HIV/AIDS in the Southern United States SASI Study Data Report funded by the Ford Foundation Susan Reif, Duke University Center for Health Policy and Inequalities Research

SASI Research Reports Initial SASI analysis report (December 2011): Included 2009 HIV epidemiology, outcomes, care financing, and factors contributing to the Southern HIV epidemic. Update of Southern HIV epidemiology and care financing for 2010 included on the SASI website and update of HIV epidemiology for 2011 published in the journal AIDS Care. A report on HIV in Southern metropolitan areas was released in July 2013 on the SASI website.

Definitions Southern United States (Census Definition): AL, AR, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX,VA, WV, DC HIV Diagnosis Rate: Newly diagnosed cases of HIV per 100,000 population HIV Prevalence Rate: People living with HIV per 100,000 population

HIV and AIDS Diagnoses Rates, 2011 The rate of new HIV diagnoses per 100,000 population in the Southern US was the highest of any US region. Eight of 10 states/DC with the highest rates of new HIV diagnoses were located in the South (DC, FL, GA, LA, MD, MS, SC, TX). Nearly half (49%) of new HIV diagnoses were in the South although the South accounted for only 37% of the US population. The South accounted for 49% of new AIDS diagnoses and had the highest AIDS diagnosis rate of the 4 Census Bureau regions. Data from the CDC HIV Surveillance Report for

HIV Diagnosis Rates, 2011

HIV and AIDS Prevalence Rates (rates of people living with HIV) 42% of people living with HIV in the US reside in the Southern region (2011). The Southern region has the second highest HIV prevalence rate per 100,000 population. AIDS prevalence is also high in many Southern states, as Southern states/District of Columbia represent 6 of the 10 areas with the highest AIDS prevalence rates (DC, MD, FL, DE, GA, LA). CDC HIV Surveillance Report for 2011

Characteristics of Individuals with HIV in the South A majority of HIV diagnoses (57%) in the South were among African Americans (2010).* The South had the highest proportion of HIV diagnoses among individuals in rural areas (11%). A majority (65%) of individuals with HIV who live in rural areas reside in the South.* 6 of 10 states with the highest HIV diagnosis rate among Latinos in 2011 were in the South ( ). *Prejean et al HIV diagnoses and prevalence in the southern region of the United States, Journal of Community Health)

HIV in 9 Targeted Southern States A group of Southern states has been particularly affected by the HIV epidemic in recent years and shares common characteristics such as overall poorer health, high poverty rates, and a cultural climate that likely contributes to HIV infection and poorer HIV outcomes. (AL, FL, GA, LA, MS, NC, SC, TN, TX/East Texas) HIV and other STDS disproportionally affect the targeted states and the states share similarities in HIV-related outcomes.

HIV Diagnosis Rate/100,000 population HIV Surveillance Report 2011

HIV/AIDS in the Targeted States, 2011 The targeted states have the highest HIV and AIDS diagnosis rates when compared to other US regions Six of 10 states with the highest rates of new HIV diagnoses are targeted Southern states (FL, GA, LA, MS, SC, TX). Nearly one-third (32%) of HIV diagnoses were in the targeted states, which contain only 22% of the US population. CDC HIV Surveillance Report for 2011

HIV/AIDS in the Targeted States Seven of the 10 metropolitan areas (MAs) with the highest HIV diagnosis rates were in the targeted states in of the 10 MAs with the highest AIDS diagnosis rates were in the targeted states in The MA not in the targeted states was Baltimore MD. CDC HIV Surveillance Report for 2011

10 Cities with Highest AIDS Diagnosis Rate, 2011

Rural HIV in the Targeted States

Deaths from HIV Disease, 2010 HIV Death rate: Deaths from HIV per 100,000 population in a given year 8 of 10 states/district with the highest HIV death rates in 2010 were in the South. 5 of these states were targeted states (FL, GA, LA, MS, SC). All of the targeted states were among the 15 states with the highest HIV death rates in the US. Kaiser Family Foundation, State Health Facts (

HIV Case Fatality Rate ( ) HIV Case Fatality Rate: Deaths from HIV per 1000 persons with an HIV diagnosis in a given year Nine of the 10 states with the highest case fatality rates were in the South; 8 were targeted states (MS, LA, OK, NC, TN, GA, SC, AL, FL). Mississippi had the highest case fatality rate in the US. * 37 states with data from available data; Hanna D, Selik R, Tang T, Gange S. Disparities among states in HIV-related mortality in persons with HIV infection, 37 U.S. STATES, AIDS

