SASI Research Team and CDC Publish New Findings about the HIV burden and Deaths in 9 Deep South States
December, 2014: SASI research team collaborates with the Centers for Disease Control to publish new article in the Journal of Community Health: HIV Diagnoses, Prevalence and Outcomes in Nine Southern States , Reif, Pence, Hall, Hu, Whetten & Wilson, Journal of Community Health, 19 December 2014, DOI:10.1007/s10900-014-9979-7.
SASI researchers have previously documented the high burden of HIV in SASI’s targeted deep south states: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee and Texas. In 2011, 38% of those diagnosed with HIV in the United States were in the targeted states region; the targeted state region also had the highest number of persons living with HIV of any region in the US.
In this article, researchers analyze the characteristics of people diagnosed with HIV in the targeted states. They also examine 5-year HIV and AIDS survival and deaths among persons living with HIV.
Key Demographic Findings:
- More people diagnosed with HIV and living with HIV in the targeted states are black/African American, female and aged 13-24 than in any US region.
- More than a quarter of persons diagnosed with and living with HIV in the targeted states region live outside of urban areas (population 500,000 or greater)—highest of any US region.
- As a region, the targeted states had a higher percentage of HIV transmissions attributed to heterosexual contact and a lower percentage due to injection drug use of any US region.
- The targeted states region has a higher percentage of both males and females living with HIV with heterosexual contact as the reported transmission category than any US region.
Five-year Survival among persons diagnosed with HIV and AIDS:
- Overall, 5-year survival among persons diagnosed with HIV or AIDS was lower in the targeted state region than in any other US region.
- 15% of persons diagnosed with HIV in the region had died within 5 years of diagnosis.
- 27% of persons diagnosed with AIDS in the region had died within 5 years of diagnosis.
- In the region, Louisiana had the lowest survival rates after a diagnosis of HIV or AIDS, followed by Mississippi.
- In Louisiana, 19% of persons diagnosed with HIV had died within 5 years and one-third of persons diagnosed with AIDS had died within 5 years.
- 5-year survival after a diagnosis with HIV or AIDS was lower in the rural and suburban areas of the region than in the urban areas.
- 29% of females diagnosed with AIDS and 26% of males in the targeted states had died within 5 years of diagnosis.
- Blacks had the lowest 5-year HIV and AIDS survival of any race/ethnicity in the region.
Deaths Among Persons Living with HIV (rate of deaths among 1,000 PLWH in 2010):
- The death rate among persons living with HIV was higher in the targeted states than in any other US region (even after adjusting for age, sex, transmission category and area population size).
- Blacks had a higher death rate among persons living with HIV in the region than whites.
- Women had a higher death rate among persons living with HIV in the region than males.
- Suburban and rural residence at diagnosis significantly predicted greater death rates among persons living with HIV in the region compared to urban residence at diagnosis.
- Louisiana had the highest death rate among persons living with HIV followed by Alabama, South Carolina and Florida.
Connections and Recommendations:
- Characteristics of persons diagnosed with HIV in the targeted states differ from the US overall.
- “These differences are crucial to consider, as are other factors prominent in the targeted states including poverty and stigma, when creating strategies to address HIV in this region.”
- Higher death rates among persons living with HIV in the targeted states
- “…contributing factors likely include characteristics of the targeted states such aslower levels of income, education, and insurance coverage and higher levels of HIV stigma and racism.”
- “An additional contributing factor may be the social class system unique to the US South that has traditionally allowed for little social mobility, along with marginalization of, and discrimination against certain groups and often resulting in distrust of systems of care among those in a lower social strata.”
- “Additional research is needed to better determine and understand the factors that influence the higher death rate among persons living with HIV in the targeted states and to identify effective mechanisms to address known barriers including HIV stigma.”
- “The targeted states with the most concerning mortality statistics, particularly Louisiana, may especially be in need of focused attention on addressing the factors contributing to these concerning statistics.”
- Higher death rates in the suburban and rural areas
- “Identifying effective ways to structure prevention and care services so that they address common barriers to care such as accessibility and pervasive stigma will be critical to improving HIV outcomes in rural and suburban areas of the targeted states.”
- “suggests a disconnect between diagnosis and maintenance of HIV care in this region—particularly in non-urban areas.”
- Higher diagnosis rates among youth
- Could be attributed, in part, to: lack of education about HIV transmission; less gravity placed on HIV infection due to improvements in available drug regimens.
- “Development and implementation of effective prevention and treatment strategies for the younger population will be critical to stemming HIV transmission in the targeted Southern states.”
