When the AIDS epidemic first surfaced in the U.S. 30 years ago, the illness was primarily an urban problem, centered in cities such as New York, San Francisco and Los Angeles. Today New York State and California still rank among the highest in the number of cases, according to the Centers for Disease Control and Prevention, with more than 150,000 people living with AIDS (the later stages of HIV infection) between them. But in recent years HIV has begun to take a disproportionate toll on the southern U.S., including in rural areas. Despite making up 37 percent of the population, the 16 states plus the District of Columbia that constitute the American South accounted for half of the 45,000 new cases of HIV infection in the U.S. in 2009. Moreover, the South has the highest rate of newly reported infections and the highest number of deaths caused by AIDS.
This regional anomaly has set off alarm bells at state and federal health departments alike, because it shows that current efforts are failing to contain the infection. Considering all that is now known about how HIV is transmitted and how it can be prevented, the rate of new infections should be falling rapidly. Furthermore, deaths should be declining as well because combination therapy that inhibits the progress of the disease has been available since 1996 and the states’ AIDS Drug Assistance Programs have been covering the cost of care for many people who can least afford it since 1987. Nor is there anything unusual about the way HIV spreads in the South. Unprotected sex between men remains the most common method of transmission, followed by sharing contaminated needles or having sex with people who fall into either of those categories.
What explains the disturbing numbers, and what can be done about them? Research has identified several interrelated causes—among them poverty, culture and prejudice. Now a few states in the area are attempting to turn the findings into helpful programs. Surprisingly, Mississippi, a state whose many failings in the struggle against AIDS were well documented in a recent 59-page report by Human Rights Watch, could help show the way—although plenty of pitfalls remain.
Facing a Stacked Deck
HIV is, of course, not the only health problem that looms large in the South. The region has long suffered more than its fair share of diabetes, heart disease, certain types of cancer and obesity compared with the Northeast, Midwest and West. As with all these other health problems, however, addressing the HIV epidemic in the southern U.S. requires much more than just having effective and affordable medicine. It demands an understanding of why individuals in the South turn out to be particularly likely both to delay testing and to seek medical attention only in the later stages of HIV infection, when it is most difficult to treat.
One reason seems to be the strong stigma in the South attached to HIV infection and AIDS, an attitude that is reinforced by many cultural and religious attitudes against homosexuality. Indeed, some young HIV-positive men say they would rather pretend to have a heroin habit than let anyone think they had slept with another man. In response, those at risk often shun testing, and people who do test positive for HIV tend to hide their status until their health deteriorates beyond denial. Meanwhile the virus continues to spread.
Poverty, says Kevin Fenton, director of the cdc’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, is another major cause for delay in testing and treatment. (Mississippi is the poorest state in the Union, according to the U.S. Census Bureau, followed by West Virginia, Arkansas and South Carolina). For people who have little money, HIV may seem like the least of their worries as they struggle to find food, buy clothes and keep a roof over their heads. Many cannot afford health insurance but still make too much money at their low-paying jobs to qualify for Medicaid and other free or low-cost health care benefits. These hassles of everyday living lead large numbers of infected individuals to put off medical care until they are seriously ill.