Disproportionate Impact of HIV in the South has been Consistent from 2008 – 2011

3/11/14:  New SASI ReportHIV/AIDS in the Southern US: Trends from 2008-2011 Show a Consistent Dispropotionate Epidemic.  The SASI research team analysis of CDC HIV surveillance data over a four year period (2008-2011) shows that the deep south region (AL, FL, GA, LA, MS, NC, SC, TN, TX) has had the highest HIV and AIDS diagnosis rates as well as the highest HIV and AIDS case fatality rates for each year during this time period. These states also had the highest number of people living with HIV of any region in 2011. In 2011, 40% of new HIV diagnoses were in the targeted deep south states, a region that contains only 28% of the US population.

Figure 1: Regional HIV Diagnosis Rates 2008-2011

Figure 4- Regional AIDS Diagnosis Rates 2008-2011

Figure 1A-Number of HIV Diagnoses by Region and Year

Figure 2A-Number of AIDS Diagnoses by Region and Year

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SASI Article published in the Journal, AIDS Care, highlights continued disproportionate epidemic in the US South

January 17, 2014:  SASI publishes article in AIDS Care: HIV/AIDS in the Southern United States: A Disproportionate Epidemic. Abstract available here.

Using 2011 CDC data, SASI researchers have documented the continuing disproportionate epidemic in the Southern United States and particularly in 9 targeted deep south states, Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and East Texas.

New HIV Diagnosis Rate Map

2011 data re: HIV/AIDS in the Southern Region

  • 49% of new HIV diagnoses and 49% of new AIDS diagnoses in 2011 were located in the South, a region that accounts for only 37% of the US population.
  • The South had the highest HIV diagnosis rate in the US.
  • The South had the highest HIV diagnosis rate and the highest AIDS diagnosis rate in the US in 2011.
  • All 10 metropolitan areas with the highest AIDS diagnosis rates in 2011 were in the South.

2011 data re: HIV/AIDS in the targeted Deep South

 (AL, FL, GA, LA, MS, NC, SC, TN and East Texas)

  • 32% of new HIV diagnoses in 2011 were located in 9 targeted deep south states that account for 22% of the US population.
  • The targeted deep south states, when considered as a geographic region, had the highest HIV diagnosis rate and the highest AIDS diagnosis rate in the US in 2011.
  • Nine of the 10 metropolitan areas with the highest AIDS diagnosis rates in 2011 were in the targeted deep south states. 

Southern States had some of the worst HIV Death rates 

  • The Southern US had significantly lower 3-year HIV survival rates than the US average.*
  • Nine of the 10 states with the highest HIV case fatality rates were in the South; 8 were in targeted deep south states.**

The article highlights social determinants of health that may contribute to the Southern HIV epidemic, including high rates of sexually transmitted diseases, high poverty rates, stigma, the disproportionate impact of HIV on racial minorities in the South, state geography and culture, and the lack of adequate health care financing.

* Hanna, D., Selik, R., Tang, T., & Gange, S. (2011). Disparities among states in hiv-related mortality in persons with hiv infection, 37 U.S. STATES, 2001-2007. AIDS, Early Release.

** Prejean, J., Tang, T., & Hall, I. (2012). HIV diagnoses and prevalence in the southern region of the United States, 2007-2010. Journal of Community Health, Epub.

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South Carolina ends Segregation of HIV+ Inmates

July 10, 2013:  The ACLU announced today that South Carolina, the last state to segregate HIV+ inmates, has agreed to end that practice.

“Ending a long out-dated policy that stigmatized human beings and ignored modern medical information is a tremendous victory for human rights,” said Susan K. Dunn, legal director of the ACLU of South Carolina and SASI Steering Committee member.  “While the segregation of HIV-positive prisoners has long been an unnecessary and ineffective tool for preventing the transmission of HIV, it has had the profound effect of humiliating and isolating prisoners living with the disease.”

Alabama ended a similar segregation policy last year after the policy was held to violate the Americans with Disabilities Act by a United States District Judge in response to ACLU litigation.