If we are to achieve the goals of the National HIV/AIDS Strategy, federal and state public health officials and policy makers must direct a laser focus on the deep south region of the US where HIV diagnosis rates are highest and more people are living and dying with HIV. This article gives us a deeper understanding of the characteristics of those most affected by HIV in our region and documents the dire consequences that having an HIV diagnosis in the deep south has for too many in our region.
November, 2014: HIV Infrastructure Study: Columbia, SC , Susan S. Reif, Elena Wilson, & Carolyn McAllaster.
The latest SASI Infrastructure Study, HIV Infrastructure Study: Columbia, SC , was released at the annual South Carolina HIV/STD and Viral Hepatitis Conference in Columbia, SC.
Columbia is the largest city and the capital of South Carolina.
According to the Report and despite the fact that South Carolina has a robust AIDS Drug Assistance Program that pays for medications for uninsured HIV+ persons earning up to 300% of the federal poverty level AND reimburses for insurance premiums, copays, and deductibles for insured HIV+ persons earning up to 550% of the federal poverty level,
- 36% of persons living with HIV/AIDS in South Carolina were not in care. (2013 HIV Epidemiological Profile of South Carolina)
- Columbia had the 10th highest death rates for HIV+ men and women in the United States in 2011.
- In 2011, Columbia ranked 7th in the country in HIV diagnoses among 13-24 year old males.
The Report identifies the following as some of the barriers to HIV Care & Preventionin Columbia:
- Lack of transportation
- Pervasive Stigma
- Few trained HIV medical providers in the more remotes areas of the Columbia Metropolitan Area
- Lack of political will
- Inadequate funding for prevention.
Some suggested strategies identified in the Report for addressing the HIV epidemic in Columbia include:
- Establishment of a telemedicine program to address lack of transportation and medical care in more remote areas;
- Co-location of HIV care with other services to combat stigma;’
- Increased educational efforts for PLWHA, health care professionals, churches, and community to address stigma.
September 18, 2014: SASI HIV Infrastructure Study: Baton Rouge, Susan S. Reif, Elena Wilson, Carolyn McAllaster, & Casteel Scherger.
SASI researcher, Kristen Sullivan, and SASI Steering Committee member, Sharon Decuir (of Baton Rouge, LA) released and discussed the SASI HIV Infrastructure Study: Baton Rouge at the SPEAK UP! National Summit for Women Living with HIV in Ft. Walton Beach, Florida.
According to the Report:
- Baton Rouge had the highest AIDS diagnosis rate of any US metropolitan area in 2011;
- Baton Rouge had the highest HIV diagnosis rate among females overall of any US metropolitan area in 2010;
- 34.5% of new diagnoses occurred among women in Baton Rouge in 2010;
- Only 70% of those diagnosed with AIDS in Baton Rouge survived for 3 years after diagnosis in the years 2002-2006.
Despite community strengths that include generally available HIV medical care, committeed HIV advocates and service providers, new funding for programs focused on the epidemic among people of color, and the use of Ryan White funds to purchase insurance for PLWHA through the Affordable Care Act, significant barriers to prevention and care remain:
- Pervasive stigma and discrimination that drives the epidemic into the shadows and leads to reluctance for HIV testing, prevention and treatement;
- Lack of state prevention funding accompanied by the lack of comprehensive and highly visible prevention efforts;
- Lack of tranportation options;
- Limited mental health and substance abuse treatment options;
- Lack of affordable housing.
The Report identifies the following strategies needed to address the epidemic in Baton Rouge: Additional resources for prevention and comprehensive prevention efforts that raise the visibility of the disease and address stigma as well as greater interagency collaboration, consumer participation in prevention and care planning, and greater resources for HIV case management, transportation, mental health, housing, and legal services.
July 18, 2014: The Potential for Elimination of Racial-Ethnic Disparities in HIV Treatment Initiation in the Medicaid Population Among 14 Southern States; Shun Zhang, Shanell L. McGoy, Daniel Dawes, Mesfin Fransua, George Rust, David Satcher; PLOS One, April 2014.
Medicaid Matters! Important new research from the Morehouse School of Medicine with Tennessee’s State AIDS Director Shanell L. McGoy, Ph.D MPH as co-author finds that access to Medicaid has the potential to eliminate racial-ethnic disparities in the initiation of antiretroviral (ARV) treatment of HIV. Researchers found no significant diference between black (35.8%) and non-Hispanic whites (35.7%) in 14 Southern States who received ARVs when on Medicaid. Hispanics/Latinos (26.2%) were significantly less likely to receive ARVs, a finding that was linked to structural barriers, including US immigration policies, experienced by Hispanic and Latino patients in enrolling in Medicaid.
Multiple SASI research reports have demonstrated that the Southern region of the United States is disproportionately impacted by HIV. In their study, researchers at Morehouse School of Medicine explored the racial and ethnic disparities in the initiation of ARV/ART among HIV positive Medicaid enrollees 18-64 years of age in 14 southern states.
