March 9, 2011

IV. Background

HIV/AIDS continues to pose a major public health threat in the United States. Every nine-and-a-half minutes someone in the US is infected with HIV; 56,000 people are newly infected each year. More than 1.1 million people are living with HIV, and almost half of Americans know someone infected with the virus. [1] AIDS is caused by the human immunodeficiency virus, or HIV. HIV progressively destroys the body's ability to fight infections and certain cancers by killing cells in the immune system called CD4+ T (CD4) cells. Regular monitoring of CD4 cells and the amount of HIV in the body, or viral load, is essential to determining appropriate treatment. Antiretroviral therapy (ART) treats HIV with a combination of medications, each of which attacks the virus's life cycle in a different way. Based on laboratory test results, doctors also prescribe different prophylactic drugs to prevent patients from developing opportunistic infections such as pneumocystis pneumonia (PCP). [2]

A key aspect to achieving the benefit of ART is full adherence to the therapy regimen. Due to the rapid multiplication and mutation rate of HIV and other factors, very high levels of adherence to antiretroviral schedules are necessary to avoid viral resistance. In comparison with patients who are adherent to ART, non-adherent people have higher mortality rates, less improvement in CD4 cell count, and spend more days in the hospital. Viral resistance not only affects the health of the individual but also that of the community, as resistant strains can be transmitted to others.[3]

In the United States, racial and ethnic minorities bear the overwhelming burden of the disease. Comprising just 13 percent of the US population, 46 percent of people living with HIV/AIDS are black. Blacks are disproportionately represented in every transmission category, including men who have sex with men, women, heterosexual men, injection drug users, and children.[4] The President’s Office of National AIDS Policy has called the toll of the epidemic on the black community “staggering.”[5] Latinos and Asian-Pacific Islanders also have rates of HIV infection out of proportion to their numbers in the general population.[6]

The South is at the epicenter of the HIV epidemic in the United States,[7] with more people living with HIV and dying of AIDS than in any region in the country. The South has:

  • the highest rates of new infections,
  • the most AIDS deaths,
  • and the largest numbers of adults and adolescents living with HIV/AIDS.[8]

Though only 36 percent of the US population lives in the region, about half of people living with HIV or AIDS in the US live in the South.[9]

HIV has had a particularly devastating impact on minorities in the South. In southern states such as Alabama, Louisiana, Georgia, and Mississippi, blacks comprise approximately 30 percent of the population but have 65-75 percent of HIV cases.[10] Of the 10 states with the highest rates of new HIV diagnosis for Latinos, seven are in the South.[11]

People living with HIV in the South die of AIDS at a higher rate than in other regions. [12] A recent study found that being black, female, and living in the South were all associated with “substantially higher rates of death from AIDS” than in other geographic areas including other countries such as Canada, Australia, and Brazil. [13] In the South, many people are diagnosed with HIV late in the progression of the disease, at or near the point of full-blown AIDS, when treatment is less effective. [14] In many southern states, including Mississippi, more than half of people who test positive for HIV do not get adequate care. This is significantly higher than the national percentage of 33 percent of people living with HIV who are not in care. [15]

The concentration of the HIV epidemic in the South is not new or sudden: between 2000 and 2003 the number of AIDS cases rose 35.6 percent in the six states that comprise the Deep South, while rising 5.2 percent nationally.[16] By 2003 the South led the country in people living with HIV, people dying of AIDS, and diagnoses of AIDS.[17] Yet federal funding for HIV/AIDS, chronically inadequate to address the nation’s epidemic, has shortchanged the southern region for decades by relying on a formula based on cumulative AIDS cases, including deaths from the disease since the 1980s, rather than targeting money toward areas with rising rates of infection.[18] The Obama Administration’s National AIDS Strategy acknowledges this problem and declares an intention to rectify it, but it remains to be seen whether that intention will translate into a revised funding formula or the equally important goal of adequate funding for HIV nationally.[19] Moreover, changes in federal policy alone are not enough. In many states in the South, socio-economic conditions combine with discriminatory, stigmatizing, or ineffective state laws and policies that are incompatible with human rights and put people at risk for HIV infection or exclude them from care.[20] Strong federal and state leadership is required to address state policies if the goals of the National AIDS Policy are to be realized.

