HIV/AIDS in the South A Tale of Two Souths & the Great Equalizer


GONE WITH THE WIND are the Antebellum days of Scarlet O’Hara’s Old South. Since the Civil War (AKA the War of Northern Aggression), the New South has experienced unprecedented economic growth. However, it seems A Tale of Two Cities is a more accurate literary representation.

As the first chapter opens: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way…”

And so it seems when one observes the disparity in prosperity between our southern metropolitan areas and our southern rural areas.

Except for HIV/AIDS. The great equalizer of the South.

When we compare the rural South to the metropolitan areas of the South, there is little difference in the HIV/AIDS epidemic. In 2011, the Southern states of Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas made up 37 percent of the US population, yet accounted for 49 percent of all new HIV/AIDS cases.

These targeted states had the highest new HIV diagnoses rates, as well as the highest AIDS mortality rates. Seven of the 10 metropolitan areas with populations of at least 500,000 with the highest HIV diagnoses rates were in these targeted Southern states and they also have the highest number of individuals living with HIV, death rates greater than the US average, and the highest STI rates.

HIV/AIDS disproportionately affects Blacks, Latinos, the poor, and the disenfranchised in both the rural South and in the Southern metropolitan areas. And while these two Souths may look very different, the unmet needs of these groups are very similar. Access to healthcare, transportation, food security, housing security, childcare, consistent telephone service, for example, are challenges for both South lands.

In addition to unmet needs, there is stigma and discrimination to the vulnerable sub-populations, such as men who have sex with men (MSM), transgender/transidentified individuals, and sex workers. The stigma and discrimination occurs both from within and from outside of these groups.

Religious persecution in the Bible Belt states is rampant. The dichotomy between love and judgment within our houses of worship, particularly, impact these vulnerable groups.

Healthcare and Other Concerns

While access to healthcare is being addressed through the implementation of the Affordable Care Act (ACA), the targeted states region is unlikely to benefit from the ACA because none of those states have elected to implement Medicaid expansion yet. They are likely to experience a greater disparity in the resources available to individuals living with HIV/AIDS.

Many of the unmet needs our patients experience in the rural South, as well as in the metropolitan areas, are due to poverty. Poverty reaches 50 percent or more in many areas. A collaborative partnering at the local, state, and federal level is required to address the unmet needs tied to poverty.

The stigma and discrimination from without and within the vulnerable groups are more complex. What our patients espouse in the office is often not what is espoused in the barber shops and beauty salons.

Distrust, misinformation, and suspicion must be dispelled calmly, with patience and forgiveness. The medical community has proffered much harm to our patients, including The Tuskegee Syphilis Trials between 1932 & 1972, the pseudoscience of reparative/conversion therapy, the outcasting/second classing of transidentifying patients, and the marginalizing of sex workers.

The Southern medical community’s knowledge base must be improved, as well as the patient knowledge base. There is a misconception in both communities that HIV is a death sentence.

The Multicenter AIDS Cohort Study (MACS) of 1984 stated a patient diagnosed with HIV at that time had approximately 18 months to live. With the advent of highly active antiretroviral therapy (HAART) in 1995, the paradigm of palliative care shifted to one of longer life. Indeed in 1997, the MACS reassessed the data and decided a patient had approximately 10 years to live. In 2010, the MACS reassessed the life span to 20 years. And in 2012, the data revealed that with proper adherence to medications coupled with diet and lifestyle modification, HIV would not appreciatively shorten the lives of patients.

As I travel the Southern US lecturing on HIV/AIDS, I am continually amazed at medical professionals and patients who are unaware of this data.

The medical community is woefully undereducated on post exposure prophylaxis (PEP). Emergency Departments (ED’s) in many hospitals have refused to test and start PEP, despite state guidelines being amended to match the CDC recommendations.

Pre-exposure prophylaxis (PrEP) with Truvada is understood even less. Despite the literature citing 96 percent efficacy with daily use, matching condom efficacy, the medical community has been slow to discuss and prescribe PrEP because of a general concern that prescribing PrEP will promote sex without a condom.

As a medical provider in the daily trenches of HIV/AIDS care, I can confirm we have already lost the battle in condom use. Condom fatigue and sero-sorting have won

A Team Effort

President Obama, in his World AIDS Day address December 2, 2013, referenced the three goals of the National HIV/AIDS Strategy (NHAS): 1) reducing HIV incidence, 2) increasing access to care and optimizing health outcomes, and 3) reducing HIV-related health disparities. He said the success we have experienced in the field of HIV care has not been achieved
by a single government or foundation or corporation working alone. It is the result of countless people.

In our clinic, the healthcare team includes the receptionist, the nursing staff, the phlebotomist, the billing clerk, medical records, the patient advocates, the physician assistant, the
physician, and yes, the cleaning crew. From the clean rooms we use, to the medications we prescribe, each of us contributes to the care of our patients.

In Charlotte and surrounding communities, our HIV care team includes the community based organizations (CBO’s), AIDS Service Organizations (ASO’s), local pharmacists and their adherence counseling, philanthropists small and large, houses of worship, civil society, activists, and most of all, our patients who have stood up and demanded care with dignity
and respect.

So where do we go from here?

The Southern HIV/AIDS Strategy Initiative (SASI) report, HIV/AIDS in the Southern US: Trends from 2008–2011 Show a Consistent Disproportionate Epidemic, has identified the need for a “holistic approach that includes local, state, and federal partnerships and has addressed the multiple factors that contribute to the disproportionate epidemic in the South, such as lack of resources and regional resource inequities, as well as stigma and high STI rates, are needed to adequately address HIV in the region.”

Only through partnership and collaboration can we address the epidemic of HIV in the South. Communities, states, patients, and the entire healthcare teams must work together to define the need, identify the resources and opportunities, and enact change.

Maybe then we will have the new New South.