HIV in the Southern United States
Strengthening Prevention and Care in the Nation's Most-Affected Region
In the decades since the first AIDS cases ere reported in Los Angeles and New York City in 1981, the epicenter of the nation's HIV epidemic has shifted from urban centers along the coasts to the 16 states and District of Columbia that make up the South.* The South now experiences the greatest burden of HIV infection, illness, and deaths of any U.S. region, and lags far behind in providing quality HIV prevention and care to its citizens. Closing these gaps is essential to the health of people in the region and to our nation's long-term success in ending the epidemic.
State of the HIV Epidemic in the South
Southern states today account for an estimated 44 percent of all people living with an HIV diagnosis in the U.S.,1 despite having only about one-third (37%) of the overall U.S. population.2 Diagnosis rates for people in the South are higher than for Americans overall. Eight of the 10 states with the highest rates of new HIV diagnoses are in the South, as are the 10 metropolitan statistical areas (MSAs) with the highest rates.1
The South faces internal disparities based on geography. Like the rest of the country, the majority of HIV diagnoses occur in urban areas. The region, however, has higher HIV diagnosis rates in suburban and rural areas as compared to other regions nationwide, which poses unique challenges to HIV prevention efforts (see "Addressing HIV in the Rural South" below).3
The impact of HIV in the South also varies by race. African Americans are severely affected by HIV in the South, accounting for 54 percent of new HIV diagnoses in 2014. However, the rate of new HIV diagnoses mirrors that of African Americans in the Northeast. Black gay, bisexual, and other men who have sex with men (MSM) face an especially heavy burden, accounting for 59 percent of all HIV diagnoses among African Americans in the South. In fact, of all black MSM diagnosed with HIV nationally in 2014, more than 60 percent were living in the South. Black women face an equally disproportionate burden of the disease, accounting for 69 percent of all HIV diagnoses among women in the South.1
Fewer people living with HIV in the South are aware of their infection than in any other region. Consequently, fewer people in the South who are living with HIV receive timely medical care or treatment, fewer have their virus suppressed, and a disproportionate number are missing out on the opportunity to preserve their health and avoid transmitting HIV to their partners. Mortality remains alarmingly high as a result -- people living with HIV in some southern states have death rates that are three times higher than people living with HIV in some other states. Although death rates have declined recently, the South still accounted for nearly half (47%) of the 16,281 individuals diagnosed with HIV who died in 2013 nationwide.1,4
Factors Driving the Southern HIV Epidemic
The heavy burden of HIV in the South is driven in part by unique socioeconomic factors. Income inequality, poverty, and poorer health outcomes have long been more widespread in southern states, compared to the rest of the nation. These factors are not unique to HIV -- people in the region have long suffered poorer health outcomes overall. These include disproportionately high rates of obesity, diabetes, cancer, and infant mortality, as well as higher overall mortality rates -- for all causes than in other regions.5
Many people in greatest need are not benefitingfrom access to health care services, and southern states generally continue to have the highest numbers of people without health insurance. The four states with the highest proportions of people without health insurance are in the South: Texas (18.8%), Oklahoma (18.1%), Georgia (17.5%), and Florida (17.2%).6
Cultural factors may also play a key role. Issues such as homophobia and transphobia, racism, and general discomfort with public discussion of sexuality may be more widespread in the South and can lead to higher levels of stigma, which may limit people's willingness to seek HIV testing, care, or prevention services.7 These challenges can also limit access to accurate sexual health information, which people need to protect themselves from infection.
Another challenge is that southern states have not yet widely adopted new HIV prevention advances, such as antigen/antibody combination HIV tests that can detect infection in its early, or acute, stages when it is most easily transmitted.8 Being able to diagnose acute infection is critical to ensure people living with HIV get treatment to protect their health and to protect their partners from infection. In addition, due in part to local policies and laws, several southern states do not report complete laboratory data (all levels of CD4 cell counts and viral load) that are needed to track progress, and to ensure that prevention and care resources are directed where they are most needed.9
Reducing the South's HIV Burden Through High-Impact Prevention
Since 2010, CDC has pursued a high-impact prevention (HIP) approach. Through HIP, CDC supports combinations of scientificall proven, cost-effective, and scalable HIV prevention interventions, targeted to the most heavily affected populations and geographic areas. By definition, the outh's disproportionate burden of HIV and disparities makes the region a core focus of prevention efforts. In addition, reducing the impact of HIV in the South is a core focus of the National HIV/AIDS Strategy: Updated to 2020.
CDC has realigned prevention resources to more accurately reflet the disproportionate impact of HIV in the South. Funding to the region, which is primarily directed to state and local health departments, has increased in recent years and is now roughly proportional to the region's burden of the epidemic. In 2015, HIV prevention funding to southern health departments and community-based organizations totaled $201 million, a 22 percent increase compared to 2010.