HIV/AIDS in Mississippi

Mississippi is a state of 2.9 million people living in 82 counties. More than half of the population lives in rural areas, and Jackson, the largest city, has fewer than 250,000 people. [21] Mississippi is not a healthy state. Mississippi ranked last of 50 states and the District of Columbia in two recent evaluations of “overall health” that examined a wide variety of factors including poverty and access to health care, quality of care, education levels and health literacy, obesity and nutrition, infant mortality, and life expectancy. [22] On a “human development” index that rated factors such as capability to earn an adequate living, to make decisions about one’s own life, to have access to quality education and health care, enjoy cultural liberty, and live free from fear and violence, Mississippi ranked lowest of 50 states. Moreover, the index was marked by significant racial disparities, with levels of education, health, and income for African-Americans well below those of white residents of the state. [23]

Mississippi is one of the poorest states in the nation. Median household income in Mississippi was $36,646 in 2009, well below the national median of $50,221.[24] One in five people live below the federal poverty line ($22,000 in annual income for a family of four), the most of any state in the country.[25] In some economically depressed counties of the Mississippi Delta almost half of the population (48 percent) live below the federal poverty level.[26] In Mississippi, 28 percent of children live at or below the poverty level, compared to 19 percent nationwide.[27] Blacks live in poverty at three times the rate of whites.[28] Compared to 14 percent of whites, 43 percent of black children live in poor families.[29]

Poverty is strongly linked with health disparities in the United States, as low-income people have less access to health coverage, less stable housing, and less healthy environments.[30] Poverty particularly impacts people with HIV as higher rates of homelessness, poor overall health, and drug dependence often combine with lack of access to health care to raise the risk of infection and produce significantly worse outcomes in HIV-positive persons, particularly in the South.[31]

The US Centers for Disease Control and Prevention (CDC) recently found that heterosexuals living in urban poverty are five times more likely to be HIV-positive than their wealthier counterparts, citing the importance of factors such as homelessness and lack of access to health care as critical obstacles to HIV prevention efforts. The CDC study recommended a similar study of HIV and poverty in rural areas, particularly in the South where rural poverty and HIV rates are high.[32]

The Mississippi Department of Health in the State Comprehensive HIV/AIDS Plan for 2009 recognized the impact of poverty on HIV:

The link between low economic status and HIV risk exacerbates the existing barriers of effective behavioral intervention, testing, early diagnosis and early intervention for newly infected persons.[33]

Mississippi has the 10th highest rate of AIDS diagnosis among US states and the 16th highest rate of diagnosis of HIV.[34]In 2009 the state had 9,212people living with HIV or AIDS.[35]According to the Mississippi Department of Health, this figure underestimates the HIV/AIDS population, as 10-25 percent of people living with HIV in the state are considered to be unaware of their status.[36] The number of people living with HIV or AIDS in the state increased nearly 5 percent during the period 2007- 2009. The number will continue to rise as the advent of antiretroviral therapy reduces deaths from the disease, as will the need for a range of HIV-related services.

Racial and ethnic disparities in HIV/AIDS are dramatic in the state. Blacks comprise 37.5 percent of the population, but 72 percent of Mississippians living with HIV/AIDS are African-Americans. Of newly diagnosed HIV infections, 76 percent are in African-Americans. The death rate from HIV among African-Americans is 10 times that of whites. Among the Hispanic population, Hispanic males are infected at a rate four times that of whites, and Hispanic females are infected at a rate eight times that of whites.[37]

The largest proportion of HIV cases are diagnosed in men who have sex with men. Women having sex with men are the next largest category of infection; injection drug users are the smallest category.[38] Overall, the epidemic in Mississippi has remained relatively stable since 2000, with minor changes in the number of new cases diagnosed each year in the last decade. Specific populations, however, have seen variations in the rates of infection. For example, HIV cases among women, both white and African-American, have reduced in the last several years.[39]

