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.