CDC-funded programs focus on multiple high-impact prevention strategies:
- Increasing diagnosis of HIV infection by making HIV testing simple, accessible, and routine.
- Ensuring that people with HIV are linked to early, ongoing care and treatment, which not only sustains their health but can reduce HIV transmission by 96 percent.
- Making condoms readily available to anyone at risk for or living with HIV.
- Increasing awareness and uptake of pre-exposure prophylaxis, or PrEP, the use of a daily HIV prevention pill by people at high risk for infection; studies have shown that PrEP, when used as prescribed, can reduce the risk of sexual transmission by more than 90 percent.
- Supporting behavior change education and support, with a focus on select interventions and strategies shown to have the greatest impact.
CDC's funding for health departments supports HIV prevention and surveillance activities, and indirectly supports the efforts of many local community-based organizations (CBOs) and health institutions. To intensify prevention in key urban areas, where the epidemic is concentrated, CDC also directly funds select CBOs with the capacity to reach people most at risk in their communities. While this funding is important, it is relatively small in comparison to CDC's health department commitments or to funding provided to CBOs directly by health departments.
Critical for States to Improve Performance
While CDC has expanded and strengthened its support for HIV prevention in the South, success ultimately depends on a variety of prevention partners, including policymakers, at the state, county, and municipal levels. States should consider taking aggressive steps to improve prevention and care outcomes and make more rapid progress toward goals established by the National HIV/AIDS Strategy.
In particular, areas for southern states to consider focusing on include:
- Achieving viral suppression for all residents diagnosed with HIV, which is critical to improving health outcomes and slowing transmission. For example:
- Immediately linking people newly diagnosed with HIV to care and providing them with HIV treatment -- ideally with a starter pack of medication on the same day they receive their diagnosis.
- Pursuing innovative strategies for residents who were previously diagnosed but are not in care. States could pursue innovative strategies to identify and re-engage these individuals and help them obtain effective treatment. CDC's Data to Care strategy, which has been pursued in Louisiana under the LaPHIE program, and in a number of other states, provides a proven model that states could follow.
- Continuing to forge close partnerships with health care providers in their communities. Health departments and CBOs could pursue this strategy for all people living with HIV.
- Improving early diagnosis of acute HIV infection, in part through adoption of antigen/antibody combination HIV tests in all settings. Given that late diagnosis is associated with higher mortality, strengthening HIV testing efforts could help significatly reduce the South's disproportionate death rates among people living with HIV.
- Promoting PrEP as an option for people at highest risk of HIV infection. CDC estimates that many Americans -- including 25 percent of sexually active adult gay and bisexual men, nearly 20 percent of adults who inject drugs, and less than 1 percent of heterosexually active adults -- could benefit fom PrEP.10
- Providing complete reporting of lab data, including viral load and CD4 cell counts, which are critical to monitoring progress and directing resources to meet the greatest needs.
- Strengthening HIV education and awareness, particularly among young people and in communities most affected by HIV. In addition to accurate school-based HIV education, communities can implement HIV awareness campaigns, including elements of CDC's various Act Against AIDS campaigns.
More broadly, to address disparities in the southern states it will be important to work toward unfettered access to quality health care, particularly among people of color, gay and bisexual men, and transgender people. This could be accomplished through a variety of methods, including addressing issues related to insurance coverage, co-pays, and deductibles.
While the challenges to effective HIV prevention in the South remain significant, they are surmountable with the HIV prevention tools available today. By fully embracing the latest advances and committing to the highest standards of prevention and care, southern states can ensure a healthier future for millions of people living with or at risk for HIV.
* As defined by the U.S. Census Bureau, the South region includes: Alabama, Arkansas, Delaware, the District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.
- Centers for Disease Control and Prevention (CDC). HIV Surveillance Report, 2014; vol. 26. Published December 2015.
- U.S. Census Bureau. Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2014. Accessed November 13, 2015.
- Reif S, Pence BW, Hall I. HIV Diagnoses, Prevalence and Outcomes in Nine Southern States. J Community Health. 2015;40(4):642-51.
- CDC. State HIV Prevention Progress Report, 2010-2013. Published December 2015.
- Department of Health & Human Services, Office on Women's Health. Health Disparities Profiles, 2014.
- Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Key Facts about the Uninsured Population. Accessed November 25, 2015.
- Valdiserri RO. HIV/AIDS Stigma: An Impediment to Public Health. Am J Public Health. 2002;92(3):341-34.
- CDC and Association of Public Health Laboratories (APHL). Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations. Published June 27, 2014.
- CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data -- United States and 6 dependent areas -- 2013. HIV Surveillance Supplemental Report 2015;20(No. 2). Published July 2015. Accessed November 20, 2015.
- CDC. Vital Signs: Estimated Percentages and Number of Adults with Indications for Preexposure Prophylaxis to Prevent HIV Acquisition -- United States, 2015. MMWR 2015;64(Early Release);1-6.