Overlap of HIV and low health literacy in the southern USA

The HIV epidemic has plagued the USA for 30 years. Over 1 million people are infected,¹ and the burden of HIV and HIV case fatality rates are highest in the south.² A study by Reif and colleagues² found that nine southern states sometimes referred to as the deep south—Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas—have the highest prevalence and rate of diagnosis of HIV in the USA.² Although the deep south has only 28% of the US population, these states account for 38% of HIV diagnoses in the USA.² Additionally, the 5 year survival of the deep south population with HIV is lower and their death rate is higher than in the rest of the country.²

The excess burden of HIV in the southern states has been attributed to many factors including poverty, overall health status of southern residents, increased rates of sexually transmitted infections, lower rates of insurance coverage, stigma, and inadequate education about HIV prevention.² The disproportionate burden of HIV in the deep south is also influenced by racial disparities in the HIV epidemic. Specifically, African-Americans are disproportionately affected by HIV nationally³ and in the deep south.² 54·2% of people with HIV in the deep south are African-American, compared with 43·6% nationally.² Furthermore, African-Americans in the region have lower HIV and AIDS survival rates than other racial and ethnic groups.²

Low health literacy is one under recognised potential contributor to the HIV epidemic among African-Americans, especially in the southern states. As noted in an editorial in The Lancet, health literacy is a “silent epidemic” that “exacerbates health inequity”.⁴ Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”.⁵ Low health literacy is more common among African-Americans than among people of European descent⁶ and has notable disparate regional effects. Whereas 14% of people nationally have below basic literacy skills,⁶ the in the deep south the proportion is 17%.⁷ Low health literacy is associated with low use of preventive health services⁸ and poorer health outcomes,⁹ and could contribute to worse HIV outcomes among African Americans in the deep south.² In fact, health literacy level—rather than race—might be a more salient factor in use of preventive health services and in the prediction of health outcomes.¹⁰

Unfortunately, low health literacy among African-Americans increases the likelihood of people being unaware of or not knowing about HIV transmission risks.^11,12 Not understanding how they can acquire HIV may partly explain why many African-Americans get tested late, resulting in less time for the morbidity and mortality benefits of antiretroviral therapy and other health-care interventions.³ Low health literacy also seems to affect HIV disease management. Among a predominantly African-American HIV-infected popu-lation, people with low health literacy were less likely to be on¹³ or to adhere to¹⁴ antiretroviral therapy than were those with higher health literacy and were more likely to have low CD4 cell counts¹³—all known mediators of HIV mortality.¹³ Additionally, HIV positive patients with low health literacy have less understanding of HIV-related health indicators, another mediator of health status and outcomes.¹³

Given that the regional and demographic differences in health literacy levels are similar to the patterns seen in HIV and HIV health outcomes in the deep south,^2,6,7 poor health literacy might be a crucial contributing factor to the high burden of and mortality from HIV among African-Americans in the region. To date, the link between health literacy and HIV has not been fully explored, and the link between health literacy and HIV prevention, including HIV testing, is even less well understood. Research is needed to explore whether assessing and promoting health literacy might improve access to and use of HIV prevention and care initiatives. This is crucial for African-Americans and an important step to combating the HIV epidemic among this population, especially in the deep south.