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April 24, 2013: Mississippi Bureau Director for HIV/AIDS Care promises that its suspended HOPWA program will be up and running soon

The U.S. Department of Housing & Urban Development (HUD), which grants funds to cities and states for Housing Opportunities for Persons with AIDS (HOPWA),  suspended Mississippi’s program in August 2012 for noncompliance with federal regulations. The suspension abruptly cut off all HOPWA funding for persons living with HIV/AIDS (PLWHA), except in limited amounts for emergency situations, and left pending applications in limbo.  Initially, the Mississippi Department of Health (MSDH) said the suspension would only last until November 2012.  But as of this month, HOPWA applications are still pending and PLWHA are still not receiving the housing aid they need.

In February 2013, the MSDH sent a memo to State HIV Case Managers, AIDS Service Organizations, and Ryan White Grantee Programs explaining that HUD suspended the program for noncompliance with the Short-term Rent, Mortgage, and Utility (STRMU) federal requirements for documenting client eligibility based on housing need and planning for permanent housing.  In addition to giving these reasons, the memo said that the STRMU program was “operating as a continuous rental assistance solution” whereas the HUD regulations intended for STRMU to provide only “short-term interventions.”

Last week, SASI convened a call and invited Dr. James Stewart, interim director of the Mississippi HIV/STD Office, to discuss the status of the HOPWA program with representatives from the community, academia, and non-profit and community-based organizations.  Dr. Stewart stated that MSDH is working with consultants from HUD to reinstate the HOPWA program as soon as practicable.  He  assured the group that his office would release the new HOPWA policies and program details within a few weeks.

The anticipated changes include:

  • Increased communication between MSDH and PLWHA about the HOPWA program;
  • Increased eligibility for STRMU Assistance to 80% of the federal poverty level;
  • Reinstated STRMU program and expanded Tenant-based Rental Assistance (TBRA) program to  address a wider array of housing needs; and
  • Increased collaboration with community partners.

Although the Mississippi HOPWA program clearly needed fixing, many PLWHAs and their advocates felt that the way the program suspension was handled was a disservice to PLWHA.  The program was abruptly suspended with little explanation and without putting a temporary program in place, leaving HOPWA applicants without the resources to meet their housing needs.  Eight months after the initial suspension, applications are still pending and PLWHA are not receiving the aid they need.  However, it is encouraging that Dr. Stewart has now pledged to work with Mississippi housing advocates to find resources for PLWHA whose HOPWA applications are still pending.

If other states are at risk for similar suspensions, the state and HUD must work together to prioritize communication with PLWHA and to create temporary programs so that PLWHA do not needlessly suffer from bureaucratic red tape.

Find out more about STRMU eligibility.

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SASI at AIDS Watch

February 25, 2013: 

SASI (Southern HIV/AIDS Strategy Initiative) was well-represented at AIDS Watch 2013!  We had delegates from all of the Deep South states except Mississippi.  Our advocacy is important in light of the fact that the South has 46% of new HIV diagnosis while representing only 37% of the US population. We held a SASI meeting to talk about how the AIDS Watch policy agenda affects our regions—the refusal of some Southern states to expand Medicaid, the continuing need for Ryan White funding and for all the funding streams identified by AIDS United.  And we added to our legislative agenda the need to change the HOPWA funding formula so that cumulative AIDS cases are no longer in the mix.

SASI delegation meets with White House Director of the Office of National HIV/AIDS Policy, Dr. Grant Colfax

SASI representatives also met with Dr. Grant Colfax, director of the White House Office of National HIV/AIDS Policy and with Dr. Ron Valdiserri, Office of HIV/AIDS and Infectious Disease Policy, to first thank them for the new CDC CAPUS grants focused on the South and to urge the creation of a convening to bring together federal, state, local and community experts to discuss interventions for the HIV crisis in the South.

AIDS Watch is always a powerful experience for me.  Watching the energy that builds as we get our training, meet with our state colleagues to formulate our visit strategy, and then actually making the visits is impressive.  I also love watching first time attendees realize the advocacy power they can have by just telling their stories.  Thanks to TAEP and AIDS United for a well-run AIDS Watch and for bringing us together once again to hold our elected representatives accountable!

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Sequestration’s Impact on PLWHA in the South

“While sequestration will have an impact on all ADAPs…it will have a significant impact on individuals living in the South. As of June 2012, southern states accounted for 33 percent of all ADAP clients served; through sequestration, up to half of the clients that will loss ADAP services reside in southern states.”

