Article by Marc Kolman

Top 10 Possible Reasons for the High HIV
Infection Rate in the Southern U.S.
By Marc Kolman, M.S.P.H.June 17, 2010

According to the Southern States Manifesto, more than 36,000 people have died
of AIDS in the South as estimated by the CDC and in 2005 the South was burdened
with half of all deaths from AIDS in the United States. The Southern US is
clearly burdened with HIV to a degree unwarranted by its population size. This
is a concern expressed by many and, to some degree, remains a mystery.

Recently, I was on a panel discussion as part of the Week of Prayer in Durham, NC. The last questioner of the
evening asked, "Why is HIV so prevalent in the South?" We didn't come up with a
scientific list of reasons, and I don't know if there really is such a list, but
here's what we came up with (in no particular order) ...

• Stigma. Stigma refers to attitudes about how people are different
  for something they're not responsible for such as race, gender, class, sexual
  orientation, or HIV status. Stigma is a leading issue in the struggle against
  the HIV epidemic in the Southern US and elsewhere and until stigma is addressed
  effectively, it will continue to affect how people deal with the epidemic. I've
  written more on this topic before for
  TheBody.com.
• Conservative religious and moral values. The Southern US is sometimes
  referred to as the Bible Belt, meaning the vast majority of people are actively
  religious, primarily Southern Baptist. As a result, to a large degree, churches
  influence what people think about and talk about. There are a lot of churches
  that talk openly about HIV, sex, and substance abuse. Unfortunately, however,
  many keep to the straight and narrow and don't talk about controversial topics,
  including HIV, substance abuse, or mental health. I'm grateful for churches like
  First Calvary Baptist Church in Durham that actively deals with HIV by
  supporting HIV-positive congregants, providing education about HIV, and having
  an AIDS Care Team. If churches, with their key role in influencing behaviors and moral
  beliefs, took an active role in addressing HIV, I think it more likely that
  congregants and parishioners would work towards eliminating HIV as well.
• Intolerance for others. Intolerance can include people who are
  perceived as different (see discussion on stigma, above) including anyone from
  outside of one's immediate social circle. If a community is so insular that
  other behaviors and people are not tolerated, it will be very difficult to
  address any behaviors that are considered outside of the realm of 'normal'. The
  result being that it is once again difficult to address issues that lead to HIV
  infection such as substance abuse and high-risk sexual activities.
• Economic and class oppression. Economic issues underlie a host of
  behaviors that impact risk for HIV infection and the likelihood that those
  already infected will seek treatment. We often talk about HIV, substance abuse,
  mental health, and incarceration as co-morbidities, or conditions that are
  closely connected. Each of these conditions is impacted by economics. There is
  much to say about this, but perhaps one example will serve to illustrate the
  point. One in 100, a report from the Pew Charitable Trust, states
  that 1 of every 100 adults in the US is incarcerated in a jail or prison (1 in 9
  for Black men between the ages of 20 and 34). Those who are incarcerated are
  often from poorer economic backgrounds and their incarceration results in
  adverse economic impact on their families and communities. Chances are, if
  someone has substantial financial assets, they're not in prison and, if they
  are, they're in for a shorter length of time. Incarceration has a detrimental
  effect on one's ability to seek employment upon release thereby impacting their
  economic status and therefore impacting their likelihood of having health
  insurance, access to HIV medications, mental health or substance abuse services,
  and other health resources.
• Racism. There is so much to say about racism. Does racism affect the
  HIV epidemic? As clearly as racism underlies so many oppressions -- I often
  think of racism as the glue that holds all the other oppressions in place -- it
  affects our ability to deal effectively with HIV. Is racism different in the
  Southern US? Racism continues to persist everywhere. As a result of historic
  issues largely stemming from the Civil War, the South is often blamed for
  racism. However, as has been clearly dealt with in the work of many, including
  Howard Zinn's A People's History of the United States, the South has
  been treated as a colony of the North, exploited for economic gain, and has in
  effect taken much of the blame for racism although racism, including slavery,
  has been a part of the economic system in place throughout the United States for
  years leading up to the Civil War. Regardless of where blame lies, racism plays
  a significant role in placing people in situations that put them at risk for HIV
  infection and for challenges related to their ability to effectively seek
  treatment once infected. It is debatable as to how this plays out differently in
  the Southern US as compared to anywhere else.
• Lack of jobs. As discussed above, economic oppression places people
  at risk for a host of conditions that do not support HIV prevention and
  treatment efforts, including access to health care, and both substance abuse and
  mental health services. A recent list using data from the Bureau of Labor Standards
  shows that 6 of the 15 states with the highest rates of unemployment are in the
  South. These statistics may be limited in showing the real struggles of
  unemployment. However, there are real challenges posed by the cycle of no work,
  no income, and no hope that are likely to lead to behaviors that stifle HIV
  prevention and treatment efforts.
• Lack of health care resources, including substance abuse and mental
  health. As an example, the substance abuse and mental health system in North
  Carolina was gutted over the past few years in an effort to streamline services
  and save costs. The resulting lack of public resources clearly stresses the
  limits of those without the ability to cope with life's challenges. In addition
  to substance abuse and mental health, many states in the South have fewer health
  care and medical providers, placing additional stress on health care and social
  support systems that struggle to support those with limited resources.
• Rural. Though not as rural as many western states, the Southern US is
  rural in comparison to much of the country. Rural areas generally have fewer
  resources, including health care and social service providers. Distances to
  access existing resources may also pose transportation issues. And finally,
  isolation from others could pose challenges in getting needed supports --
  physical, emotional, and social.
• Transportation and other services. As said several times, lack of
  resources such as transportation are often listed as barriers to getting
  effective care and treatment, and place additional burdens on already challenged
  and over-taxed health and human service providers. Transportation poses an
  additional expense in terms of both time and money. In North Carolina, lack of
  adequate transportation has been continually cited as a problem.
• Hot weather. Someone thought that long, hot summer days (and nights)
  would result in greater sexual activity and, we supposed, more unprotected sex,
  and ultimately, more HIV infections. We didn't agree, but thought it would be an
  interesting addition to this list. What do you think?

This is, of course, a quick summary of a number of very complex issues, each
of which could be dealt with much more extensively. One excellent organization
that works to address this issue is the Southern AIDS
Coalition, whose mission is to promote accessible and high quality systems
of HIV and STD prevention,
care, treatment, and housing throughout the South through a unique partnership
of government, community, people living with HIV disease, and business entities.
The Southern States Manifesto, updated in 2008, discusses HIV in
the South and proposes action steps and plans for addressing the situation.
Thanks again for reading.
Marc