Dr. Shanell L. McGoy, Director of HIV/STD, Tennessee Department of Health states, “we are hopeful with persistent and collective efforts, particularly in policy and advocacy, we can eliminate not only geographic but also racial-ethnic disparities in HIV.”
From the article: “The fact that black-white racial disparities in treatment initiation have been eliminated in the Medicaid populations of fourteen southern states is a profound affirmation of the possibility of achieving equality in treatment and outcomes. In this case, Medicaid matters!”
April 23, 2014: Updated SASI Research Report released: HIV/AIDS in the Southern US: Trends from 2008-2011 Show a Consistent Disproportionate Epidemic
- The percentage of new HIV and AIDS diagnoses that were black or African-American MSM increased fastest in the targeted deep south states.
- In 2011, the highest percentage (47%) of new diagnoses among black or African American MSM were in the targeted deep south states.
- The large disparity in HIV diagnosis rates between black or African American and white women remains high in the targeted states.
- Overall, in 2011, the targeted states had the highest number of people living with HIV of any region and the highest number diagnosed.
February 21, 2014: New SASI Research Report released: HIV/AIDS in the Southern US: Trends from 2008-2011 Show a Consistent Dispropotionate Epidemic. The SASI research team analyzes 4 years of HIV/AIDS epidemiological data for the Southern Region to explore trends in the Southern HIV/AIDS epidemic.
- From 2008-2011, the deep south states consistently had the highest HIV and AIDS diagnosis rates in the U.S.
- During this 4-year period, the deep south states also had 9 of the 10 metropolitan areas with the highest AIDS diagnosis rates in the country.
- Most telling, the deep south region had the highest HIV case fatality rates in the country (deaths among people living with HIV).
- African Americans were hardest hit in the deep south comprising the majority of AIDS diagnoses (range 58-60%) in 2008-2011.
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.
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.
SASI releases new research report analyzing CDC data in Metropolitan Statistical Areas (MSAs: with populations greater than 500,000). “Fifteen of the 20 MSAs … with the highest HIV diagnosis rates were located in a 9 state region of the South (AL, FL, GA, LA, MS, NC, SC, TN, and East TX).” Nine of the 10 MSAs with the highest HIV diagnoses rates in 2008-2010 were in these targeted states.
“Nearly one-half of new HIV diagnoses in 2010 in Jackson MS (45%), Atlanta GA (47%) and Charleston, SC (47%) were among African-American MSM.”
“Baton Rouge LA had the highest percentage of new HIV diagnoses occurring among African American females, at nearly one-third of new diagnoses (31%).”
The HIV epidemic is not concentrated solely in MSAs in the South, “the South has a higher proportion of new HIV diagnoses in rural and suburban areas than all other regions and also has higher HIV diagnoses rates per 100,000 population in suburban and rural areas than the other US regions.”
“More research is needed to better understand the limitations of the HIV care and prevention infrastructures in the South and to determine how these infrastructures are influenced by state poverty and culture and how they in turn impact HIV incidence.”
February 23, 2013: Housing Opportunities for Persons with AIDS (HOPWA): Distribution of Funding to the Southern States
SASI releases new research report: Housing Opportunities for Persons with AIDS (HOPWA): Distribution of Funding to the Southern States. This report analyzes the HOPWA entitlement grant funding formulas. Specifically, 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.
SASI’s analysis of this HOPWA funding stream concludes that the South is receiving 4.1% less of this funding than it would receive if the formula was based on living HIV/AIDS cases.
Nov. 22, 2012: HIV Diagnoses & Prevalence in the Southern Region of the US
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…”
November 28, 2012: SASI Update–The Continuing HIV Crisis in the US South
SASI releases updated report, SASI Update: The Continuing HIV Crisis in the US South. Report highlights include:
- 8 of the 10 states with the highest HIV diagnosis rates were in the South*; 7 were in targeted southern states (AL, FL, GA, LA, MS, NC, SC, TN, (East) TX).
- 48% of new HIV diagnoses were in the South, while the South contained only 37% of the population.
- 32% of new HIV infections in 2010 were in the 9 targeted southern states, which contain only 22% of the US population.
- The targeted southern states had the highest new diagnosis rates in the US.
- 7 of the states/district with the highest AIDS diagnosis rates were in the South; 4 were in targeted states (FL, LA, MS, SC).
- 9 of the 10 metropolitan areas with the highest HIV diagnosis rates were in these targeted southern states, including Miami, FL and Jackson, MS.
- 9 of the 10 metropolitan areas with the highest AIDS diagnosis rates were in the South; 7 were in targeted states.
