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HIV in the Southern United States

May 2016

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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

New HIV Diagnoses, Southern United States, 2014

New HIV Diagnoses, Southern United States, 2014

Source: CDC. HIV Surveillance Report, 2014.

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

Percentage of People Living With HIV Who Are Aware of Their Status, by State, 2012

Percentage of People Living With HIV Who Are Aware of Their Status, by State, 2012

Source: CDC. State HIV Prevention Progress Report, 2010-2013.

Death Rate Among People With Diagnosed HIV, Aged ≥ 13 Years, by State, 2012

Death Rate Among People With Diagnosed HIV, Aged ≥ 13 Years, by State, 2012

Source: CDC. State HIV Prevention Progress Report, 2010-2013.

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.

Addressing HIV in the Rural South

While the Southern epidemic is primarily urban, the region does have a greater number of new diagnoses in rural or suburban areas than anywhere else in the country. This poses unique challenges:

  • Rural communities may have especially limited access to health care services.
  • Health care providers may have limited experience with HIV and be less likely to provide testing or PrEP.
  • Providers may also be less equipped to provide quality HIV care.
  • Public health infrastructure may be limited.
  • Rural communities may have higher levels of poverty and HIV-related stigma.

CDC's primary means of addressing these challenges is through funding to state health departments. States have the flxibility to allocate resources according to the distribution of their epidemic, and are encouraged to do so.

As in all communities, local expertise is critical to the success of prevention in rural and suburban areas. CDC-funded health departments are encouraged to partner with rural CBOs and health care providers to close gaps in HIV prevention and care.

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This article was provided by U.S. Centers for Disease Control and Prevention. Visit the CDC's website to find out more about their activities, publications and services.

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