HIV Infection in the South: Need to Take Aim Now

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The CDC has outlined updated plans for “reducing the South’s HIV burden through high-impact prevention.”¹

Why the focus on the South?

According to the CDC, the South (defined by the CDC as Texas, Oklahoma, Arkansas, Louisiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia, West Virginia, Virginia, Maryland, Delaware, Washington DC, North Carolina, South Carolina, and Florida) now experiences the greatest burden of HIV infection, illness, and deaths of any US region, and “lags far behind in providing quality HIV prevention and care to its citizens.”¹ Specifically:

• In 2014 (the last year for which data are available), the South accounted for 44% of all persons living with HIV/AIDS, while accounting for only 37% of the US population.
• Eight of the 10 states with the highest rates of new HIV infections (incidence) are in the South.
• The 10 metropolitan statistical areas with the highest incidence rates are in the South.
• African Americans living in the South accounted for 54% of all new HIV diagnoses in 2014.
• Of all black men who have sex with men diagnosed with HIV in 2014, 60% lived in the south.
• Of all women living in the South diagnosed with HIV in 2014, 69% were black.

There are many factors behind these alarming statistics, and while many have been known for years, some are only recently being appreciated:

• Poverty: In Alabama, for instance, 46 of the state’s 67 counties have poverty rates higher than the national average. Nationally, 44% of HIV-infected persons in care are living at or below the federal poverty level.²
• Stigma: culture, homophobia, racism, religious beliefs, and below-average educational systems all play a role, and seem to be more pronounced in the South. Lack of awareness of risk-- perhaps linked to substandard schools-- likely plays a role.
• Transportation: Once again using Alabama as an example, only 4 or 5 of the state’s 67 counties have any public transportation system.
• The Affordable Care Act expansion of Medicaid: Eleven of the 17 states or jurisdictions in the South are not planning to implement Medicaid expansion. In those 11 states, there is no Medicaid coverage of childless adults-- regardless of income.
• The diagnosis-linkage to care-retention in care continuum. Newer antigen/antibody combination HIV tests that can detect HIV infection in the acute stage have not been widely adopted in the South. In addition, lack of access to care reduces the likelihood of testing with any available HIV test. Lack of timely diagnosis is a “missed opportunity” for linkage to care. As for retention in care, several states in the South have laws that prohibit the reporting of CD4+ cell count and HIV RNA data, making allocation of scarce resources to areas that need them most almost impossible.¹

The reality is that, today, it is the South that is at the epicenter of the ongoing HIV epidemic in the US. In response, the CDC has allocated more prevention resources to the South, totaling $201 million in 2015, an increase of 22% from 2010.¹ I am skeptical that this amount is enough, given the barriers that exist to the access of quality care facilities. It likely will require a major national infrastructure expansion to rectify that situation. In addition, the opposition to expansion of Medicaid is not likely to change any time soon in the region.

And there are many regions throughout the US that suffer from the same barriers to timely diagnosis, lack of access to care, linkage to care, and retention to care. It really is time, in my opinion, for a major increase in funding, on the national level, to make a substantial impact on reducing new HIV infections. Failure to do so now will make it that much harder, and that much more expensive, to do so even 5 years from now.

References:

• HIV in the southern United States. CDC Issue Brief; Updated May 2016. Accessed online at: https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-in-the-south-issue-brief.pdf
• CDC. 2010 HIV Surveillance Special Report 9. Accessed online at: http://www.cdc.gov/hiv/library/reports/surveillance/#special.