- 6 of the 10 states with the highest HIV prevalence rates in the US were in the South (FL, GA, LA, DE, SC, MS).
- Southern states/DC represented 6 of the 10 areas with the highest AIDS prevalence rates (DC, MD, FL, GA, DE, LA).
- 9 of the 10 US states with the highest rates of death due to HIV are in the South, and all 9 targeted southern states are among the 15 states with the highest HIV death rates.
January 2012: HIV/AIDS Epidemic in the South Reaches Crisis Proportions in the Last Decade
In January 2012, SASI released the report, HIV/AIDS Epidemic in the South Reaches Crisis Proportions in the Last Decade, prepared by the Duke Center for Health and Inequalities Research. The Executive Summary of this report was released in November 2011. Some of the report’s highlights are included below.
HIV in the Southern United States
- New HIV diagnoses:
- In 2009, 50% of individuals newly diagnosed with HIV infection resided in the Southern USi and the rate of diagnosis of HIV infectionii in the South was the highest of all the US regions.1,2 Seven Southern states (FL, GA, LA, MS, NC, SC, TX, VA) were among the 10 statesiii with the highest rates of diagnosis of HIV infection in 2009.1
- 9 of the 10 metropolitan areas with the highest rates of diagnosis of HIV infection in 2009 were in the Southern US.1 Two of these Southern cities (Miami and Atlanta) are part of the 12 Cities Project.3
- Individuals living with HIV (HIV prevalence): Forty-three percent of people who are HIV-positive live in the Southern US while the South comprises only 37% of the population.1,2 Southern states account for 7 of the 10 statesiii with the highest HIV prevalence rates in the US in 2009 (FL, GA, LA, MS, SC, TX, VA).1
- Death Rates: Data on deaths among individuals with HIV that occurred from 2001-2007 indicated that nine of the ten states with the highest age adjusted HIV case-fatality rates were located in the Southern US (AL, MS, FL, GA, LA, OK, NC, TN, SC).4
- Rural HIV/AIDS: 64% of individuals living with an AIDS diagnosis in rural areas reside in the Southern US.5 In the South, 22% of individuals living with HIV resided in rural areas or metropolitan areas with populations under 500,000 in comparison to 11% nationally. Providing HIV care in rural areas may be particularly challenging due to barriers such as lack of transportation, shortages of medical providers, and fear of discrimination and confidentiality breaches.6,7
- Race/ethnicity: African Americans are disproportionally represented among new HIV diagnoses (2005-2008) in the South, as 50% of men and 71% of women diagnosed with HIV in the South were African American.8 African Americans with HIV have been identified as having higher levels of morbidity and mortality.4,9
i The Census Bureau defines the Southern US as including Alabama, Arkansas, Delaware, DC, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
ii Rates are calculated as new HIV cases per 100,000 population
iii Among the 40 states with mature HIV reporting systems (CDC technical notes1).
1. Centers for Disease Control. Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2009. HIV Surveillance Report, Volume 21. Available at http://www.cdc.gov/hiv/surveillance/resources/reports/2009report/index.htm. Accessed October 2011.
2. U.S. Census Bureau, Population Division. Table 1, Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1 2009. Released December 2009.
3. Gomez M. The 12 Cities Project. 2011. Available at http://blog.aids.gov/2011/02/the-12-cities-project.html.
4. David B. Hannaa, Richard M. Selikb, Tian Tangb and Stephen J. Gange. Disparities among States in HIV-related mortality in Persons with Hiv Infection, 37 U.S. States, 2001–2007. AIDS, 2011, published ahead of print.
5. Centers for Disease Control. HIV Surveillance in Urban and Nonurban Areas. 2011. Available at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/urban-nonurban/. Accessed October 2011.
6. Sutton M, Anthony MH, Vila C, McLellan-Lemal E, Weidle PJ. HIV Testing and HIV/AIDS Treatment Services in Rural Counties in 10 Southern States: Service Provider Perspectives, The Journal of Rural Health. 2010;26: 240-247.
7. Reif S, Whetten K, Raper J. Characteristics of HIV-Infected Adults in the Deep South and their Utilization of Mental Health Services: A Rural Vs. Urban Comparison. AIDS Care, 2006;18(Supp 1):10-17
8. Centers for Disease Control. Disparities in Diagnoses of HIV Infection Between Blacks/African Americans and Other Racial/Ethnic Populations – 37 States, 2005—2008. Mortality and Morbidity Weekly Report, 2011.60(4):93-98.
9. Meditz A, Mawhinney S, Allshouse A, et. al, Sex, Race, and Geographic Region Influence Clinical Outcomes Following Primary HIV-1 Infection, Journal of Infectious Diseases, 2011: 203(15); 442-451.