SOCIAL DETERMINANTS OF HIV INFECTION IN THE DEEP SOUTH

The commentary presented by Reif et al.1 summarizing the state of HIV in the southeastern United States did not fully address key determinants that explain, in part, how the interaction between individual-level factors, patterns of sexual partnerships and sexual networks, and societal forces affect HIV transmission.

The lack of viable employment, quality education, access to medical care, decent housing, pleasant neighborhoods, and overall community infrastructure perpetuates economic inequalities among African Americans.2 These contextual features promote health disparities, including HIV. For example, a population-based, case–control study of HIV in a rural community of Florida illustrates these points. In adjusted analysis that controlled for individual risk behaviors, residence in neighborhoods where prostitution and crack cocaine use occur was also associated with HIV.3

In addition, the crack epidemic over the past 20 years has fueled the “war on drugs,” which has disproportionately affected African Americans.4 The threshold for incarceration for drug-associated offenses was lowered and sentencing laws for these offenses toughened. Although African Americans account for 12% of the population in the United States, approximately 40% of incarcerated persons are African American, and 12% of African American men 18–29 years-old were incarcerated in 2005.5 Ecological studies demonstrate that high incarceration rates are correlated with elevated rates of sexually transmitted infections and adolescent pregnancies, which are also characteristic of counties in the United States that experienced the highest rate increase in AIDS over the past decade.6^,7

Furthermore, the loss of African American men from their communities, in part because of excess incarceration and mortality rates and the low ratio of African American men to women, has affected sexual partnerships and sexual networks in ways that exacerbate sexually transmitted infection transmission and heterosexual HIV infection.2 Incarceration disrupts sexual relationships. Qualitative data suggest that incarceration promotes concurrent sexual partnerships, which has been confirmed quantitatively in a study of African Americans in eastern North Carolina.8^,9 Concurrent sexual partnerships are a feature of sexual networks that accelerate HIV transmission. The shortage of men also promotes discordant sexual mixing patterns between predominately lower-risk African American women and men at higher risk for HIV.2 Not surprisingly, young African American women in the South are the fastest growing population with heterosexually acquired HIV.10

Contrary to the authors’ suggestion that “little research has been published regarding the cause of the sharp increase in HIV/AIDS in the Deep South,”1^(p972) we understand much more about the HIV epidemic in the South than was presented in this commentary.