Miami. Baton Rouge. Jacksonville. Columbia, South Carolina: these are not the places that immediately come to mind when considering America’s HIV epidemic. But in the ranking of US cities with the highest HIV rates, they are numbers one, two, three and six, respectively.

On Thursday The New York Times ran an important story by Donald McNeil Jr. about the “new face” of HIV— young, poor black and Hispanic men who have sex with men. One thing not mentioned in the article—which focuses on New York City—is the geography of the epidemic, which is now concentrated and most deadly in the Southern states. While only 37 percent of Americans live in the South, half of new HIV infections originate there. Eight of the ten states with the highest rate of infection are in the South, as are nine of the ten states with the highest AIDS fatalities rates.

McNeil focuses mostly on the scarcity of resources available to fund targeted messaging in black and Hispanic communities, and that’s certainly a problem. But the regional dynamics of HIV, and the fact that young men of color who have sex with men actually engage in less high-risk behavior than their white cohorts suggest that messaging isn’t the only thing needed. McNeil’s conclusion is that when it comes the spread of HIV among young men of color, “the prospects for change look grim” because “the national response is fragmented and hesitant.”

There are two policies on the table that could have a profound effect on the rate of new infections in the United States, which has hovered near 50,000 new cases a year for a decade: the expansion of Medicaid, and comprehensive immigration reform. The implications of these policies for HIV are magnified by the fact that their impact would be particularly strong in the South.

Medicaid and immigration reform won’t change the social conservatism of the Bible Belt, which expresses itself in a lack of comprehensive sex education, stigma, absence of needle exchange programs and a general “sweeping under the rug” of conversations about sexual health and risk reduction, explained Susan Reif, a researcher at Duke University’s Center for Health Policy and Inequalities Research. But those policies can change some of the material circumstances that have made the Deep South the locus of the HIV epidemic, namely the higher rates of poverty, higher proportions of uninsured people and more limited access to care.

“Right now, Medicaid expansion is really one of the most important things that we need,” said Rainey Copps, executive director of the Southern Aids Coalition. Eligibility criteria are more stringent in Southern states than in other regions, leaving many of the people who are at highest risk for HIV uninsured, limiting their access to preventive care, testing and treatment. The Affordable Care Act was designed to close this coverage gap by expanding eligibility to all adults with incomes below 133 percent of the federal poverty level. Every state in the Deep South except Arkansas has opted out of the expansion.

Because of the South’s stringent eligibility requirements, Medicaid programs in those states cover far fewer HIV-positive individuals than others do. Nationally, Medicaid is the primary form of insurance coverage for people with HIV/AIDs, and still a quarter of HIV-positive Americans are uninsured. In the Deep South, HIV-positive patients below the poverty line have to be so sick with AIDS that they reach disability status before they qualify for coverage.

“With the Medicaid expansion we could have included a lot more people who are HIV-positive in Medicaid, and therefore they would more readily be able to access medication and medical care. It’s very disappointing that that’s not going to happen,” said Reif. She noted that increasing access to treatment isn’t important only for people who are already sick. It also helps to slow transmission of the virus.

Because of the significant economic benefits that the expansion offers states, it’s likely that Southern lawmakers will eventually come around on Medicaid. But that will still leave out one group at high risk for HIV: undocumented immigrants, who don’t qualify for any coverage under the Affordable Care Act. Without legal protections, undocumented immigrants are less likely to seek out testing and treatment, and they’re harder to reach with public health campaigns. Accordingly, immigration reform that offers a path to citizenship, as well as access to care for people in the process of legalization, should be a priority.

“The nationwide, government-led effort to increase HIV testing and awareness and to incorporate HIV-positive individuals into the care system as quickly as possible will flounder [sic] if any sectors of the population are excluded due to a short-sighted reluctance to extend benefits based on immigration status,” warns the Deep South Project and the Latino Commission on AIDS.

It may not be a coincidence that the region with the worst HIV rates also has the fastest-growing Hispanic population, one increasingly subject to discrimination. “We have an area where the epidemic is high, an area where we know that there is a community that has lived in the shadows for years, and where access to information, care, prevention, testing and treatment is limited,” said Robin Lewy, director of education at the Florida-based Rural Women’s Health Center. She doesn’t believe that lack of awareness or stigma within Hispanic communities necessarily accounts for their vulnerability to HIV. The problem, Lewy said, is that “immigrants in general cannot prioritize HIV. Their priorities are survival, economic realties, problems of acculturation and xenophobia.”

Of course, not all Hispanics are immigrants, and Lewy believes that demographic research that goes beyond race is needed in order to understand how HIV really plays out between groups. “You have to distinguish a Mexican-American third generation man from a Guatemalan man who crossed the border three months ago,” she said. “We have to respond to great inequalities within the epidemic, and one of the ways to do that is to recognize and celebrate the uniqueness of our different communities.”

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