Budget sequestration is scheduled for today.  In other words, “a series of automatic, across-the-board cuts to government agencies, totaling $1.2 trillion over 10 years,” and split evenly between defense and domestic discretionary spending, will take effect. (Source)

Overall, budget sequestration will reduce funding for HIV/AIDS programs, “greatly compromise state health departments’ ability to implement programs,” and “erode the nation’s ability to meet the goals of the National HIV/AIDS Strategy (NHAS).”  (Source) Specifically, the National Alliance of State & Territorial AIDS Directors (NASTAD) estimates in The Impact of Budge Sequestration on Federal Funding for State HIV/AIDS and Viral Hepatitis Programs in FY2012 that, if sequestration occurs:

  • ADAP will face an estimated $77 million in cuts, impacting 15,708 clients.
  • Ryan White Part B to state health departments will face cuts of approximately $25 million.
  • Funding for enhanced HIV testing will face approximately $5.4 million in cuts, which will lead to an estimated 412 HIV+ individuals not being identified each fiscal year.
  • Health departments’ HIV surveillance efforts will face approximately $9.7 million in cuts.

Additionally, a new report, The Effect of Budget Sequestration on HIV/AIDS in the United States: Protecting the Human Impact in Fiscal Year 2013, by The Foundation for AIDS Research (amfAR) and the National Minority AIDS Council (NMAC), estimates that:

  • Over 6,760 PLWHA of color will loss access to ADAP (of the approximately 10,130 PLWHA that amfAR and NMAC estimate will loss access to ADAP).
  • Under the Housing Opportunities for Persons with AIDS Program (HOPWA), an estimated 1,360 fewer households will receive permanent housing and 1,780 fewer will receive short-term assistance.  Notably, “1,920 households that include at least one person of color [will] lose HOPWA housing services; 580 households that include at least one Hispanic person [will] lose housing services.”
  • The National Institutes of Health (NIH) will face approximately $163 million in cuts to AIDS research funding. Specifically, “297 AIDS research grants [will] go unfunded, including 32 specifically funding AIDS vaccine research.”
  • CDC-funded state and local prevention efforts will face more than $41.7 million in cuts.

Additionally, the impact of ADAP cuts will be disproportionately felt by the South. NASTAD recently released a one-page fact sheet entitled, The Devastating Impact of Sequestration on ADAP in the South: Sequestration Would Leave Thousands of People without Access to Life-saving Medications.  This fact sheet highlights that, of the approximately 15,000 clients losing access to ADAP, “[a]lmost half of the people that will be disenrolled live in the South, which as of 2010 accounted for 45 percent of all new AIDS diagnoses in the U.S.”  (Source)  Specifically:

  • In Florida, it is anticipated that more than 1,000 clients will be impacted.
  • In North Carolina and Texas, it is anticipated that 301-1,000 clients will be impacted.
  • In Georgia, South Carolina, and Tennessee, it is anticipated that 201-300 clients will be impacted.
  • In Alabama, Louisiana, Kentucky, Oklahoma, and Virginia, it is estimated that 101-200 clients will be impacted.
  • In Arkansas, Mississippi, and West Virginia, it is estimated that less than 100 clients will be impacted.

Many southern states will also not be expanding Medicaid (Source), which would “provide coverage for the many people living with HIV in South who are currently uninsured.”  (Source)  ADAP underfunding will thus have far reaching consequences, including the exacerbation of existing structural barriers to health, as well as an increase in new infections, “particularly in the South and among people of color who are already disproportionately impacted by the HIV epidemic.”  (Source)

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New SASI Report analyzes HOPWA funding formula and concludes that the South Receives Disproportionately Lower HOPWA Funding Than Other Regions

Housing Opportunities for Persons with AIDS (HOPWA) is a HUD program that provides States and cities with approximately $330 million in funding for the housing needs of persons with AIDS (~$300,000,000 for entitlement grants and ~$30,000,000 for competitive grants).  HUD uses a formula based on cumulative AIDS cases to distribute approximately $225 million of the $300 million entitlement grants to cities and states for short-term and long-term housing for over 61,000 households.  Because over half of the individuals included in cumulative AIDS cases are deceased individuals, the distribution is not representative of the current state of the disease.  If HUD used a formula based on the number of persons living with HIV/AIDS instead of a formula based on cumulative AIDS cases, the south would receive 4.1% more funding, or ~$9.23 million.

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“Everyone has role to play in ending HIV epidemic in America.”

