Hiv/aids in Metropolitan Statistical Areas: 9 Southern States



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HIV/AIDS in Metropolitan Statistical Areas: 9 Southern States

Duke Center for Health Policy and Inequalities Research


Susan Reif, PhD, LCSW

Elena Wilson MPH

Kristen Sullivan PhD, MSW

Donna Safley MPS

Kathryn Whetten, PhD, MPH


©Duke Center for Health Policy and Inequalities Research (CHPIR), Duke University, Durham, NC. March 2013.


Executive Summary:

The Southern US has been disproportionately affected by HIV, having the highest HIV diagnosis rates and the largest proportion of individuals diagnosed with HIV in 2010.1 Fifteen of the 20 Metropolitan Statistical Areas (MSAs: with populations of greater than 500,000) with the highest HIV diagnosis rates were located in a nine state region of the South (AL, FL, GA, LA, MS, NC, SC, TN, and East TX).2 This region, hereafter referred to as the targeted states, shares a similar cultural history and a disproportionate HIV epidemic.3 The analysis for this report utilized data from CDC surveillance reports, 2008-2010, to examine the epidemiology and demographic characteristics of HIV in MSAs in the targeted states. Findings of this analysis included:



  • Nine of the 10 MSAs with highest HIV diagnosis rates in 2008-2010 were in the targeted states. These 9 MSAs consistently appeared in the 10 highest MSA HIV diagnosis rates for all three years with the exception of Columbia SC, which entered the top 10 in 2010 and Charlotte NC, which moved out of the top 10 to the 12th highest HIV diagnosis rate in 2010.

  • In 2010, nearly one-third (30%) of HIV diagnoses reported in MSAs were in the targeted states.

  • In 2010 and 2008, 8 of the 10 MSAs with the highest HIV prevalence rates were in the targeted states and in 2009, 9 of the 10 MSAs with the highest HIV prevalence rates were in the targeted states.

  • Seven of the 10 MSAsi with the highest HIV diagnosis rates among African-American men and African-American women were in targeted states.

  • Nearly one-half of new HIV diagnoses in 2010 in Jackson MS (48%), Atlanta GA (47%) and Charleston, SC (47%) were among African-American MSM. These MSAs had the highest percentage of new HIV diagnoses occurring among African-American MSM in the country. The average proportion of African-American MSM diagnosed with HIV in MSAs was 22%.

  • Baton Rouge LA had the highest percentage of new HIV diagnoses occurring among African American females, at nearly one-third of new diagnoses (31%).

Conclusions: Analysis of the HIV epidemiology and demographics for MSAs indicates that the vast majority of MSAs with the highest HIV diagnosis and HIV prevalence rates are in the targeted states. This trend was consistent over the last 3 years of available data (2008-2010) so is unlikely to be explained by fluctuations in HIV diagnosis rates over time. Targeted states contained some of the MSAs with the highest proportion of new diagnoses among women as well as the MSAs with the highest proportion of newly diagnosed cases among African-American MSM, a risk group that has been particularly affected by HIV and has not experienced the same declines in new HIV diagnoses as other populations.4 However, it is important to note that the HIV epidemic in the South is not solely concentrated in MSAs, as the South has a higher proportion of new HIV diagnoses in rural and suburban areas than all other regions and also has higher HIV diagnosis rates per 100,000 population in suburban and rural areas than the other US regions.1 These findings indicate the critical need for a focus on identifying and implementing effective HIV prevention and care strategies in order to abate the HIV epidemic in the Southern targeted states.



