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Top 10 Possible Reasons for the High HIV Infection Rate in the Southern U.S.

By Marc Kolman, M.S.P.H.

June 17, 2010


According to the Southern States Manifesto, more than 36,000 people have died of AIDS in the South as estimated by the CDC and in 2005 the South was burdened with half of all deaths from AIDS in the United States. The Southern US is clearly burdened with HIV to a degree unwarranted by its population size. This is a concern expressed by many and, to some degree, remains a mystery.

Recently, I was on a panel discussion as part of the Week of Prayer in Durham, NC. The last questioner of the evening asked, "Why is HIV so prevalent in the South?" We didn't come up with a scientific list of reasons, and I don't know if there really is such a list, but here's what we came up with (in no particular order) ...

  • Stigma. Stigma refers to attitudes about how people are different for something they're not responsible for such as race, gender, class, sexual orientation, or HIV status. Stigma is a leading issue in the struggle against the HIV epidemic in the Southern US and elsewhere and until stigma is addressed effectively, it will continue to affect how people deal with the epidemic. I've written more on this topic before for
  • Conservative religious and moral values. The Southern US is sometimes referred to as the Bible Belt, meaning the vast majority of people are actively religious, primarily Southern Baptist. As a result, to a large degree, churches influence what people think about and talk about. There are a lot of churches that talk openly about HIV, sex, and substance abuse. Unfortunately, however, many keep to the straight and narrow and don't talk about controversial topics, including HIV, substance abuse, or mental health. I'm grateful for churches like First Calvary Baptist Church in Durham that actively deals with HIV by supporting HIV-positive congregants, providing education about HIV, and having an AIDS Care Team. If churches, with their key role in influencing behaviors and moral beliefs, took an active role in addressing HIV, I think it more likely that congregants and parishioners would work towards eliminating HIV as well.
  • Intolerance for others. Intolerance can include people who are perceived as different (see discussion on stigma, above) including anyone from outside of one's immediate social circle. If a community is so insular that other behaviors and people are not tolerated, it will be very difficult to address any behaviors that are considered outside of the realm of 'normal'. The result being that it is once again difficult to address issues that lead to HIV infection such as substance abuse and high-risk sexual activities.
  • Economic and class oppression. Economic issues underlie a host of behaviors that impact risk for HIV infection and the likelihood that those already infected will seek treatment. We often talk about HIV, substance abuse, mental health, and incarceration as co-morbidities, or conditions that are closely connected. Each of these conditions is impacted by economics. There is much to say about this, but perhaps one example will serve to illustrate the point. One in 100, a report from the Pew Charitable Trust, states that 1 of every 100 adults in the US is incarcerated in a jail or prison (1 in 9 for Black men between the ages of 20 and 34). Those who are incarcerated are often from poorer economic backgrounds and their incarceration results in adverse economic impact on their families and communities. Chances are, if someone has substantial financial assets, they're not in prison and, if they are, they're in for a shorter length of time. Incarceration has a detrimental effect on one's ability to seek employment upon release thereby impacting their economic status and therefore impacting their likelihood of having health insurance, access to HIV medications, mental health or substance abuse services, and other health resources.
  • Racism. There is so much to say about racism. Does racism affect the HIV epidemic? As clearly as racism underlies so many oppressions -- I often think of racism as the glue that holds all the other oppressions in place -- it affects our ability to deal effectively with HIV. Is racism different in the Southern US? Racism continues to persist everywhere. As a result of historic issues largely stemming from the Civil War, the South is often blamed for racism. However, as has been clearly dealt with in the work of many, including Howard Zinn's A People's History of the United States, the South has been treated as a colony of the North, exploited for economic gain, and has in effect taken much of the blame for racism although racism, including slavery, has been a part of the economic system in place throughout the United States for years leading up to the Civil War. Regardless of where blame lies, racism plays a significant role in placing people in situations that put them at risk for HIV infection and for challenges related to their ability to effectively seek treatment once infected. It is debatable as to how this plays out differently in the Southern US as compared to anywhere else.
  • Lack of jobs. As discussed above, economic oppression places people at risk for a host of conditions that do not support HIV prevention and treatment efforts, including access to health care, and both substance abuse and mental health services. A recent list using data from the Bureau of Labor Standards shows that 6 of the 15 states with the highest rates of unemployment are in the South. These statistics may be limited in showing the real struggles of unemployment. However, there are real challenges posed by the cycle of no work, no income, and no hope that are likely to lead to behaviors that stifle HIV prevention and treatment efforts.
  • Lack of health care resources, including substance abuse and mental health. As an example, the substance abuse and mental health system in North Carolina was gutted over the past few years in an effort to streamline services and save costs. The resulting lack of public resources clearly stresses the limits of those without the ability to cope with life's challenges. In addition to substance abuse and mental health, many states in the South have fewer health care and medical providers, placing additional stress on health care and social support systems that struggle to support those with limited resources.
  • Rural. Though not as rural as many western states, the Southern US is rural in comparison to much of the country. Rural areas generally have fewer resources, including health care and social service providers. Distances to access existing resources may also pose transportation issues. And finally, isolation from others could pose challenges in getting needed supports -- physical, emotional, and social.
  • Transportation and other services. As said several times, lack of resources such as transportation are often listed as barriers to getting effective care and treatment, and place additional burdens on already challenged and over-taxed health and human service providers. Transportation poses an additional expense in terms of both time and money. In North Carolina, lack of adequate transportation has been continually cited as a problem.
  • Hot weather. Someone thought that long, hot summer days (and nights) would result in greater sexual activity and, we supposed, more unprotected sex, and ultimately, more HIV infections. We didn't agree, but thought it would be an interesting addition to this list. What do you think?

