Transcript HIV/AIDS in the Southern United States SASI Study Data Report funded by the Ford Foundation Susan Reif, Duke University Center for Health Policy and.

HIV/AIDS in the Southern
United States
SASI Study Data Report
funded by the Ford Foundation
Susan Reif, Duke University Center for Health Policy and Inequalities
Research
SASI Research Reports
 Initial SASI analysis report (December 2011): Included 2009 HIV
epidemiology, outcomes, care financing, and factors
contributing to the Southern HIV epidemic.
http://southernaidsstrategy.org/research/
 Update of Southern HIV epidemiology and care financing for
2010 included on the SASI website and update of HIV
epidemiology for 2011 published in the journal AIDS Care.
http://www.ncbi.nlm.nih.gov/pubmed/23944833
 A report on HIV in Southern metropolitan areas was released
in July 2013 on the SASI website.
http://southernaidsstrategy.org/research/
Definitions

Southern United States (Census Definition): AL, AR,
DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN,
TX,VA, WV, DC

HIV Diagnosis Rate: Newly diagnosed cases of HIV
per 100,000 population

HIV Prevalence Rate: People living with HIV per
100,000 population
HIV and AIDS Diagnoses Rates, 2011

The rate of new HIV diagnoses per 100,000 population in the
Southern US was the highest of any US region.

Eight of 10 states/DC with the highest rates of new HIV diagnoses
were located in the South (DC, FL, GA, LA, MD, MS, SC, TX).

Nearly half (49%) of new HIV diagnoses were in the South although
the South accounted for only 37% of the US population.