HIV/AIDS in Metropolitan Statistical Areas Located in 9 Southern States
According to 2010 data from the Centers for Disease Control and Prevention (CDC), nine of the 10 Metropolitan Statistical Areas (MSAs) with populations of greater than 500,000 with the highest HIV diagnosis rates and 15 of the top 20 MSAs with the highest HIV diagnosis rates were located in 9 southern states, primarily in the Southeast.2 These states, AL, FL, GA, LA, MS, NC, SC, TN, and East TX, are hereafter referred to as the targeted states. They share similar cultural histories as well as similar HIV epidemics.2,3,5,6

This report uses data published by the CDC to examine HIV diagnosis and prevalence rates for targeted state MSAs in 2010 and to study trends in diagnosis and prevalence rates from 2008-2010 for targeted state MSAs.2,7,8 In addition, the report utilizes information from a recent CDC data report that presented HIV epidemiology among adults and adolescents in MSAs by characteristics such as gender, age, and race/ethnicity.9 Finally, the report includes a simple sensitivity analysis to examine the extent to which selected MSAs would change in the ranking for highest HIV diagnosis rates if they had 10-25% fewer individuals diagnosed with HIV. This analysis provides information about how sensitive the rankings of these MSAs would be to relatively small changes in the numbers diagnosed.


HIV Diagnosis Rates in MSAs 2008-2010 (Table 1):

The CDC HIV Surveillance Report, 2010, provided information about the MSAs that had the highest HIV diagnosis rates (Figure 1). Nine of the ten MSAs with the highest HIV diagnosis rates were in the targeted states, including Miami, Baton Rouge, New Orleans, Jackson MS, Memphis, Orlando, Columbia SC, Atlanta, and Jacksonville FL (in order from highest diagnosis rate). New York City ranked 7th for HIV diagnosis rates and was the only MSA in the top 10 for HIV diagnosis rates not located in the targeted states. In 2010, nearly one-third (30%) of HIV diagnoses reported in MSAs were in the targeted states. The targeted states also had 9 of the 10 MSAs with the highest HIV diagnosis rates in 2008 and 2009 (Figure 2). Consistent with the 2010 findings, Miami had the highest HIV diagnosis rates of any MSA in 2008 and 2009. Other targeted state MSAs changed rankings somewhat over the 3-year period. For example, Columbia SC increased from the 15th highest diagnosis rate in 2008 to 11th in 2009 and 8th in 2010, while Atlanta went from 2nd in 2008 to 9th in 2010. For seven of the MSAs among the top 10 highest HIV diagnosis rates in 2010, the HIV diagnosis rates decreased since 2008. However, for some areas such as Columbia SC and Baton Rouge the rates did not improve over time.untitled:users:susan:documents:susan\'s old files:fordfoundation:2010analysis:ford hiv results_2010 data updatesr:slide04.jpg


Table 1: Ten MSAs with the highest HIV diagnosis rates 2008-2010




Population

201010 (ref)

2010

Ranking

2009

Ranking

2008

Ranking

Miami FL

5,414,772

49.7

1

52

1

70.3

1

Baton Rouge LA

774,327


43

2

43.1

2

44

5

New Orleans LA

1,134,029

36.9

3

37.1

6

41

7

Jackson MS

537,285

34

4

39.2

3

33.9

10

Memphis TN

1,285,732



33.7

5

38.8

4

45.1

3

Orlando FL

2,054,574

32.9

6

34.7

8

41

6

New York City

19,006,798



32.3

7

34.2

9

36.7

8

Columbia SC

728,063

30.9

8

30.2

11

28.7

15

Atlanta GA

5,376,285

30

9

37.7

5

47

2

Jacksonville FL

1,313,228



29.3

10

36.4

7

44.1

4

Charlotte

1,701,799

26.3

12

30.2

10

36.6

9



HIV Prevalence Rates in MSAs 2008-2010 (Table 2):

For HIV prevalence, the targeted states contained 8 of the 10 MSAs with the highest HIV prevalence rates, including Miami, New Orleans, Jackson MS, Memphis, Baton Rouge, Columbia SC, Orlando, and Jacksonville FL (in order from the highest HIV prevalence rate) in 2010. In 2009, the targeted states had 9 of the 10 MSAs with the highest HIV prevalence rates. However, San Francisco did not have estimated HIV prevalence data available in 2009 so was not included among the MSAs with the highest HIV prevalence rates. In 2008, the targeted states contained 8 of the 10 MSAs with the highest HIV prevalence rates. New York and New Haven CT were also included in the 10 highest HIV prevalence rates in 2008. Similar to HIV diagnosis rates, Miami topped the list for highest HIV prevalence rates in 2008-2010. Prevalence rates decreased from 2008-2010 in about half of the targeted state MSAs that were among the 10 highest HIV prevalence rates in 2010.


