Even when HIV-positive Southerners do attempt to find care, they often have difficulty getting the treatment they need. Federal government surveys have found that more than half of all people living with HIV in many southern states do not get adequate treatment—compared with a third in other regions. For one thing, states sometimes impose payment rules that tie doctors’ hands. Mississippi’s Medicaid program, for example, limits beneficiaries (including those with HIV) to just five prescription drugs per month, despite the fact that it often takes many more medications to keep viral levels in check. A sheer lack of doctors plays a part as well. Mississippi has one of the lowest ratios of primary care physicians to resident population in the country. (Primary care clinicians handle the health problems that most people have most of the time.) And practitioners may not be eager to see infected individuals. The Human Rights Watch report included anonymous testimony from clinical workers that many health care practitioners in Mississippi refuse to treat HIV-positive individuals, resulting in long waiting lists for those willing to see such patients. Yet research shows that early treatment improves outcomes, lowers the cost of care and diminishes risky behavior. “People who are in care tend to know more and tend to have less unprotected sex,” says Deborah J. Konkle-Parker, associate professor in the department of medicine and infectious diseases at the University of Mississippi Medical Center.
One group that has been especially hard-hit by HIV’s ties to poverty and prejudice in recent years is African-Americans. More than half of all households that are poor and black are in the South. Public health experts report that black men who have sex with other men are particularly unlikely to think of themselves as homosexual or at risk for HIV and therefore deny the need for condoms, which reduce the transmission of the virus. Among black men who have sex with men, more new cases of AIDS were diagnosed in the South in 2006 than in all other regions of the country combined. In Mississippi, state health officials report that the number of new cases of HIV among black men aged 13 to 31 years who had sex with other men rose by 48 percent from 2005 to 2007.
Money cannot cure all the obstacles to improving the HIV picture in the South, but it could certainly help. In July 2010 the Obama administration issued a national strategic plan to tackle HIV in the country’s hardest-hit regions, including the South. Increases in funding were announced in February 2011. But with cuts looming in spending on Medicaid, which is paid for by state and federal governments, the people who most need help may end up not getting much more assistance after all.
In the meantime, some states are trying to innovate on their own. South Carolina has an HIV education program that aims to reduce stigma by reaching out to churches and ministers. Arkansas, for the first time, has allotted funds to test the feasibility of offering routine HIV screening to the general population. And Mississippi has zeroed in on what might seem like a surprising solution for a state in the Bible Belt: in March the state passed a law requiring school districts to offer sex education. Nick Mosca, who was appointed director of Mississippi’s program for addressing sexually transmitted diseases and HIV a few months earlier, and Mary Currier, the state’s health officer, argue that sex education is a top priority—and with good reason. Seventy-five percent of the state’s high school seniors report being sexually active, and one in four new HIV cases occurred in young people between the ages of 13 and 24 years.
Mosca also hopes to work with Mississippi’s Department of Education to begin testing all students in selected high schools for HIV, whether or not they appear to fall into a high-risk group. The move would help anyone who is HIV-positive and does not know it to get treatment. But testing everyone also acts to diffuse any stigma that might be attached to HIV screening because no one is singled out.