July 21, 2008

HIV/AIDS: A Rural/Southern Epidemic?

UPDATE: The Daily Dish points to another map reflecting disparities in US health/life expectancy, this one ranked by congressional district.  Not surprisingly, the bottom five contains two districts from Mississippi and two from Louisiana - I assume that the bottom of the bottom is an Appalachian district, and that the top of the top is peopled by congressional aides.  Here's the source.


This is one of several emerging trends that reflect a decline of the overall health of those living in rural portions of the deep South:
"Rising infection rates, coupled with inadequate funding, resources and infrastructure have resulted in a catastrophic situation in our public health care systems in the South," the report says.
Kathy Hiers, chief executive officer of AIDS Alabama and co-author of the report, told The Birmingham News that HIV/AIDS is taking hold in isolated parts of the South.
"The ruralness of the epidemic is what's becoming painfully clear," Hiers told the paper.
The report says the number of deaths from AIDS dropped in the rest of the nation between 2001 and 2005 but continued to increase in the South.
Health authorities have known for years that the 16-state Southern region was leading the country in the number of new infections. But, Hiers said, they thought the increase was concentrated in big cities in Florida, not spread across the region.
Experts have now focused in on the Deep South - Alabama, Georgia, Louisiana, Mississippi, North Carolina and South Carolina. They have found HIV infections rising in rural areas populated by blacks with financial, health and social problems.
Gary A. Puckrein is the president and CEO of National Minority Quality Forum in Washington. He said the shift in HIV infections has to be highlighted.
"Certainly one of the big misconceptions is it is big cities on the West Coast and East Coast that are really driving the disease, and it's not so," Puckrein said. "It's moved both in terms of geography and demography. It's really important for people in Southern states to know that because they're not getting their fair share of support."
This image is from the much reported story earlier in the year on declining life expectancy in the South, especially among women:



Pomeroy Kinsey said...

Starting several years ago, HIV stopped being a predominantly White male infection in the US. It's not slightly more likely to be Black, and the composition within Black infections is higher incidence of heterosexual transmission and female incidence. Jon Cohen called the rising rates of infection HIV among Black women the "silent epidemic" because so few were becoming aware of the shift. If we were to overlay imprisonment rates by race on top of that map, you'd also see I think significant correlations.

jennifer said...

This seems so complicated. The imprisonment rates Pomeroy mentioned add another piece to the puzzle, but the three things that strike me about rural places in the South (particularly Louisiana and Mississippi) are the lack of adequate health care -- high malpractice insurance has driven many doctors elsewhere --, the near-direct correlation between poverty and health, and a lack of decent sex (and health) education. I'm wondering if the rise in HIV among African Americans crosses class lines too, or is it primarily among working class and poor folks? Certainly, in MS and LA, a high proportion of the rural poor are black; Pomeroy, do the imprisonment rates follow socioeconomic lines too? I guess what I'm wondering is how much of this is really about poverty, when it's often talked about in terms of race?

Pomeroy Kinsey said...

Jennifer - I'm not sure about socioeconomic differences, because the national estimates come from the CDC's ongoing HIV surveillance report, which does not ask information about education or income. It's very hard to get that kind of information ongoing because HIV is still a fairly rare infection. But, some of the broader demographics suggest that among Blacks, it is probably falling more heavily on lower class folks. For Whites, it's not clear, because it skews towards men who have sex with men predominantly, and that demographic tends to have above average education. But, for blacks, it does look like it's following class lines.

Part of it could be inadequate healthcare, but I suspect it's largely due to the presence of Blacks in Southern states. AIDS is going to have more to do with healthcare than HIV, because AIDS only happens if a person cannot get access to HIV treatments early enough (which is going to be the case for lower income individuals with relatively weak access to the healthcare system).

Imprisonment most definitely does follow class lines, though. 12% of all Black males are in jail or in prison, but if you slice the data to focus by education, you find that the probability of imprisonment for college educated, young Black males (aged 18-30) falls to something like 2-3%. The racial disparities, mind you, do exist at all education levels - conditional on college education, a Black male is still more likely to be incarcerated than a White male, in other words. But if you look at only Black young males who are either high school dropouts, or only have a high school education or GED equivalent, then the rate of imprisonment rises from 12% to around 30%. The probability of being "ever imprisoned" for an uneducated Black male by the age of 30 is something like 60%, according to sociologist Bruce Western. So, it is largely a class/race/gender/youth phenomenon.

I suspect that the high correlation between region and HIV is due to the concentration of Black youth in the Southeast. The other reason is the higher incidence of syphilis and gonorrhea among Blacks. This could be due to inadequate healthcare, actually now that I think about. Higher rates of other sexually transmitted infections will amplify the transmission of HIV from an infected partner to an uninfected partner by as much 10-fold. For reasons we don't completely understand, poor Blacks utilize the healthcare system for treatment - even when it's free through Medicaid and Medicare - than Whites, and when they do get treatment for an STD, the number of months since innoculation is considerably larger than Whites. All of those factors together alone will cause the spread of STDs to increase in the population, because the person is sexually active while infected.

The incarceration story makes it even more complicated. The high rate of incarceration can itself lead to increased transmission because of the higher prevalence of HIV and other STDs in prisons and jails. If men are having sex with men in prison (even heterosexual men are believed to do this consensually, but there is also non-consensual intercourse), and are engaging in high risk sexual acts (usually unprotected), the high rates of incarceration could be feeding HIV back into the community as former inmates return to their "normal" heterosexual relations upon release. The other possibility is that HIV is higher among Blacks due to incarceration creating a shortage of men, causing the non-imprisoned men to have multiple partners. Multiple partners will itself amplify the spread of an STD.

It's all very complicated, and probably the quality of healthcare is part of it. But I think it's primarily rooted in behaviors related to early detection, early treatment, rates of multiple partnerships, and incarceration's effect on sexual networks, plus the presence of high rates of other STDs. That's my theory, I mean.

jennifer said...

That's a fascinating explanation -- thanks for taking the time to write it. I guess I'm most interested in the way health care and education tie into this because it seems like there are some sociocultural factors that could help to illuminate the statistics. For instance, Harriet Washington's book Medical Apartheid suggests that the historical abuse of blacks in medical research is one of the reasons there's such widespread mistrust of the medical establishment in black communities (which, it has been suggested elsewhere, is more concentrated in less educated populations): that might help explain why poor blacks are less likely to get treatment early or often.

The same kind of thing happens among poor black women who are pregnant: adequate prenatal care is one of the factors that can be a significant influence on maternal health and infant mortality, but while black women are four times more likely to die in childbirth than white women are, and their babies are twice as likely to die within the first year, they are the least likely to enroll in prenatal care.

Of course, that disparity is also exacerbated by poverty and overall health, and, black feminists would suggest, a deeply embedded cultural mythology that pathologizes black motherhood, but suspicion of medical institutions might be one reason black women don't go to the doctor when they're pregnant (regardless of cost, as you suggest).

The behaviors you mentioned -- especially early detection and treatment, along with the presence of STD's -- could also be impacted by educational disparities (it seems to me, at least); it's no secret that some of the nation's worst schools are in rural, largely black areas of the South and in impoverished inner cities.

Which I'm sure contributes to the drop-out rate, which contributes to the incarceration rate, etc.

It seems difficult to understand any of these problems out of context; I wonder if there's any collaboration between the folks studying the statistics and the folks studying the social and cultural forces at work? I tend to travel in the social science/humanities world of trying to piece together useful understandings of disparities in health (particularly for pregnant women), but it seems like traveling even further afield (say, to economics!), might be useful.

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