Table 2: Ten MSAs with the highest HIV prevalence rates 2008-2010




2010

Ranking

2009

Ranking

2008

Ranking

Miami FL

868.5

1

859.5

1

888

1

New York

739.3

2

770.6

2

708.5

2

New Orleans LA

620.2

3

637.8

3

657.7

3

Jackson MS

545.8

4

535.4

4

562.8

4

San Francisco

535

5

No data




No Data




Memphis TN

528.1

6

500.5

5

495.6

6

Baton Rouge

480.2

7

481.9

7

467

7

Columbia, SC

474.8

8

494.4

6

511.9

5

Orlando, FL

451.3

9

439.2

8

446.3

8

Jacksonville FL

424.7

10

416.3

10

419.4

9

Atlanta

424.2

11

433.9

9

396.3

11


HIV Diagnosis Rates in MSAs by Gender, Age, and Race/Ethnicity, 2010 (Table 3):

The CDC report on HIV diagnosis and prevalence in MSAs presented HIV diagnosis data by gender and then further separated the data by race/ethnicity and age.


Gender:

In 2010, 8 of the 10 MSAs with the highest HIV diagnosis rate among men were located in targeted states. Miami had the highest HIV diagnosis rate in the US for men, followed by Baton Rouge, New Orleans, Jackson MS, and Memphis TN. For women, the targeted states contain 9 of the 10 MSAs with the highest HIV diagnosis rates. Baton Rouge had the highest HIV diagnosis rate among women of any MSA followed by Miami, Jacksonville FL, New Orleans, and Memphis TN. The targeted states also had 3 of the 5 MSAs with the highest proportion of women among individuals newly diagnosed with HIV. These MSAs included Cape Coral/Fort Myers (35.1%), Baton Rouge (34.4%), and Jacksonville FL (33.8%).


Gender and race/ethnicity and mode of transmission:

Men: Similar to the findings for all men, the rate of HIV diagnosis among African-American men was highest in Miami, with Baton Rouge only slightly lower. Seven of the 10 MSAsii with the highest HIV diagnosis rates among African-American men were in targeted states. However, Jackson MS had the highest proportion of new HIV diagnoses occurring in African-American men (64%) followed by Memphis (62%). For mode of HIV transmission, there were relatively large disparities between targeted state MSAs in the proportion of new HIV diagnoses reported among MSM. For example, in Atlanta 65% of new HIV diagnoses were reported to be among MSM while only 43% of new HIV diagnoses in Baton Rouge were reported to be among MSM.

According to CDC estimates, nearly one-half of new HIV diagnoses in 2010 in Jackson MS (48%), Atlanta GA (47%) and Charleston, SC (47%) were among African-American MSM. These MSAs had the highest percentage of new HIV diagnoses occurring among African-American MSM. The next highest proportions of estimated HIV diagnoses occurring among African-American MSM were in Birmingham AL (44%), Memphis TN (43%), Columbia SC (43%), Charlotte NC (43%) and Greensboro NC (43%). Among MSAs, the average proportion of those diagnosed with HIV that were African-American MSM was 22%. The figures for MSM may be subject to error, particularly in highly stigmatized areas, as transmission category is often unreported or reported as unknown.


Women: For African-American females, the HIV diagnosis rate was highest in the Cape Coral-Fort Myers FL MSA and second in Miami. Seven of the 10 MSAs with the highest HIV diagnosis rates among African-American women were in the targeted states.iii However, Baton Rouge had the highest percentage of new HIV diagnoses occurring among African American females, at nearly one-third of new diagnoses (31%). The MSAs with the next highest proportion of new HIV diagnoses occurring in African-American women were Jacksonville FL (26%), Bridgeport-Stamford-Norwalk CT (26%), Memphis (23%) and New Orleans (23%), Cape Coral-Ft. Myers (23%), and Richmond VA (23%).
Gender and Age:

The CDC report also stratified the HIV diagnoses in MSAs by gender and age and found that Columbia SC had the highest rate of new HIV diagnoses among 13-24 year old males (101.8), followed by Jackson MS (88.6) and New Orleans (88.5). All of the ten MSAs with the highest diagnosis rates among males 13-24 were in the targeted states and 8 of the 10 MSAs with the highest diagnosis rates among females 13-24 were in the targeted states. The highest rate of new HIV diagnoses in females 13-24 was in Baton Rouge LA (34.4) followed by New Orleans (26.3).