However, Mississippi has seen an alarming rise in the number of HIV cases among young black men who have sex with men. Between 2005 and 2007 the cases of HIV diagnosed in black men ages 13-31 increased by 48 percent.[40] This prompted an investigation in 2008 by the CDC and the Mississippi Department of Health. The investigation found high rates of unprotected anal sex combined with low rates of awareness of potential risk of HIV infection. The majority of HIV-infected men who participated in the study was also uninsured, had no primary health care provider, and was unlikely to have been previously tested for HIV.[41]

Most people living with HIV in Mississippi are in the 25-44 year old age group. But Mississippi’s epidemic is becoming younger, as 13-24 year olds have replaced 45-64 year olds as the state’s second-largest category of both new infections and people living with HIV. [42]

Many Mississippians living with HIV are not receiving treatment. The US Health Research and Services Administration (HRSA) requires each state receiving federal HIV/AIDS funding to report an estimate of “unmet need” for HIV care and services. This is defined as the percentage of people who have been tested for HIV and are aware of their status but have not received basic health care services for HIV.[43] In Mississippi, estimates of “unmet need” are at least 50 percent, significantly higher than the national average of 33 percent.[44] The Director of Mississippi’s STD/HIV Office said:

Save yourself a transatlantic airline fare to a developing country. Just come to Mississippi, where we have a vast underserved population.[45]

In Mississippi, the percentage of people with HIV not receiving care or support services is comparable to that in Botswana, Ethiopia, and Rwanda.[46]

[1] US Centers for Disease Control (CDC), Estimates of New HIV Infections in the United States, August 2008; Hall, H., et al, “HIV Infection- United States, 2005 and 2008,” in CDC, Morbidity and Mortality Weekly Report, “CDC Health Disparities and Inequalities Report- United States 2011,” January 14, 2011, p. 87.

[2] Department of Health and Human Services, Guidelines for the use of Antiretroviral agents in HIV-1 infected adults and adolescents, January 2011.

[3] Ibid.

[4] CDC, HIV/AIDS Surveillance Report 2007; CDC, HIV/AIDS Surveillance by Race/Ethnicity, slide set, 2007.

[5] G. Millett, Office of National AIDS Policy Blog, “White House Meeting on Black Men and HIV,” June 4, 2010, http://www.whitehouse.gov/blog/2010/06/04/white-house-meeting-black-men-and-hiv (accessed October 25, 2010).

[6]CDC, HIV/AIDS Among Hispanics/Latinos, August 2009 http://www.cdc.gov/hiv/hispanics/index.htm, (accessed October 25, 2010); CDC, HIV/AIDS Among Asians and Pacific Islanders, August 2008, http://www.cdc.gov/hiv/resources/factsheets/API.htm (accessed October 25, 2010).

[7] As used in this report, “the South” refers to the 17 states of Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Texas, Tennessee, Virginia and West Virginia, unless otherwise noted. This is the definition utilized by the majority of primary reference databases cited in this report including the US Centers for Disease Control and Prevention , the US Census Bureau and the Kaiser Family Foundation HIV/AIDS database. These sources, in turn, are relied upon in secondary documents cited such as the National AIDS Strategy for the United States and the Southern AIDS Coalition Manifesto and Update.

[8] CDC, HIV/AIDS Surveillance Report ,2007; for comprehensive discussions of disproportionate impact of HIV/AIDS on minorities in the south, see, Southern AIDS Coalition, “Southern States Manifesto: Update 2008, HIV/AIDS and Sexually Transmitted Diseases in the South, July 21, 2008; Sutton, M., et al, “A review of the Centers for Disease Control and Prevention’s Response to the HIV/AIDS Crisis Among Blacks in the United States, 1981-2009,” American Journal of Public Health, (2009) 99:No. S2, pp. 351-9; CDC, HIV/AIDS Epidemic and HIV/AIDS Prevention in the Hispanic/Latino Community: Consultation with Leaders from the Hispanic/Latino Community, April 2008.

