State of HIV in the US Deep South
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.
KeywordsHIV 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.US Census Bureau. (2016). United States population growth by region. https://www.census.gov/popclock/data_tables.php?component=growth. Accessed September 2016.
- 2.United Health Foundation. (2015). Annual report. In: America’s Health Rankings. http://www.americashealthrankings.org/reports/Annual-stateranking. Accessed September 2016.
- 3.Kaiser Family Foundation. (2016). State health facts: Poverty rate by age. http://kff.org/other/state-indicator/poverty-rate-by-age/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Total%22,%22sort%22:%22desc%22%7D.
- 4.U.S. Census Bureau. Census regions and divisions of the United States. http://www.census.gov/geo/www/us_regdiv.pdf. Accessed November 2011.
- 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.NCHHSTP Atlas. (2014). http://www.cdc.gov/nchhstp/atlas/. Accessed Jul 2016.
- 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.Government Accountability Office. (2005). Ryan White Care Act: Factors that impact HIV and AIDS funding and client coverage. http://www.gao.gov/new.items/d05841t.pdf.
- 10.Office of National AIDS Policy. (2015). National HIV/AIDS Strategy for the United States, Updated to 2020. https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas-update.pdf. Accessed September 2016.
- 11.Office of National AIDS Policy. (2015). National HIV/AIDS strategy for the United States.Google Scholar
- 12.Centers for Disease Control and Prevention. (2016). Underlying cause of death 1999–2014 on CDC Wonder Online Database. 2016. http://wonder.cdc.gov/ucd-icd10.html.
- 13.Kaiser Family Foundation. (2016). State health facts. http://kff.org/state-category/hivaids/. Accessed September 2016.
- 14.Centers for Disease Control and Prevention. (2015). Underlying cause of death 1999–2014 on CDC Wonder Online Database. 2015. http://wonder.cdc.gov/ucd-icd10.html.
- 15.Kaiser Family Foundation. (2015). State Health Facts: Total federal HIV/AIDS grant funding by agency. http://kff.org/hivaids/state-indicator/total-federal-grant-funding. Accessed 2015.
- 16.Kaiser Family Foundation. (2011). Medicaid and HIV: A national analysis. http://www.kff.org/hivaids/upload/8218.pdf. Accessed October 2011.
- 17.Garfield, R., & Damico, A. (2016). The coverage gap: Uninsured poor adults in states that do not expand Medicaid. http://files.kff.org/attachment/Issue-Brief-The-Coverage-Gap-Uninsured-Poor-Adults-in-States-that-Do-Not-Expand-Medicaid.
- 20.Kaiser Family Foundation. (2016). State health facts: Median annual household income. http://kff.org/other/state-indicator/median-annual-income/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
- 25.Kaiser Family Foundation. (2016). State health facts: Percent of adults who have ever been told by a doctor that they have hypertension, 2013. http://kff.org/other/state-indicator/percent-of-adults-who-have-ever-been-told-by-a-doctor-that-they-have-hypertension/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Yes%22,%22sort%22:%22desc%22%7D.
- 26.Kaiser Family Foundation. (2016). State Health Facts: Percent of adults who have ever been told by a doctor that they have diabetes, 2014. http://kff.org/other/state-indicator/adults-with-diabetes/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Yes%22,%22sort%22:%22desc%22%7D.
- 27.Reif, S., Whetten, K., Wilson, L., & Gong, W. (2011). HIV/AIDS epidemic in the South reaches crisis proportions in the last decade. Durham. https://southernaids.files.wordpress.com/2011/10/research-report-final-revised10-26-121.pdf. Accessed July 2012.
- 28.Kaiser Family Foundation. (2016). Unemployment Rate 2015. http://kff.org/other/state-indicator/unemployment-rate/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
- 29.Kaiser Family Foundation. (2016). State Health Facts: Health insurance coverage of the total population. http://kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Uninsured%22,%22sort%22:%22desc%22%7D.
- 30.Heiman, H., & Artiga, S. (2016). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. 2015. http://kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/.
- 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.Centers for Diseases Control and Prevention. (2016). Leading causes of death by age, black females, 2013. https://www.cdc.gov/women/lcod/2013/womenblack_2013.pdf.
- 33.Centers for Diseases Control and Prevention. (2016). Leading causes of death by age, black males, 2013. https://www.cdc.gov/men/lcod/2013/blackmales2013.pdf.
- 34.National Poverty Center Poverty in the United States. (2011). http://www.npc.umich.edu/poverty/. Accessed November 2011.
- 36.CERD Working Group on Health and Environment Health Unequal Health Outcomes in the United States. (2008). http://www.prrac.org/pdf/CERDhealthEnvironmentReport.pdf. Accessed November 2011.
- 38.Fullilove, R. (2006). African Americans, recommendations for confronting the epidemic in Black America health disparities and HIV/AIDS. National Minority Council. http://www.thenightministry.org/070_facts_figures/030_research_links/050_hiv_aids/NMACAdvocacyReport_December2006.pdf. Accessed November 2011.
- 45.Centers for Disease Control and Prevention. (2016). HIV among African Americans. http://www.cdc.gov/hiv/group/racialethnic/africanamericans/.
- 47.Kaiser Family Foundation. (2011). HIV/AIDS at 30: A public opinion perspective. http://kff.org/hivaids/report/hivaids-at-30-a-public-opinion-perspective/. Accessed March 2016.
- 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. https://southernaids.files.wordpress.com/2016/03/hiv-aids-care-and-prevention-infrastructure-in-the-u-s-deep-south1.pdf.
- 49.Health Resources and Services Administration. (2016). African-Americans: A living history, the Ryan White HIV/AIDS Program. http://hab.hrsa.gov/livinghistory/issues/African-Americans.pdf.
- 50.Koll, G., & Gutierrez. (2009). Stigma and homophobia: Fueling the fire. The body. http://www.thebody.com/content/art54913.html.
- 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.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
- 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
- 60.Kaiser Family Foundation. (2016). Medicaid benefits: Physician services. 2012. http://kff.org/medicaid/state-indicator/physician-services/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
- 61.Kaiser Family Foundation. (2016). Medicaid benefits: Prescription drugs. In: State health facts. 2012. http://kff.org/medicaid/state-indicator/prescription-drugs/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
- 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.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
- 65.Human Rights Watch. (2011). Southern Exposure: Human Rights and HIV in the Southern United States. 2010. http://www.hrw.org/sites/default/files/related_material/BPapersouth1122_6.pdf. Accessed 2016.
- 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
- 72.Wilson, C. (2004). Religion and the US South. In: Southern spaces. https://southernspaces.org/2004/overview-religion-and-us-south.
- 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
- 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.Centers for Disease Control and Prevention. (2016). CDC issue brief: HIV in the Southern United States. https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-in-the-south-issue-brief.pdf.
- 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
- 89.Center for HIV Law and Policy. (2016). State-by-state chart of HIV-specific statutes and prosecutorial tools, 2014. http://www.hivlawandpolicy.org/sites/www.hivlawandpolicy.org/files/StateByStateHIVLawsChartupdatedMay2014.pdf.
- 92.Kaiser Family Foundation. (2011). Total HIV/AIDS Federal Grant Funding, FY 2011. http://www.statehealthfacts.org/comparetable.jsp?ind=528&cat=11. Accessed November 2011.
- 93.Funders Concerned about AIDS. (2016). HIV Philanthropy for the US South. http://files.constantcontact.com/3d94026f001/addc858a-3a04-426d-9ca5-ce2b3124e4c0.pdf. Accessed September 2016.