Ending the HIV Epidemic in the United States Must Start with the South

The United States (U.S.) is at a crossroads for addressing the HIV epidemic in the southern states (“the South”). Since the height of the HIV epidemic in the late 1980s, prevention work has yielded tremendous successes. Scientific analyses, informed programmatic interventions, and community mobilization have substantially reduced new HIV diagnoses annually. However, progress has stagnated in recent years, as annual HIV diagnoses remain stable at approximately 40,000, and HIV-related disparities persist [1]. Disparities are especially evident in the South. Despite comprising just 38% of the U.S. population, the South represented 52% of HIV diagnoses and 45% of persons living with diagnosed HIV infection in 2017 [1]. Moreover, approximately 50% of all undiagnosed HIV infections during 2010–2016 occurred in the South [2]. The factors that contribute to the disproportionate HIV burden in the South are complex and multi-layered. The solutions will require in-kind responses to address these disparities.

Since the 1980s, programmatic efforts have produced numerous strategies, tools, and interventions to reduce HIV infection risk [3]. These advances include the growing sophistication of HIV testing technologies that have allowed individuals to become aware of their HIV status, be diagnosed at an earlier stage of infection, and access prevention or care services [4, 5]. Evidence-based behavioral interventions have been developed and disseminated to promote risk reduction practices such as consistent and correct condom use and partner communication [6]. Biomedical interventions involving the use of antiretroviral therapy (ART) represent a recent paradigm shift in HIV prevention strategies. For example, pre-exposure prophylaxis (PrEP), which involves the use of ART by persons without HIV infection to prevent HIV, has emerged as an effective strategy for reducing HIV acquisition risk [7]. Also, ART is used to prevent HIV by achieving and maintaining viral suppression among persons with HIV (PWH) so that they have effectively no risk of transmitting HIV to others [8]. These innovations are examples of inroads that have drastically improved the overall circumstances of the epidemic.

Unfortunately, such prevention strategies have been less successful in reducing HIV-related disparities in the South. These disparities are profound among men who have sex men (MSM) who account for 65% of HIV diagnoses in the South [9]. Disparities also exist among persons of color in the region. Blacks/African Americans and Hispanics/Latinos represent 53% and 21% of HIV diagnoses in the South, respectively; these percentages are disproportionate relative to their population sizes in the region [9]. Among Hispanics/Latinos in the Deep South, the HIV diagnosis rate increased 18% during 2012–2017 [9]. The data reflect the increased vulnerability of these populations in the South, as well as the limited benefit that existing prevention strategies and tools might have for these populations.

Social and structural factors that are especially prevalent in the South contribute to these disparities. Income inequality, poverty, and poor overall health are examples of systemic challenges that directly and indirectly increase HIV risk and related negative health outcomes among vulnerable populations in the region [10]. In addition, homophobia, racism, and HIV stigma are factors that are particularly prevalent in the South [11]. The various expressions of stigma can impede the most at-risk individuals (e.g., Black/African American MSM) from accessing HIV prevention services [12]. The South also includes large populations residing in nonmetropolitan areas characterized by disproportionately high HIV incidence and diagnosis rates compared to nonmetropolitan areas in other U.S. regions [9]. Increasing HIV and hepatitis C comorbidity is also emerging in nonmetropolitan areas of the South, which reflects the region’s growing opioid crisis driven by injection drug use [13]. Much of HIV transmissions in the South is from the approximately 81,900 persons with undiagnosed infection [2], who, along with diagnosed but untreated persons, likely contribute to over 80% of all new infections in the region [2].

New approaches are needed to better address the multi-layered and fluid social and structural factors that contribute to these disparities and are relevant for both local and regional public health responses across the South. Consequently, the Centers for Disease Control and Prevention (CDC) has recently realigned funding and programmatic efforts to better allocate resources to the right people in the right places [14]. Government efforts alone cannot improve these circumstances. Success will require broader vision focused on the underlying causes of HIV-related disparities. Active engagement among community stakeholders and public health partners throughout the region can facilitate success.

On April 19, 2017, CDC held its first ever “HIV in the South” town hall meeting [14]. This meeting focused on reducing HIV-related disparities in the Deep South states: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas. Invited individuals included persons from these regions with expertise in HIV prevention. The purpose of the meeting was to obtain the perspectives and opinions from participants to inform CDC’s future HIV prevention efforts in the South.

Participants discussed a range of challenges and lessons learned from their experiences in addressing HIV prevention in their respective southern jurisdictions [14]. Common challenges mentioned across several breakout discussions included HIV-related stigma, provider barriers, immigration status and lack of prevention efforts for persons at high risk for HIV infection. They also shared several successes and lessons learned from their experiences. Discussions included innovative approaches to engaging gay and bisexual men and Hispanic/Latinos; ideas for promoting PrEP use; developing more effective service delivery models for persons living with and without HIV; and creating local, state, and federal partnerships to address social determinants of health. The general sentiment was clear: a “one-size-fits-all” approach has not worked and will not work for ending HIV in the South. Synergistic and scientifically-sound initiatives are required; health equity must be at the core of such efforts.

Both CDC officials and town hall participants were fully aware that the productive one-day meeting would be meaningless without informed and deliberate follow-up action. They concluded that subsequent steps must include in-depth inquires and innovative strategies to inform future directions for HIV prevention in the South. Prevention strategies will need to involve a broad spectrum of perspectives including those from government, academia, and community-based organizations.

This AIDS and Behavior special issue, “HIV in the South: Context, Responses, Challenges, and Partnership Opportunities for Ending the Epidemic,” represents one of these outputs from the town hall intended to extend the discourse. The original call for papers outlined thematic tracks that reflect major topics shared during the April 2017 meeting. The themes included the following: (1) epidemiology and context of HIV; (2) programmatic responses and challenges; and (3) partnerships and collaboration. These manuscripts address a range of research topics and analyses to inform HIV prevention activities in the South.

This special issue also coincides with the recently announced federal initiative titled Ending the HIV Epidemic: A Plan for America (EHE) [15]. This national initiative will provide enhanced levels of resources for state and territorial health departments to reduce new HIV infections in the United States by more than 90% over 10 years. The overall strategic approach entails leveraging scientific advances in HIV prevention, diagnosis, and treatment via coordination of multiple resources and programs. This collection of manuscripts is a timely resource that can help support local EHE jurisdictional planning in the South, the region most in need of this targeted initiative.

Given the regional burden and existing disparities, eliminating HIV in the United States must include intensified action and resources for the South. Scientific analyses and programmatic lessons learned focused on this region need to be at the forefront of this national initiative. Broad-based regional collaborations and community-derived plans must address social and structural inequities that contribute to the HIV rates in the South. The articles included in this special issue represent a small effort towards this cause. Without this and other similar discourse, we risk squandering this unique opportunity to make historic inroads into the HIV epidemic and save countless lives, particularly those in the South.