Among those that are HIV-positive or have AIDS, southerners have the lowest five-year survival rates, Duke research finds.
In a study published in the December edition of the Journal of Community Health, researchers from Duke—in conjunction with University of North Carolina at Chapel Hill Gillings School of Public Health and the Southern HIV/AIDS Strategy Initiative—found new evidence that indicates HIV diagnosis rates and death rates are higher in the South than in any other region of the United States.
The research was aggregated more than ten years of data from the Centers for Disease Control and Prevention to examine the characteristics of people diagnosed with HIV or AIDS in nine southern states—including North Carolina, Alabama, Florida, Georgia, Louisiana, Mississippi, South Carolina, Tennessee and Texas. The research revealed that beginning in 2003, the five-year survival probability among those diagnosed with HIV/AIDS in the South was lower than the national average and that of any other region.
“There’s a persistent public perception that HIV is a disease of young gay white men in New York and San Francisco, and that hasn’t been the case for 20 years or more now,” said Brian Wells Pence, assistant professor of epidemiology at Gillings and one of the authors of the study.
The ultimate goal is to use research to inform SASI's advocacy agenda, focused on getting increased prevention and care funding for the Southern states, said Carolyn McAllaster, a professor at the Duke School of Law who heads the Southern HIV/AIDS Strategy Initiative.
“We ultimately want to look at the drivers of the epidemic, and how we can seek funding for more effective interventions that target those specific drivers,” she said.
Susan Reif, lead author of the study and a researcher from the Center for Health Policy and Inequalities Research at the Duke Global Health Institute, said these statistics are evidence that the characteristics and life outcomes of people with HIV are different in the deep South.
“We found that in the targeted states more than other U.S. regions, people are more likely to be younger, female, African-American or of a minority, and living in a rural area,” Reif said.
Evaluating the characteristics of those with HIV/AIDS documents how the epidemic is shifting in the South, and enables the framing of more effective policy solutions for the region, McAllaster said.
The study also found that in 2011, those diagnosed with HIV in the targeted states represented 38 percent of all individuals diagnosed in the entire country that year. Almost a quarter were female, and 57 percent were African-American.
Despite differences in demographic makeup between the South and other regions of the US, the researchers found other factors accounted for the South's high HIV prevalence. Reif explained that even after controlling for race, age, gender and rural living, the South still demonstrated the highest death rates. She attributed these rates to elements such as poverty, education, health systems and social stigma.
“The fact that we have such high death rates and lower survival rates is probably telling us that people are getting diagnosed but they’re not staying in care,” McAllaster added. “Because if an HIV-positive person stays in care and is in treatment, they can live a normal lifespan.”
Although the study did not collect data on the stigma surrounding HIV/AIDS, the researchers agreed that the stigma is more pronounced in the South, especially because the disease is more concentrated in rural areas. Rural states typically hold more conservative views, and Reif added that being HIV-positive in the South is often related to sexual orientation issues.
The stigma associated with HIV/AIDS also acts as a disincentive to getting tested, getting treatment, and taking medication, Pence said. He added that states in the deep South have some of the most stringent qualification criteria to receiving HIV treatment.
"There are a lot of people who can’t afford health insurance and can’t afford to be on medication,” he said. “Enabling people to get on treatment is a major public health priority, and it’s an area this region is lagging behind in.”
SASI plans to study the role of stigma as a barrier to treatment and to seek funding for the most effective interventions, McAllaster said. She added that one of the CDC's funding policies delegates a majority of money to large urban areas, despite the HIV epidemic's concentration in smaller rural cities.
"So we’ll use these findings and advocacy with the CDC to examine that money-allocation policy," she said.
As further questions arise from this study, SASI is looking to conduct more research on the impact of HIV-associated stigma in the South and to address the other factors behind HIV prevalence.
“It’s exciting to have this great partnership between advocacy and research,” Reif said. “We’re pleased to see advocacy being evidence-based; it just makes a lot more sense.”
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