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.

Even when HIV-positive Southerners do attempt to find care, they often have difficulty getting the treatment they need. Federal government surveys have found that more than half of all people living with HIV in many southern states do not get adequate treatment—compared with a third in other regions. For one thing, states sometimes impose payment rules that tie doctors’ hands. Mississippi’s Medicaid program, for example, limits beneficiaries (including those with HIV) to just five prescription drugs per month, despite the fact that it often takes many more medications to keep viral levels in check. A sheer lack of doctors plays a part as well. Mississippi has one of the lowest ratios of primary care physicians to resident population in the country. (Primary care clinicians handle the health problems that most people have most of the time.) And practitioners may not be eager to see infected individuals. The Human Rights Watch report included anonymous testimony from clinical workers that many health care practitioners in Mississippi refuse to treat HIV-positive individuals, resulting in long waiting lists for those willing to see such patients. Yet research shows that early treatment improves outcomes, lowers the cost of care and diminishes risky behavior. “People who are in care tend to know more and tend to have less unprotected sex,” says Deborah J. Konkle-Parker, associate professor in the department of medicine and infectious diseases at the University of Mississippi Medical Center.

One group that has been especially hard-hit by HIV’s ties to poverty and prejudice in recent years is African-Americans. More than half of all households that are poor and black are in the South. Public health experts report that black men who have sex with other men are particularly unlikely to think of themselves as homosexual or at risk for HIV and therefore deny the need for condoms, which reduce the transmission of the virus. Among black men who have sex with men, more new cases of AIDS were diagnosed in the South in 2006 than in all other regions of the country combined. In Mississippi, state health officials report that the number of new cases of HIV among black men aged 13 to 31 years who had sex with other men rose by 48 percent from 2005 to 2007.

Moving Forward
Money cannot cure all the obstacles to improving the HIV picture in the South, but it could certainly help. In July 2010 the Obama administration issued a national strategic plan to tackle HIV in the country’s hardest-hit regions, including the South. Increases in funding were announced in February 2011. But with cuts looming in spending on Medicaid, which is paid for by state and federal governments, the people who most need help may end up not getting much more assistance after all.

In the meantime, some states are trying to innovate on their own. South Carolina has an HIV education program that aims to reduce stigma by reaching out to churches and ministers. Arkansas, for the first time, has allotted funds to test the feasibility of offering routine HIV screening to the general population. And Mississippi has zeroed in on what might seem like a surprising solution for a state in the Bible Belt: in March the state passed a law requiring school districts to offer sex education. Nick Mosca, who was appointed director of Mississippi’s program for addressing sexually transmitted diseases and HIV a few months earlier, and Mary Currier, the state’s health officer, argue that sex education is a top priority—and with good reason. Seventy-five percent of the state’s high school seniors report being sexually active, and one in four new HIV cases occurred in young people between the ages of 13 and 24 years.

Mosca also hopes to work with Mississippi’s Department of Education to begin testing all students in selected high schools for HIV, whether or not they appear to fall into a high-risk group. The move would help anyone who is HIV-positive and does not know it to get treatment. But testing everyone also acts to diffuse any stigma that might be attached to HIV screening because no one is singled out.

Improving access to health care will probably take longer. The Prevention and Public Health Fund, a component of the Affordable Care Act, has allotted $198 million toward training 500 new primary care physicians and 600 new primary care nurse practitioners across the country by 2015. But Governor Haley Barbour of Mississippi has argued that the state does not need the kind of assistance that the law provides. For now the state’s health experts hope that their education and testing initiatives can help lessen the alarmingly high rates of HIV infection and death in the U.S.’s poorest state. They have their work cut out for them.