3 Year Survival Post AIDS Diagnosis 7 of the 9 targeted states had 3-year survival rates for individuals diagnosed at Stage 3 (AIDS) in 2006 lower than the US average. The US average percentage of individuals surviving 3 years post AIDS diagnosis was 84% whereas the percentage of individuals surviving after 3 years in Louisiana was 76%. CDC (2012). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data. Surveillance Supplemental Report, _no_2.html

HIV Care Financing Issues The Ryan White funding inequities for the Southern US, particularly the targeted states, detected in the early 2000s appear to have narrowed, however an estimated gap between the targeted states and the US average in overall Ryan White funding per person living with HIV was $180 in The South provided Medicaid coverage for a lower proportion of individuals with HIV in the region when compared to the national average in Data from Kaiser State Health Facts, statehealthfacts.org

Factors Contributing to the Disproportionate HIV Epidemic in the Southern US Overall poorer health: - 8 of the 10 states with the worst health ratings were in the South in ( Higher rates of STIs: 8 of 10 states with the highest Chlamydia rates in 2011 were in the South; 6 targeted states.* Economics: The South has some of the lowest median income figures in the country, as 8 of 10 states with the lowest median incomes from were located in the South; 5 were targeted Southern states.* * Data from Kaiser State Health Facts, statehealthfacts.org

Poverty and HIV Case Fatality

Contributing Factors – Race/Ethnicity African Americans are disproportionately represented in low-income communities and among the uninsured. Even after controlling for poverty, African American race has been consistently associated with poorer health. A report by the National Minority AIDS Council discussed contributing factors to HIV among African Americans such as unstable housing, higher rates of incarceration, stigma, and lack of trust in the government. References in the SASI report (

Contributing Factors – Stigma The cultural conservatism in the South likely plays a role in stigma for people living with HIV. NASTAD study identified greater HIV-related stigma in the South and Midwest. ( NASTAD-Stigma%20Seminar-and-Public-Health-USCA FINAL.pdf) HIV-related stigma has been found to negatively affect preventive behaviors, care-seeking and adherence, mental health, and quality of care (

Contributing Factors - Policy Lack of evidence-based sex education in the South Criminalization of HIV-related behaviors Lack of Syringe Exchange Programs Information from Kaiser State Health Facts and Human Rights Watch. Southern Exposure: Human Rights and HIV in the Southern United States. 2010

Conclusions CDC data indicate a consistent and disproportionate effect of HIV in the Southern states; particularly the targeted states. HIV case fatality rates in the South, especially in the targeted states, are striking and indicative of the critical need to improve HIV detection/treatment. Economic and social factors such as poverty, stigma and culture are all interrelated, each affecting the others, and all contributing to the disproportionate share of HIV in the US South.

Ingredients for a successful research/advocacy partnership A well defined research agenda that is both feasible from a research standpoint and relevant for advocacy efforts A commitment to unbiased research and research results findings Education from both research and advocacy partners regarding terminology (jargon), critical concepts and ideas and willingness to learn from partners Common goals (i.e publishing, policy)

SASI Analysis Plans Examine trends in HIV diagnosis and prevalence, now that 4 years of more consistently reported data are available ( ). Replicate the CDC Southern HIV Analysis using data from the Targeted States – CDC/SASI collaboration. Prejean et al, Journal of Community Health Examine demographic characteristics of newly diagnosed individuals and compare targeted states to other regions Calculate 3 year HIV survival rates and compare targeted states to other regions

Additional Planned SASI Analyses Examining the HIV cascade: What data are available in the targeted states and what data need to be collected Comparing HIV testing in targeted states to other regions Examining HIV prevention and care efforts in DC to assess for interventions that could be replicated in the targeted states Availability of HIV specialists in the targeted states in comparison to other regions

HIV Infrastructure Study Study HIV care and prevention infrastructure in specific targeted state cities by examining available data and conducting key informant interviews and focus groups to determine: HIV prevention services structures and challenges HIV care services: funding, community support, availability Stigma and other barriers to HIV care and prevention Compare targeted state cities to cities in other regions that have similar demographics but lower HIV disease rates