February 22, 2012: Today, a few members of SASI, including SASI Director Carolyn McAllaster, attended the National HIV/AIDS Strategy (NHAS) Implementation Assessment meeting in Chapel Hill, North Carolina. At this meeting, Dr. Grant Colfax, Director of the Office of National AIDS Policy (ONAP) and Dr. Ron Valdiserri, Director of the Office of HIV/AIDS and Infectious Disease Policy at the U.S. Department of Health and Human Services (HHS), addressed steps taken to fulfill the goals of the NHAS, as well as next steps and challenges. 

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An Update on the National HIV/AIDS Strategy

“Don’t Get Mad, Get Data”: Dr. Grant Colfax emphasized that the NHAS is an evidence-driven strategy that has galvanized the national response to the HIV epidemic. ONAP advises President Obama on domestic HIV issues, while a wide range of federal partners, including the Department of Justice, implement various aspects of the strategy.

The NHAS aims to achieve a more coordinated response to the HIV epidemic among federal agencies, and between federal, state, and local stakeholders. ONAP has been focusing on both (1) areas with high AIDS concentrations and (2) communities most impacted by health disparities, including gay men, MSMs, and people of color. Specifically, MSM and gay men account for 2/3 of all new infections, and in 2010, 44% of new infections were among Black individuals and 21% were among Latinos. Black women account for half of new infections among all women. And, according to the CDC’s Greg Millett, “[a]lthough black MSM account for less than 1% of the U.S. population, they comprise one in four of new infections every year.” [Source]

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The 12 Cities Project: Dr. Colfax discussed the 12 Cities Project, which focused on U.S. urban areas with the highest AIDS prevalence, including Atlanta, Dallas, Houston, Miami, and Washington, DC. Highlights of the 12 Cities Project discussed today included communication and collaboration between federal, state, and local entities; an alignment of data collection; and an enhanced focus on outcomes, as opposed to process. Now one of the project’s primary focuses is sustainability. The full 12 Cities Project evaluation can be found here.


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NHAS Next Steps: A Focus on HIV/AIDS among Minorities; CAPUS Grants

While the 12 Cities Project focused on areas of high AIDS prevalence, the Care and Prevention in the United States (CAPUS) grants, part of the Secretary’s Minority AIDS Initiative, focus on enhancing HIV/AIDS diagnosis, and linkage to and retention in care, among minority communities most impacted by the epidemic. Eight grants were awarded–six to Southern states, including Georgia, Louisiana, Mississippi, North Carolina, Tennessee, and Virginia. Illinois and Missouri also received CAPUS funding.

The HIV/AIDS Treatment Cascade: “We can’t treat our way out of the epidemic, but we must treat to end epidemic.” (Dr. Colfax)

Both Dr. Colfax and Dr. Valdiserri emphasized the HIV/AIDS treatment cascade, which illustrates the stark gaps between those diagnosed with HIV and those who have a suppressed viral load. Overall, it is estimated that 82% of people know their status; 66% of those who know their status are linked to care; 37% of those are retained in care; 33% receive ART; and 25% have undetectable viral loads. [Source]

These numbers become even more stark in reference to communities that are disproportionately impacted by HIV/AIDS.


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Dr. Valdiserri emphasized that the CAPUS grants are aimed at identifying and implementing local solutions to combat those disadvantageous determinants of health which lead to the disproportionate impact of HIV/AIDS among minority groups.

An Update on the Affordable Care Act (ACA)

Dr. Colfax also discussed ACA, particularly its expansion of coverage, increased prevention services, and the fact that—starting in 2014—no one living with HIV/AIDS can be denied health insurance for having a pre-existing condition. Additionally, HIV/AIDS will be included on the list of chronic conditions for Medicaid health homes, which approximately half of states are implementing.

North Carolina

For more information about what North Carolina is doing to combat HIV/AIDS, and a recap of stakeholder participation in today’s National HIV/AIDS Strategy Implementation Assessment meeting, please check out my  blog post on the Duke AIDS Policy Project website.


Overall, while we have made much progress combatting HIV/AIDS, there is still much work to be done. In the words of Dr. Ron Valdiserri: “Everyone has role to play in ending HIV epidemic in America.”