Table 3: Demographic Characteristics of HIV diagnoses in MSAs^




Rate* -Males

Rate*-Female

Proportion female

Proportion MSM

Proportion African-American female

Proportion African-American MSM

Miami FL

93.1

27.5

.24

.54

.18

.15

Baton Rouge LA

70.1

35

.34

.43

.31

.34

New Orleans LA

69.8

21.3

.25

.56

.23

.35

Jackson MS

66.8

20.1

.25

.56

.22

.48

Memphis TN

65.6

20.3

.25

.53

.23

.43

Orlando FL

61.7

18.1

.23

.60

.15

.18

New York City

60.5

18.5

.25

.55

.15

.20

Columbia SC

62.3

13.8

.20

.62

.16

.43

Atlanta GA

61.4

14.3

.20

.65

.17

.47

Jacksonville FL

48.7

23.1

.34

.45

.26

.24

LA

54.5

6.1

.10

.82

.038

.17

San Francisco

51.6

5.8

.10

.70

.043

.15

*Rate per 100,000 population

^Among adolescents and adults



HIV Diagnosis Sensitivity (Table 4):

HIV diagnosis rates from specific geographic regions, particularly less populous MSAs, may be sensitive to small changes in the number of individuals diagnosed during a period of time. For example if a small to mid-size MSA had an abnormally high number of HIV tests performed in one year, that MSA may experience a greater than average number of new HIV diagnoses thus elevating the MSA’s diagnosis rate for that year. To examine the potential effect that an abnormally high testing year may have had on targeted state MSAs that were included among the MSAs with the highest HIV diagnosis rates in 2010, a sensitivity analysis was performed. This sensitivity analysis examined changes in HIV diagnosis rate rankings that would occur with a 10% and 25% decrease in HIV diagnoses in 2010 for 4 targeted state MSAs including Baton Rouge, Memphis, Jackson, and Columbia. For Baton Rouge, a decrease of 10% would not change their ranking of having the 2nd highest HIV diagnosis rate of any MSA. Even with a drop of 25% (n=85) of new diagnoses, Baton Rouge would remain among the 10 MSAs with the highest HIV diagnosis rates. The other 3 MSAs were more sensitive to decreases in HIV diagnoses. For example, a 10% decrease in diagnoses would not move the MSAs out of the 10 MSAs with the highest HIV diagnosis rates but a 25% decrease in new HIV diagnoses would move all 3 MSAs outside the 10 highest HIV diagnosis rates. However, another targeted state MSA (Houston, TX), which currently has the 11th highest HIV diagnosis rate, would then be among the 10 MSAs with the highest HIV diagnosis rate.


Table 4: Sensitivity of HIV diagnosis ranking of targeted state MSAs

City

2010 number of diagnoses, diagnosis rate and placement in top 10 for diagnosis rate

10% decrease in cases of HIV diagnoses

25% decrease in cases of HIV diagnoses

Baton Rouge

339 (43.0/100,00)

2nd



34 fewer cases – remains 2nd

85 fewer cases

moves to 7th



Jackson

184 (34.0/100,000)

4th


18 fewer cases

moves to 7th



46 fewer cases

moves to 12th



Columbia

230 (30.9/100,000)

8th


23 fewer cases

moves to 10th



58 fewer cases

moves to 18th



Memphis

440 (33.7/100,000)

5th


44 fewer cases

moves to 7th



110 fewer cases

moves to 12th




Conclusions:

