The varied nature of the US HIV/AIDS epidemic: what makes the South so different?

As of 2011, 38% of all US citizens diagnosed with HIV were from a block of nine states in the south-east, sometimes referred to as “the South”: Louisiana, Alabama, Florida, N. and S. Carolina, Georgia, Texas, Mississippi and Tennessee. Death rates among those living with HIV in this region were, by far, the highest of any US region.  A recent study (Reif & Wilson) uses CDC HIV surveillance data to seek to assign characteristics to the large number of persons in that region diagnosed with, and frequently failing to survive, HIV/AIDS, in order to determine what it is about this region of the US that makes it peculiarly vulnerable to the epidemic.

A number of these characteristics were not specific to the South, but shared by all the southern states: the high proportion of those diagnosed who are female (27%: US average 20.9%), who have contracted HIV through hetero-sexual relations (14.5%: US average 11.7%) and who fall in the 13-24 yr age group. What differentiates the South more particularly, is the considerably higher percentages of diagnoses among those living in rural (11%) and suburban (17%) areas, though even urban rates (29.6 per 100,000) are higher in the South than in other regions.  Five-year survival following AIDS diagnosis, at 73%, is considerably lower than the US average (77%), and lower than for any other region. Survival rates following HIV diagnosis were considerably lower for rural (82%) than for urban (86%) areas.  Above all, the death, rate at 27.3 per 1000, was considerably higher than in any other region of the US. (HIV mortality in the UK fell from 21.8 to 8.2 per 1000 over the years 1997-2008 (Smith & Delpech (STI))).

The high death rates for the South suggest, the authors claim, a fundamental “disconnect” between diagnosis and maintenance of care in the region. Moreover, when the figures are adjusted to take account of characteristics of individuals living with HIV, including sex, race, mode of transmission etc., the disparity remains substantively unchanged or accentuated. This likely indicates underlying structural factors affecting the states of the South.  Obvious candidates would be lower insurance coverage, lower levels of income and education. On the basis of the convergence of high death rates and the high proportion of rural and suburban HIV cases in the region, the authors also evoke, more speculatively, the “class system unique to the US South” which has traditionally allowed little social mobility.  They argue this may have contributed towards a social environment among lower strata characterized by a combination of stigmatization and distrust of medical services, which is very unconducive to retention in care.

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