This is, of course, a quick summary of a number of very complex issues, each of which could be dealt with much more extensively. One excellent organization that works to address this issue is the Southern AIDS Coalition, whose mission is to promote accessible and high quality systems of HIV and STD prevention, care, treatment, and housing throughout the South through a unique partnership of government, community, people living with HIV disease, and business entities. The Southern States Manifesto, updated in 2008, discusses HIV in the South and proposes action steps and plans for addressing the situation.

Thanks again for reading.


Send Marc an e-mail.

See Also
HIV/AIDS in the South

Reader Comments:

Comment by: Dave (Durham NC) Fri., Jan. 21, 2011 at 2:00 pm UTC
Interesting blog, more interesting you live in carrborro where I was diagnosed w Aids in 05, since then my life has been a living hell, true the bible belt has no tollerance for HIV or anything which interferes with their do good beliefs...I see it in the stores, a smug attitude while driving off in Suburbans....I have had a nightmarish time living here...the renown Dr Wohl of UNC helped to save my life but I found totally outcast from society after my diagnosis...I ended up broke and disoriented in a state 3000 miles from my has become a daily struggle for my family and I...we lost our house and only recentl;y did Ir realize that there are no jobs here outside of medicine, water management and hospitality.....little did I know I had no chance in hell here...I came here because I was in the marines in the 80s only to see poverty crime hustlers and on the flip side southerners who keep to themselves only to give a passing sneer to someone looking shabby. This place is an armpit....a hole which is hard to get out of.....I only stay because my son goes to a good school.....other than that I see myself being thrown in a waste management truck to further decompose my already beaten down carcass...
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Comment by: Dave (NJ) Fri., Oct. 22, 2010 at 11:29 pm UTC
Interesting blog. I disagree with part of what Dr.Mwanukuzi wrote in her opinion. She wrote that it is not just a matter of dispensing condoms and drugs...disease would be eliminated by now. What?! While I agree that the root cause of behavior needs to be addressed, the drugs won't eliminate this disease and while I am assuming this "Dr." is an MD., it is incorrect for her to advance this arguement. In terms of the hot weather of the south increasing sexual activity=please.
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Comment by: john (texas) Fri., Jul. 2, 2010 at 11:18 am UTC
I think you need to be more forth coming in the large black male population and their lack of precaution in having sex and using proper protection. Like it or not, they are not educating themselves nor taking precautions. Minorities are a principle reason HIV is predominant in the south and probably should be number one on your list. I don't see this as a "racism" issue and resent you playing the "race" card. The issue is lack of education and unwillingness to practice safe sex by many minorities and particularly black males.
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Comment by: Dr Elizabeth Mwanukuzi (Harare Zimbabwe) Fri., Jul. 2, 2010 at 4:26 am UTC
It's interesting to see that almost all the issues presented are what we experience in Africa south of the Sahara and in particular southern Africa. The lesson to learn is that AIDS cannot be eliminated without addressing the problems raised. It is not just a matter of dispensing condoms and drugs, otherwise the disease would have been eliminated by now! Clearly the solution to the disease is very complex and has to involve stake holders who will deal with all the difficulties referred to in the presentation. I have my doubts about hot weather. Other observers have said it is cold weather which is associated with frequent sex and not hot weather!
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Comment by: Joe (liberty, tn) Sat., Jun. 19, 2010 at 5:35 am UTC
You forgot ignorance.

Check gay cruising websites in the South, and you'll find droves of men out there advertising bareback sex with "neg only," as if simply claiming hiv- on a profile makes it true.

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The Ins and Outs of HIV/AIDS Stigma

Marc Kolman, M.S.P.H.

Marc Kolman, M.S.P.H.

Marc Kolman is a long-term public health administrator and advocate. With a passion for social justice, Marc has worked in many settings, including state and local governments and non-profit agencies. Primary interests include HIV and issues affecting the deep south. Marc is currently the executive director of the Piedmont Health Care Consortium which envisions a society in which no one is limited by oppressions, health disparities, or social injustices. Marc lives in Carrboro N.C., is an avid cyclist and is the father of three daughters.

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