CrossRefPubMedGoogle Scholar
  45. 45.
    Centers for Disease Control and Prevention. (2016). HIV among African Americans.
  46. 46.
    Kerr, J., Valois, R., DiClemente, R., et al. (2014). HIV-related stigma among African-American youth in the northeast and southeast US. AIDS and Behavior, 18, 1063–1067.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Kaiser Family Foundation. (2011). HIV/AIDS at 30: A public opinion perspective. Accessed March 2016.
  48. 48.
    Reif, S., Sullivan, K., Wilson, E., Berger, M., & McAllaster, C. (2016). HIV/AIDS care and prevention infrastructure in the U.S. Deep South. Southern HIV/AIDS strategy initiative.
  49. 49.
    Health Resources and Services Administration. (2016). African-Americans: A living history, the Ryan White HIV/AIDS Program.
  50. 50.
    Koll, G., & Gutierrez. (2009). Stigma and homophobia: Fueling the fire. The body.
  51. 51.
    Vaughan, A., Rosenberg, E., & Sullivan, P. (2014). Spatial relationships between gay stigma, poverty, and HIV infection among black and white men who have sex with men in Atlanta. AIDS Research and Human Retroviruses, 30(8), 740–751.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    National Alliance of State and Territorial AIDS Directors. (2012). Stigma and the impact on public health. Ryan White HIV/AIDS Program Grantee Meeting. Washington, DC.Google Scholar
  53. 53.
    Reif, S., Safley, D., Wilson, E., & Whetten, K. (2014). HIV/AIDS in the southern US: Trends from 2008 to 2011 show a consistent disproportionate epidemic.Google Scholar
  54. 54.
    Millett, G., Flores, S., Peterson, J., & Bakeman, R. (2007). Explaining disparities in HIV infection among black and white men who have sex with men: A meta-analysis of HIV risk behaviors. AIDS (London, England), 21, 2083–2091.CrossRefGoogle Scholar
  55. 55.
    Elopre, L., Kudroff, K., Westfall, A., Overton, E., & Mugavero, M. (2016). The right people, right places, and right practices: Disparities in PrEP access among African American men, women and MSM in the Deep South. JAIDS.Google Scholar
  56. 56.
    Poteat, T., Scheim, A., Xavier, J. et al. (2016). Global epidemiology of HIV infection and related syndemics affecting transgender people. JAIDS, 72(3), S210–S219.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Herbst, J., Jacobs, E., Finlayson, T., et al. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS and Behavior, 12(1), 1–17.CrossRefPubMedGoogle Scholar
  58. 58.
    Kattari, S., Walls, N., Whitfield, D., & Langenderfer-Magruder, L. (2015). Racial and ethnic differences in expereiences of discrimination in accessing health services among transgender people in the United States. International Journal of Transgenderism, 16, 68–79.CrossRefGoogle Scholar
  59. 59.
    Morales-Aleman, M., & Sutton, M. (2014). Hispanics/Latinos and the HIV continuum of care in the Southern USA: A qualitative review of the literature, 2002–2013. AIDS Care, 26(12), 1592–1604.CrossRefPubMedGoogle Scholar
  60. 60.
  61. 61.
    Kaiser Family Foundation. (2016). Medicaid benefits: Prescription drugs. In: State health facts. 2012.,%22sort%22:%22asc%22%7D.
  62. 62.
    Alsentzer, D., Chang, P., & Kelly, C. (2010). South Carolina state report: An analysis of the successes, challenges, and opportunities for improving healthcare access (state summary). Boston: Health Law and Policy Clinic of Harvard Law School.Google Scholar
  63. 63.
    Gilman, B., Bouchery, E., Hogan, P., et al. (2016). The HIV clinician workforce in the United States. HIV Specialist, 8(3), 2–9.Google Scholar
  64. 64.
    Heumann, C., Cohn, S., Krishnan, S., et al. (2015). Regional variation in HIV clinical trials participation in the United States. Southern Medical Journal, 108(2), 107–116.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Human Rights Watch. (2011). Southern Exposure: Human Rights and HIV in the Southern United States. 2010. Accessed 2016.
  66. 66.
    Katz, I., Ryu, A., Anuegbu, A., et al. (2013) Impact of HIV-related stigma on treatment adherence: systematic review and meta-analysis. Journal of International AIDS Society, 16(3 suppl 2), 18640.Google Scholar
  67. 67.
    Whetten, K., Reif, S., Whetten, R., et al. (2008). Trauma, mental health, distrust, and stigma among HIV-positive persons: Implications for effective care. Psychosomatic Medicine, 70, 531–538.CrossRefPubMedGoogle Scholar
  68. 68.
    Auerbach, J., Kinsky, S., Brown, G., & Charles, V. (2015). Knowledge, attitudes, and likelihood of pre-exposure prophylaxis (PrEP) use among US women at risk of acquiring HIV. AIDS Patient Care and STDs, 29(2), 102–110.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Rueda, S., Mitra, S., Chen, S., et al. (2016). Examining the association between HIV-related stigma and health outcomes inpeople living with HIV/AIDS: a series of meta-analyses. BMJ Open, 6(7), e011453.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Turan, B., Smith, W., Cohen, M., et al. (2016). Mechanisms for the negative effects of internalized HIV-related stigma on antiretroviral therapy adherence in women: The mediating roles of social issolation and depression. JAIDS, 72(2), 198–205.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Lieb, S., Prejean, J., Thompson, D., et al. (2009). HIV prevalence rates among men who have sex with men in the Southern United States: Population-based estimates by race/ethnicity. AIDS and Behavior, 15, 596–606.CrossRefGoogle Scholar
  72. 72.
    Wilson, C. (2004). Religion and the US South. In: Southern spaces.
  73. 73.