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Blacks Disproportionately Affected by HIV/AIDS in the South

February 7, 2013:  Today is National Black HIV/AIDS Awareness Day (NBHAAD) and this year’s theme is “I am my Brother/Sister’s Keeper: Fight HIV/AIDS.”  NBHAAD is focused on getting people educated, tested, involved and treated.

In the South, African Americans are disproportionately affected by HIV/AIDS.

  • In Alabama, African Americans were only 26% of Alabama’s population in 2011 but 69% of new HIV diagnoses. Moreover, African Americans are diagnosed at a rate that is 7x higher than whites.  A staggering 78% of all HIV diagnosis in females are among African American females. (HIV Integrated Epidemiological Profile 2011)
  • In Florida, Blacks accounted for 49% of total HIV diagnosis and 60% of AIDS case deaths in 2011, even though Blacks made up approximately 15% of Florida’s population. (HIV Among Blacks Fact Sheet)
  • In Georgia, Blacks compromised 77% of new HIV/AIDS diagnoses in 2009.  From 2000-2009, Black males were frequently diagnosed at a rate that was 5x that of white males and 3x that of Hispanic males. From 2000-2009, Blacks had an HIV death rate that was over 3x that of other racial/ethnic groups. (Basic Epidemiological Profile of HIV/AIDS)
  • In Louisiana, 76% of new HIV diagnosis and 76% of new AIDS diagnosis were among African Americans in 2009. (Louisiana Public Health Institute)
  • In Mississippi, African American males are 9x more likely to be diagnosed with HIV than white males. (Mississippi State Department of Health)  In 2010, African Americans only compromised 37% of Mississippi’s population, but made up 78% of new HIV infections. (The Lancet)
  • In North Carolina, in 2011, African Americans represented 68% of all HIV diagnoses. (2011 HIV/STD Surveillance Report)
  • In South Carolina, the HIV case rate among African-Americans is approximately 10x greater than whites.  African Americans make up only 28% of South Carolina’s population but 76% of recent HIV/AIDS diagnoses. Almost 7,000 African-American men in SC are living with HIV. (Maudlin Patch)
  • In Tennessee, 57% of those diagnosed with HIV through the end of 2012, and 54% of HIV deaths, have been among African Americans even though African Americans only make up 17% of Tennessee’s population. In 2012, the HIV/AIDS case rate among African Americans was 9x that of whites. (WGNS Radio)
  • In Texas, Blacks make up less than 12% of the state’s population but account for 40% of new HIV diagnoses and 38% of all people living with HIV in TX.  In 2011, black women were only 12% of Texas female population, but 58% of new HIV diagnoses among females. In 2011, the HIV rate among Black men  in Texas was 5x that of White men and 3x that of Hispanic men.  An estimated 17.5% of Black gay men & MSM are living with HIV. (Texas DSHS)
  • Washington, D.C. had the highest diagnosis rate for Blacks in the US in 2010. (Kaiser Family Foundation)

Notably, “[r]esearch shows that African Americans do not engage in riskier behavior than members of other racial/ethnic groups.” (CDC) However, social and economic factors, such as poverty, racial discrimination  stigma, incarceration, and barriers to health care and housing, all contribute to the HIV epidemic in African American communities. (CDC)

The high rates of HIV among African American communities and these underlying social and economic determinants demonstrate that it is not only important to advocate for the end of HIV/AIDS in our communities today, but every day.

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New CDC Paper Provides Further Documentation of High HIV Burden in the Southeastern United States

HIV Diagnoses and Prevalence in the Southern Region of the United States, 2007-2010, a new paper published in the Journal of Community Health by CDC authors documents the high HIV burden borne by the Southeastern United States.  According to the paper, “the southern region is home to the largest percentage of new diagnoses and the largest percentage of people living with a diagnosis of HIV infection of any region in the United States..”:

  • “In 2010 46.0% of all new diagnoses of HIV infection occurred in the South.”
  • “Compared to other regions, a higher percentage of diagnoses in the South were among women (23.8%), blacks/African Americans (57.2%)…”
  • “…a greater percentage of the estimated diagnoses of HIV infection in the South were among suburban…and rural residents…”
  • “…the estimated rate of diagnoses of HIV infection in the two youngest age groups of men (13-19 and 20-29) increased significantly…”
  • “…after diagnosis individuals in the South have worse outcomes….the percentage of persons surviving 36 months after a diagnosis of HIV infection is worse in the South than in all other areas…”
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