[9] Southern AIDS Coalition, “Southern States Manifesto,” p. 3. For additional epidemiological data on HIV/AIDS in the southern US, see, Fleming, P.L. et al, “The epidemiology of HIV/AIDS in women in the southern US”, Sexually Transmitted Diseases July 2006: 33(7) pp. S32-38; Reif,S. et al, “HIV Infection and AIDS in the Deep South,” American Journal of Public Health, June 2006: (96) 6: 970-3. For an analysis of HIV and human rights in the South, see Human Rights Watch, “Southern Exposure: HIV and Human Rights in the Southern United States,” New York, November 2010.

[10]Alabama Department of Public Health, Alabama Statewide Coordinated Statement of Need 2009; Georgia Division of Public Health, State of Georgia Comprehensive HIV Services Plan 2009-2012; Louisiana Office of Public Health, Statewide Coordinated Statement of Need and HIV Comprehensive Plan; Mississippi Department of Health, State of Mississippi 2009 Ryan White HIV/AIDS Statewide Coordinated Statement of Need and Comprehensive Plan; (hereinafter, State Comprehensive HIV/AIDS Plans).

[11] CDC, HIV/AIDS Surveillance Report 2007.

[12] CDC, HIV/AIDS Surveillance Report 2006.

[13] Meditz, A., et al, “Sex, Race, and Geographic Region Influence Clinical Outcomes Following Primary HIV-1 Infection,” Journal of Infectious Diseases, 2011, p.1-10.

[14] Krawczyk,C. et al, “Delayed Access to HIV Diagnosis and Care: Special Concerns for Southern United States”, AIDS Care (2006) 18:Supplement 1: S35-44; Meditz, et al, “Sex, Race, and Geographic Region,” p. 4.

[15] Office of National AIDS Policy, National AIDS Strategy for the United States, p. 7. “In care” for HIV is defined by the US Health Resources and Services Administration (HRSA) as receiving a minimum number of viral load and CD4 tests during a one-year period. See, HRSA, “A Practical Guide for Measuring Unmet Need for HIV-Related Primary Medical Care,” http://hab.hrsa.gov/tools/unmetneed, (accessed January 4, 2011).

[16] Whetten, K.et al, “Overview: HIV/AIDS in the Deep South Region of the United States,” AIDS Care 2006; 18 (Supp.) 51-55. Whetten defined Alabama, Georgia, Louisiana, North Carolina, South Carolina and Mississippi as the Deep South.        

[17] Kaiser Family Foundation, “The HIV/AIDS Epidemic in the United States,” September 2005.

[18] National AIDS Strategy, p. 15; United States General Accounting Office, “Ryan White Care Act of 1990: Opportunities to Enhance Funding Equity”, November 1995.Southern AIDS Coalition, “Southern States Manifesto,” p. 16.

[19] United States Office of National AIDS Policy, “National AIDS Strategy for the United States” July 2010.

[20] See Human Rights Watch, Southern Exposure: HIV and Human Rights in the Southern United States, 2010 http://www.hrw.org/node/9447.

[21] US Census Bureau, “State and County Quick Facts, Mississippi,” 2010.

[22] United Health Foundation, “America’s Health Rankings,” 2009 http://www.americashealthrankings.org/ (accessed November 15, 2010). See also: Commonwealth Fund, “Aiming Higher: State Scorecard on Health System Performance,” 2007 http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2007/Jun/Aiming-Higher--Results-from-a-State-Scorecard-on-Health-System-Performance.aspx (accessed November 15, 2010.)

[23] American Human Development Project, “A Portrait of Mississippi: Mississippi Human Development Report 2009”.

[24] US Census Bureau, “Household Income for States: 2008 and 2009”, Http://www.census.gov/prod/2010pubs/acsbr09-2.pdf (accessed November 18, 2010).

[25] US Census Bureau, “State and County QuickFacts: Mississippi,” http://quickfacts.census.gov/qfd/states/28000.html (accessed November 18, 2010).

[26] Ibid.         

[27] National Center for Children in Poverty, “Measuring Poverty in the US,” May 2009.

[28]2009 American Community Survey, http://www.census.gov/acs/www/ http://factfinder.census.gov/servlet/IPGeoSearchByListServlet?ds_name=ACS_2009_1YR_G00_&_lang=en&_ts=305733643704 (accessed October 21, 2010).