    Audet, C., McGowan, C., Wallston, K., & Kipp, A. (2013). Relationship between HIV stigma and self-isolation among people living with HIV in Tennessee. PLoS ONE, 8(8), e69564.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Darlington, C., & Hutson, S. (2016). Understanding HIV-related stigma among women in the Southern United States: A literature review. AIDS and Behavior, 21: 12–26.Google Scholar
  75. 75.
    Phillips, K., Moneyham, L., Thomas, S., Gunther, M., & Vyavaharkar, M. (2011). Social context of rural women with HIV/AIDS. Mental Health Nursing, 32(6), 374–381.CrossRefGoogle Scholar
  76. 76.
    Quinlivan, E., Messer, L., Adimora, A., et al. (2013) Experiences with HIV testing, entry, and engagement in care by HIV-infected women of color and the need for autonomy, competency, and relatedness. AIDS Patent Care and STDs, 27(7), 408–415.CrossRefGoogle Scholar
  77. 77.
    Vyavaharkar, M., Moneyham, L., Corwin, S., et al. (2010). Relationships between stigma, social support and depression in HIV-infected African American women living in the rural Southeastern United States. Journal of Association of Nurses in AIDS Care, 21(2), 144–152.CrossRefGoogle Scholar
  78. 78.
    Heckman, T., Somlai, A., Peters, J., et al. (1998). Barriers to care among persons living with HIV/AIDS in urban and rural areas. AIDS Care, 10, 365–375.CrossRefPubMedGoogle Scholar
  79. 79.
    Costelloe, S., Kemppainen, J., Brion, J., et al. (2015). Impact of anxiety and depressive symptoms on perceptons of stigma in person with HIV disease in rural versus urban North Carolina. AIDS Care, 27(12), 1425–1428.CrossRefPubMedGoogle Scholar
  80. 80.
    Golin, C., Isasi, F., Bontempi, J., & Eng, E. (2002). Secret pills: HIV-positive patients’ experiences taking antiretroviral medications in North Carolina. AIDS Education and Prevention, 14, 318–329.CrossRefPubMedGoogle Scholar
  81. 81.
    Pellowski, J. (2013). Barriers to care for rural people living with HIV: A review of domestic research and health care models. Journal of Association of Nurses in AIDS Care, 24(5), 422–427.CrossRefGoogle Scholar
  82. 82.
    Krawczyk, C., Funkhouser, E., Kilby, M., & Vermund, S. (2006). Delayed access to HIV diagnosis and care: Special concerns for the Southern United States. AIDS Care, 18(supp 1), 35–44.CrossRefGoogle Scholar
  83. 83.
    Reif, S., Pence, B. W., Hall, I., et al. (2015). HIV diagnosis, prevalence and outcomes in nine southern states. Journal of Community Health, 40(4), 642–651.CrossRefPubMedGoogle Scholar
  84. 84.
    Nelson, J., Kinder, A., Johnson, A., et al. (2016). Differences in selected HIV care continuum outcomes among people residing in rural, urban, and metropolitan areas—28 US jurisdictions. Journal of Rural Health. doi: 10.1111/jrh.12208.
  85. 85.
    Centers for Disease Control and Prevention. (2016). CDC issue brief: HIV in the Southern United States.
  86. 86.
    Weissman, S., Duffus, W., Iyer, M., et al. (2015). Rural-urban differences in HIV viral loads and progression to AIDS among new HIV cases. Southern Medical Journal, 108(3), 180–188.CrossRefPubMedGoogle Scholar
  87. 87.
    Underhill, K., Operario, D., Montgomery, P. (2007). Abstinence-only programs for HIV infection prevention in high-income countries. Cochrane Database of Systematic Reviews, 4.Google Scholar
  88. 88.
    Lehman, J., Carr, M., Nichol, A., Ruisanchez, A., Knight, D., Langford, A., et al. (2014). Prevalence and public health implications of state lawsthat criminalize potential HIV exposure in the United States. AIDS and Behavior, 18(6), 997–1006.CrossRefPubMedPubMedCentralGoogle Scholar
  89. 89.
    Center for HIV Law and Policy. (2016). State-by-state chart of HIV-specific statutes and prosecutorial tools, 2014.
  90. 90.
    Price, C., & Eibner, C. (2013). For states that opt out of Medicaid expansion: 3.6 million fewer insured and $8.4 billion less in federal payments. Health Affairs, 32, 1030–1036.CrossRefPubMedGoogle Scholar
  91. 91.
    Rosenberg, E., Grey, J., Sanchez, T., & Sullivan, P. (2016). Rates of prevalent diagnoses, and hew diagnoses among men who have sex with men in US state, metropolitan statistical areas, and counties, 2012–2013. JMIR Public Health and Surveillance, 2(1), e22.CrossRefPubMedPubMedCentralGoogle Scholar
  92. 92.
    Kaiser Family Foundation. (2011). Total HIV/AIDS Federal Grant Funding, FY 2011. Accessed November 2011.
  93. 93.
    Funders Concerned about AIDS. (2016). HIV Philanthropy for the US South. Accessed September 2016.
  94. 94.
    Meditz, A., MaWhinney, S., Allshouse, A., et al. (2011). Sex, race, and geographic region influence clinical outcomes following primary HIV-1 infection. Journal of Infectious Diseases, 203, 442–451.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Susan Reif
    • 1
    • 2
    Email author
  • Donna Safley
    • 1
  • Carolyn McAllaster
    • 3
  • Elena Wilson
    • 1
  • Kathryn Whetten
    • 1
    • 2
  1. 1.Center for Health Policy and Inequalities ResearchDuke UniversityDurhamUSA
  2. 2.Duke Global Health InstituteDurhamUSA
  3. 3.Duke University School of LawDurhamUSA

Personalised recommendations