The South accounted for 49% of new AIDS diagnoses and had the
highest AIDS diagnosis rate of the 4 Census Bureau regions.
Data from the CDC HIV Surveillance Report for 2011
http://www.cdc.gov/hiv/pdf/statistics_2011_HIV_Surveillance_Report_vol_23.pdf
HIV Diagnosis Rates, 2011
HIV and AIDS Prevalence Rates (rates of
people living with HIV)
 42% of people living with HIV in the US reside in the
Southern region (2011).
 The Southern region has the second highest HIV
prevalence rate per 100,000 population.
 AIDS prevalence is also high in many Southern states, as
Southern states/District of Columbia represent 6 of the
10 areas with the highest AIDS prevalence rates (DC,
MD, FL, DE, GA, LA).
CDC HIV Surveillance Report for 2011
Characteristics of Individuals with HIV
in the South
 A majority of HIV diagnoses (57%) in the South were
among African Americans (2010).*
 The South had the highest proportion of HIV diagnoses
among individuals in rural areas (11%). A majority (65%)
of individuals with HIV who live in rural areas reside in
the South.*
 6 of 10 states with the highest HIV diagnosis rate among
Latinos in 2011 were in the South
(http://www.cdc.gov/hiv/pdf/statistics_surveillance_raceEthnicity.pdf).
*Prejean et al. 2012. HIV diagnoses and prevalence in the southern
region of the United States, 2007-2010. Journal of Community Health)
HIV in 9 Targeted Southern States
 A group of Southern states has been particularly
affected by the HIV epidemic in recent years and shares
common characteristics such as overall poorer health,
high poverty rates, and a cultural climate that likely
contributes to HIV infection and poorer HIV outcomes.
(AL, FL, GA, LA, MS, NC, SC, TN, TX/East Texas)
 HIV and other STDS disproportionally affect the targeted
states and the states share similarities in HIV-related
outcomes.
HIV Diagnosis Rate/100,000 population
HIV Surveillance Report 2011
25
20
15
10
5
0
Northeast
Midwest
West
South
Targeted States
US
HIV/AIDS in the Targeted States,
2011
 The targeted states have the highest HIV and AIDS
diagnosis rates when compared to other US regions
 Six of 10 states with the highest rates of new HIV
diagnoses are targeted Southern states (FL, GA, LA,
MS, SC, TX).
 Nearly one-third (32%) of HIV diagnoses were in the
targeted states, which contain only 22% of the US
population.
CDC HIV Surveillance Report for 2011
HIV/AIDS in the Targeted States
 Seven of the 10 metropolitan areas (MAs) with the
highest HIV diagnosis rates were in the targeted
states in 2011
 9 of the 10 MAs with the highest AIDS diagnosis rates
were in the targeted states in 2011. The MA not in
the targeted states was Baltimore MD.
CDC HIV Surveillance Report for 2011
10 Cities with Highest AIDS Diagnosis Rate, 2011
Rural HIV in the Targeted States
Deaths from HIV Disease, 2010
HIV Death rate: Deaths from HIV per 100,000 population in
a given year
8 of 10 states/district with the highest HIV death rates in
2010 were in the South.
5 of these states were targeted states (FL, GA, LA, MS,
SC).
All of the targeted states were among the 15 states with
the highest HIV death rates in the US.
Kaiser Family Foundation, State Health Facts (www.statehealthfacts.org)
HIV Case Fatality Rate (2001-2007)
HIV Case Fatality Rate: Deaths from HIV per 1000 persons
with an HIV diagnosis in a given year
Nine of the 10 states with the highest case fatality rates
were in the South; 8 were targeted states (MS, LA, OK,
NC, TN, GA, SC, AL, FL).
Mississippi had the highest case fatality rate in the US.
*37 states with data from available data; Hanna D, Selik R, Tang T, Gange S.
Disparities among states in HIV-related mortality in persons with HIV infection,
37 U.S. STATES, 2001-2007. AIDS. 2011.
3 Year Survival Post AIDS Diagnosis
 7 of the 9 targeted states had 3-year survival rates for
individuals diagnosed at Stage 3 (AIDS) in 2006 lower
than the US average.
 The US average percentage of individuals surviving 3
years post AIDS diagnosis was 84% whereas the
percentage of individuals surviving after 3 years in
Louisiana was 76%.
CDC (2012). Monitoring selected national HIV prevention and care objectives by using HIV
surveillance data. Surveillance Supplemental Report,
http://www.cdc.gov/hiv/library/reports/surveillance/2010/surveillance_Report_vol_18
_no_2.html
HIV Care Financing Issues
 The Ryan White funding inequities for the Southern US,
particularly the targeted states, detected in the early
2000s appear to have narrowed, however an estimated
gap between the targeted states and the US average in
overall Ryan White funding per person living with HIV
was $180 in 2011.
 The South provided Medicaid coverage for a lower
proportion of individuals with HIV in the region when
compared to the national average in 2010.
Data from Kaiser State Health Facts, statehealthfacts.org
Factors Contributing to the Disproportionate
HIV Epidemic in the Southern US
 Overall poorer health: - 8 of the 10 states with the worst
health ratings were in the South in 2012.
(http://www.americashealthrankings.org/rankings).
 Higher rates of STIs: 8 of 10 states with the highest Chlamydia
rates in 2011 were in the South; 6 targeted states.*
 Economics: The South has some of the lowest median income
figures in the country, as 8 of 10 states with the lowest
median incomes from 2010-2011 were located in the South; 5
were targeted Southern states.*
*Data from Kaiser State Health Facts, statehealthfacts.org
Poverty and HIV Case Fatality
Contributing Factors –
Race/Ethnicity
 African Americans are disproportionately represented in
low-income communities and among the uninsured.
 Even after controlling for poverty, African American race
has been consistently associated with poorer health.
 A report by the National Minority AIDS Council discussed
contributing factors to HIV among African Americans
such as unstable housing, higher rates of incarceration,
stigma, and lack of trust in the government.
References in the SASI report (http://southernaidsstrategy.org/research/)
Contributing Factors – Stigma
 The cultural conservatism in the South likely plays a role in
stigma for people living with HIV.
 NASTAD study identified greater HIV-related stigma in the
South and Midwest. (http://www.nastad.org/Docs/042244_SlidesNASTAD-Stigma%20Seminar-and-Public-Health-USCA-2012-09-24-12-FINAL.pdf)
 HIV-related stigma has been found to negatively affect
preventive behaviors, care-seeking and adherence, mental
health, and quality of care
(http://southernaidsstrategy.org/research/).
Contributing Factors - Policy
 Lack of evidence-based sex education in the South
 Criminalization of HIV-related behaviors
 Lack of Syringe Exchange Programs
Information from Kaiser State Health Facts and Human Rights Watch.
Southern Exposure: Human Rights and HIV in the Southern United States.
2010
Conclusions
 CDC data indicate a consistent and disproportionate
effect of HIV in the Southern states; particularly the
targeted states.
 HIV case fatality rates in the South, especially in the
targeted states, are striking and indicative of the
critical need to improve HIV detection/treatment.
 Economic and social factors such as poverty, stigma and
culture are all interrelated, each affecting the others,
and all contributing to the disproportionate share of HIV
in the US South.
Ingredients for a successful
research/advocacy partnership
 A well defined research agenda that is both feasible
from a research standpoint and relevant for advocacy
efforts
 A commitment to unbiased research and research
results findings
 Education from both research and advocacy partners
regarding terminology (jargon), critical concepts and
ideas and willingness to learn from partners
 Common goals (i.e publishing, policy)
SASI Analysis Plans 2013-2014
 Examine trends in HIV diagnosis and prevalence,
now that 4 years of more consistently reported
data are available (2008-2011).
 Replicate the CDC Southern HIV Analysis using data
from the Targeted States – CDC/SASI collaboration.
Prejean et al, Journal of Community Health
 Examine demographic characteristics of newly diagnosed
individuals and compare targeted states to other regions
 Calculate 3 year HIV survival rates and compare targeted
states to other regions
Additional Planned SASI Analyses
 Examining the HIV cascade: What data are available in
the targeted states and what data need to be collected
 Comparing HIV testing in targeted states to other
regions
 Examining HIV prevention and care efforts in DC to
assess for interventions that could be replicated in the
targeted states
 Availability of HIV specialists in the targeted states in
comparison to other regions
HIV Infrastructure Study
 Study HIV care and prevention infrastructure in specific
targeted state cities by examining available data and
conducting key informant interviews and focus groups to
determine:
 HIV prevention services structures and challenges
 HIV care services: funding, community support, availability
 Stigma and other barriers to HIV care and prevention
 Compare targeted state cities to cities in other regions that
have similar demographics but lower HIV disease rates