[29] “Measuring Poverty in the US,” May 2009.

[30] CDC, Morbidity and Mortality Weekly Report, “CDC Health Disparities and Inequalities Report- United States 2011,” January 14, 2011, p. 87.

[31] Meditz, A., et al, “Sex, Race, and Geographic Region Influence Clinical Outcomes Following Primary HIV-1 Infection”, Journal of Infectious Diseases, 2011, pp.1-10.

[32] Denning, P. et al, “Communities in Crisis: Is There a Generalized HV Epidemic in Impoverished Urban Areas of the United States?” National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, July 2010.

[33] State of Mississippi Department of Health, 2009 Ryan White and HIV/AIDS Statewide Coordinated Statement of Need and Comprehensive Plan (hereinafter Statewide Comprehensive HIV/AIDS Plan), p. 6.

[34] Kaiser State Health Facts, “Estimated Rates (per 100,000) of AIDS Diagnosis, All Ages, 2008” and “Estimated Rates (per 100,000) of HIV Diagnosis, All Ages, 2008” http://www.statehealthfacts.org/comparemaptable.jsp?ind=513&cat=11 (accessed January 4, 2011).

[35] Mississippi Department of Health, STD/HIV Office, “HIV Disease: 2009 Annual Surveillance Summary.”

[36] Statewide Comprehensive HIV/AIDS Plan.

[37] Statewide Comprehensive HIV/AIDS Plan, p. 6, 37.

[38] Ibid.

[39] Mississippi State Department of Health STD/HIV Office, “HIV Disease: 2009 Annual Surveillance Summary.”

[40] Mississippi Department of Health, “HIV Disease in Young African-American Men Who Have Sex with Men, Mississippi, 2008.”

[41] Mississippi Department of Health, “HIV Disease in Young African-American Men Who Have Sex with Men, Mississippi, 2008.” CDC, Morbidity and Mortality Weekly Report (MMWR), “HIV Infection Among Young Black Men Who Have Sex with Men, Jackson, Mississippi 2006-2008”,February 6, 2009, Vol. 58, No. 4. Oster, A.M. et al., “HIV Risk Among Young African-American Men Who Have Sex with Men: A Case-Control Study in Mississippi, APHA Vol. 101, No. 1, January 2011, 137-143.

[42] Mississippi State Department of Health STD/HIV Office, “HIV Disease: 2009 Annual Surveillance Summary.”

[43] Basic health services are defined as a CD4 and viral load test each quarter of the previous 12 months,

HRSA, “A Practical Guide for Measuring Unmet Need for HIV-Related Primary Medical Care,” http://hab.hrsa.gov/tools/unmetneed, (accessed January 4, 2011).

[44] Mississippi Comprehensive State HIV/AIDS Plan, p. 7; Human Rights Watch interview with Craig Thompson, Director, STD/HIV Office, Mississippi State Department of Health, Jackson, Mississippi June 22, 2010. Mr. Thompson explained that while the Department of Health had verified and reported the 50 percent figure, a recent internal survey had placed the unmet need in the range of 70 percent, a figure which the Department was attempting to verify. Mr. Thompson resigned as Director on September 30, 2010, and was replaced by Dr. Nicholas Mosca effective November 1, 2010. According to the US National AIDS Strategy one-third of persons infected with HIV are not in care. National AIDS Strategy, p. 7.

[45] Human Rights Watch interview with Craig Thompson, Director, STD/HIV Office, Mississippi State Department of Health, Jackson, Mississippi June 22, 2010.

[46] President’s Emergency Plan for AIDS Relief (PEPFAR) FY 2008 Country Profiles for Botswana where 52 percent of people living with HIV are not receiving “care and support services” ), Ethiopia (56 percent), and Rwanda (41 percent). PEPFAR defines care and support to include not only medical treatment for HIV but a range of services that include testing but also TB screening , prevention education and other services at an identifiable clinic site. The HRSA definition of “in care” is more narrowly limited to those who have undergone a quarterly CD4 or viral load test in the past 12 months.