I am impressed by the recent proposal to end the AIDS epidemic in New York State. Moreover, I am inspired by the thought of ending AIDS in the South. But pondering whether we could accomplish this daunting task here in the South brings up a number of concerns.
When it comes to health disparities, we have much ground to cover in the South. I have called Memphis, Tennessee, home for almost 40 years. I've been a part of the fight against HIV for the last 15 years, and have served with some great leaders. Will I live to see a time when Memphis is free of HIV?
A Picture of HIV in Memphis
To even entertain the thought of ending AIDS in Memphis, we need to revisit the disease's history here. From 1982 to 2009 there were 21,500 HIV cases in Tennessee. Blacks make up 16% of the population of Tennessee, but 54% of people with HIV. For the last five years, Memphis has had the highest number of HIV cases in the state. So we first have to understand the makeup of the city to begin strategizing how to attack HIV.
The City of Memphis, the urban hub of the region, sits on the Mississippi River in Shelby County, which has a population of over 935,000. Memphis has a poverty rate of 34%, mainly in the African American community, which is linked to poor education, underemployment, and low-wage service jobs. The low level of education directly affects people's ability to process health information and act on it. In addition, the conservative views about HIV of many faith-based organizations are common in Southern Black communities like Memphis.
Blacks make up 63% of Memphis, and the number of new HIV infections among Blacks in Shelby County has been steadily increasing. In 2008, 85% of all men with HIV in Memphis were Black, as were 92% of positive women. As of December 2010, a total of 7,563 people were living with HIV in the Memphis area. Unfortunately, only 59% of people with HIV in Tennessee are in regular medical care. And that doesn't include people who are aware of their status but have never accessed medical care in the first place.
Examining the data by Shelby County zip codes and listening to community voices, we see that specific issues are linked to HIV risk in heterosexual women and MSM (men who have sex with men) of color: poverty, unemployment, gender roles, dependence on partners, trading sex (for drugs, food, shelter, and protection), limited partner pools, untreated mental health problems, domestic violence, and using sex as self-medication to cope with stigma, racism, and discrimination.
In considering whether Memphis could implement a plan to end AIDS, I believe it is best to hear the voices of the community. When advocates and stakeholders were asked if they believed that we could end AIDS in Memphis with a plan similar to the one being proposed in New York State, each responded affirmatively, but expressed a number of challenges that would have to be addressed for that goal to be accomplished here.
Marvell Terry, Executive Director of The Red Door Foundation, said:
I believe targeted testing has increased since the implementation of the National HIV/AID Strategy, but we must not let up. Testing should not just be limited to banking hours. How can we offer testing or PEP (see "A Magic Pill to End AIDS?" in this issue) when [someone says] I have just done something that put me at risk for HIV? I may want to get tested Saturday morning before I go to the car wash because I work during the week when most testing services are offered. Where do I go? What do I do? We have to begin to think outside of the box. But with expanded and increased testing we also need more resources and funding to care for more people who know their HIV status.
Similarly, Dr. Martha Ballard, a physician at Complete Healthcare Center, emphasized:
Rather than focusing testing in the areas which have a high incidence of HIV, agencies should focus on making testing available in places where there are large numbers of people. HIV testing should be a part of standard protocol in doctors' offices, and we need increased funding to make testing available at more providers.
To date there are only a handful of agencies funded in Memphis to provide testing in certain zip codes. This creates a skewed view of who is at risk for HIV. Programs should be targeting persons who are sexually active, rather than certain racial demographics. We must also ensure that when epidemiological data are published, they are accurately reported. The public should not be given information that misinterprets the facts or misrepresents the issues.
PrEP in the South
A 2013 survey by Gilead, the maker of Truvada, found that half of all PrEP prescriptions (drugs to prevent HIV -- see article on page 14) were for women, and a third were given in the South. But when I asked service providers to name doctors in Memphis who were willing to write PrEP prescriptions, they could only name three. They also had some major concerns about PrEP and PEP and how to integrate their use in the South.
HIV Outreach Specialist Henry Johnson said, "We first need to be able to have a mature conversation about sex in this community. If we can't do that, it'll be very difficult to integrate and promote PrEP. We also need to address substance abuse and mental health in a comprehensive fashion. Last but certainly not least we need to continue to push comprehensive sex education and condoms, and to find resources to address the high cost of PrEP."
Laronia Hurd-Sawyer, Executive Director of PEAS (Partnership to End AIDS Status) says:
Providers must consider an age-appropriate, continual, and flexible approach to PrEP and PEP. There are major barriers to accessing programs that target youth in Memphis. Most of the rules that govern these programs prohibit working effectively with this population across the board. Currently, there are rules that do not allow youth to access housing, food pantries, and other services, even when they are emancipated. So they end up in relationships with older adults, selling sex for housing or tolerating domestic violence in exchange for housing. We have to develop programs that help them change their behavior instead of focusing on stopping behaviors. We must partner with youth -- rather than shoving condoms in their hands, we have to get to the root causes of why they are using sex to handle situations.
According to Marvell Terry:
First, we must educate providers and community-based organizations on what PrEP and PEP are. I hope to accomplish that by being a part of AVAC's PxROAR Program, a program that trains advocates in HIV prevention, research, and advocacy. Secondly, we must get the conversation on the ground and empower high-risk populations to build relationships with their doctors, so they can have an honest conversation about their sexual history. Finally, we must advocate for the expansion of Medicaid in Southern states so that these medicines are affordable.