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HIV & AIDS
The Continuing Spread of HIV/AIDS in the Southern US
a report by
Han-Zhu Qian, MD, PhD
and Sten H Vermund, MD, PhD
1. Assistant Professor of Medicine and Core Scholar; 2. Professor of Medicine and Director, Institute for Global Health,
Vanderbilt University School of Medicine
The HIV/AIDS epidemic was initially recognized in 1981 in large US coastal MSM remain at alarming levels and represent half of all new cases of HIV
cities, disseminating steadily throughout the country over the next decade. infection, according to Centers for Disease Control and Prevention (CDC)
The South has led the nation in the overall number of persons living with estimates. In contrast, rates among IDUs have fallen markedly, reflecting
AIDS since 1993 and the reported incident cases (or new cases per year) successes in prevention from expanded drug treatment and needle/syringe
This brief review describes the characteristics of the epidemic exchange programs. While MSM and IDUs remain the two principal
in the South, prominent risk factors, and barriers for providing care for sub-groups for new infections, heterosexual transmission continues to
those living with HIV in this region. increase. MSM and IDU contributed to 87% of 117,781 cumulative
reported AIDS cases to December 1989, 79% of 724,656 cases by 1999,
A Disproportionate Burden and 74% of 956,019 by 2005, while the proportion of transmission via
The US Census Bureau (2005) stated that the South comprises Alabama, heterosexual contact increased by 5%, 10%, and 13% by 1989, 1999, and
Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, 2005, respectively.
These national trends are also true in the South. Women
Louisiana, Maryland, Missouri, North Carolina, Oklahoma, South Carolina, are particularly vulnerable to heterosexual transmission.
Tennessee, Texas, Virginia, and West Virginia, and is home to 35% of the the South, rural women are more likely than urban women to acquire the
US population. It has a disproportionate burden of the AIDS epidemic, to disease through sex with men at risk for HIV.
the extent that >38% of the estimated 434,000 persons living with full-
blown AIDS resided in this region in 2005 (p<0.05).
A simple way of Risk Factors
comparing growth rates is to calculate the proportion of the total The geographical disparity noted in the AIDS epidemic may be partially
cumulative cases (1981–2004) with those that occurred recently due to differences in access to and use of HIV testing, but there are
(2000–2004). The national average was 20.1%; in the South it was 25.5% no published data to verify this. African-Americans are affected
standard deviation (SD) +3.0% compared with 19.3% +4.2% SD in the rest disproportionately by HIV infection, and this may be reflected in higher
of the US (p<0.001). Of the 10 states with the highest proportion of recent southern US rates of both AIDS reports and estimated HIV infections. First,
cases compared with total cases of AIDS, nine were in the South. This higher the southern states (22.8%) have about three times the African-American
proportion of recent cases (2000–2004) to the total number reported population than other regions (7.4%). Second, this group comprises 13%
suggests that the current incidence rate in the South should be of special of the total US population, but represents more than 63% of cumulative
HIV incidence trends can help allocate resources by targeting ‘hot AIDS cases by 2005.
spots’ of transmission, just as HIV/AIDS prevalence data help to direct care
and treatment resources to where the patients are. Tracking HIV incidence The estimated prevalence rate of HIV/AIDS among blacks in 33 states with
includes those individuals who test positive for recent HIV infection but who voluntary reporting of HIV infection in 2005 was 71.3 per 100,000
do not qualify for an AIDS diagnosis, therefore identifying the venues of population, 2.6 times higher than among Hispanics (27.8 per 100,000) and
most intense transmission activity. Incidence reporting also facilitates the 8.1 times higher than among whites (8.8 per 100,000).
evaluation of impact from prevention interventions. The reporting of AIDS may facilitate HIV transmission by increasing the likelihood that high-risk
cases is compulsory in all states and territories, but until recently notification behavior actually results in higher incidence. Third, higher incarceration
of HIV infection was mandatory in only 38 states, and large states such as rates and lower male-to-female ratios in African-American communities
New York, California, and Florida did not require HIV reporting. Southern may increase the risk of acquiring HIV among African-Americans. The US
states also report disproportionate numbers of HIV infection. For example, has the world’s highest rate of incarceration (having outstripped South
among the 38 states that reported HIV, 14 southern states with 33% of the Africa and Russia in recent years), and the South has even higher
national population reported 51% of total HIV infections in 2005, while 24 incarceration rates than other regions of the country. The rate among
non-southern states with 64% of the national population reported 42% of blacks is about six times that of whites, and one in four black men is
AIDS cases in the South are more likely to be concentrated incarcerated during his lifetime.
Prisoners have experienced higher HIV risk
in less urban and rural residents than in other regions.
than non-prisoners due to IDU, non-injection drug use linked to higher
sexual risk, and/or commercial sex work. Low male-to-female ratios in
Changes in Infection Patterns black communities increase competition among black women for sexual
The early epidemic was most concentrated among men who have sex with and marriage relationships with black men, and may reduce women’s
men (MSM) and injection drug users (IDUs) in urban areas. Rates of HIV in negotiation capability for safer sex, increasing their risk of contracting HIV.
24 © T OUCH BRIEFINGS 2007