Data from the CDC regarding HIV epidemiology in US MSAs indicate a concentration of the highest HIV diagnosis and prevalence rates from 2008-2010 in the Southern US, particularly the targeted states of the South. In all three years, 9 of the 10 MSAs with the highest HIV diagnosis rates were in the targeted states. The 9 targeted state MSAs that were among the ten MSAs with the highest HIV diagnosis rates remained fairly consistent over the three year period with the exception of Columbia SC, which entered the 10 highest MSAs for HIV diagnosis rates in 2010 and replaced Charlotte NC. The Charlotte MSA had the 12th highest HIV diagnosis rate in 2010. Miami topped the list for HIV diagnosis rates in all three years while other targeted state MSAs had some movement up or down in their HIV diagnosis rankings during the 3 year period. For the majority of the MSAs, the HIV diagnosis rates decreased over the 3-year period.

Examination of the gender and racial breakdown of new HIV diagnoses in MSAs not surprisingly reveals differences between targeted state MSAs in characteristics of newly diagnosed individuals. For example, in Miami 25% of new HIV diagnoses were among women whereas in Baton Rouge, 34% of new HIV diagnoses were among women. Jackson MS had the highest percentage of new HIV diagnoses that were African-American MSM (47%), a risk group that has been particularly affected by HIV and have not experienced the declines in new HIV diagnoses that other populations have experienced.4

Although the HIV diagnosis data demonstrate that the highest HIV diagnosis rates occur in Southern MSAs, there are data limitations to be noted. Estimated HIV diagnosis rates are not available for a handful of MSAs, including Washington DC and Baltimore, which have particularly high numbers of individuals diagnosed with HIV. In addition, diagnosis rates, especially for smaller MSAs, may be sensitive to small changes in the number of individuals testing HIV-positive in a year. The use of multiple years of data provides some assurance of stability in the finding that targeted state MSAs have been particularly affected by HIV in recent years. Furthermore, although the sensitivity analyses performed for several targeted state MSAs indicated that a 25% decrease in 2010 HIV diagnoses would move some of the MSAs out of the 10 highest HIV diagnosis rates, additional targeted state MSAs would replace them as two MSAs, Houston and Charlotte, have the 11th and 12th highest MSA HIV diagnosis rates. Targeted states also account for 15 of the 20 MSAs with the highest HIV diagnosis rates.

The etiology of the high rates of HIV diagnoses in MSAs located in targeted states is not clearly elucidated; however, contributing factors such as higher levels of poverty, HIV-related stigma, and other sexually transmitted infections have been implicated as factors contributing to the Southern HIV epidemic.3,11,12 Limitations in HIV care and prevention infrastructures may also contribute to the Southern epidemic.12 For example, data from an American Medical Association (AMA) database indicate that the South, particularly the targeted states, has fewer Infectious Diseases specialists per person estimated to be living with HIV than other regions of the US.13 Furthermore, many of the MSAs with high HIV diagnosis rates in the targeted states are less populated and have epidemics that emerged later than the large urban cities where the epidemic was first concentrated, thus these cities may have fewer resources and less experience in creating the infrastructure needed to adequately address the epidemic. More research is needed to better understand the limitations of the HIV care and prevention infrastructures in the South and to determine how these infrastructures are influenced by state poverty and culture and how they in turn impact HIV incidence. Differences in poverty, culture and infrastructure may differentiate MSAs with high HIV diagnosis rates in targeted states from other US MSAs and require targeted interventions to adequately address the unique nature of the Southern HIV epidemic.

Although it is critical to examine HIV in MSAs in the South, it is also important to note that the South has the highest proportion of new HIV diagnoses residing in both rural and suburban areas, has the highest HIV diagnosis rates in suburban and rural areas, and has the highest number of individuals living with HIV in rural and suburban areas.1 For example, among both men and women in the South, the diagnosis rates in rural areas are over three times that of the Midwest and nearly twice as much as the Northeast.1 Rural and urban areas in the South may experience similar challenges such as stigma and insufficient resources; however, providing prevention and care services in rural areas may present unique challenges including lack of transportation and long distances to qualified prevention and care providers.14,15

In conclusion, the CDC data focusing on HIV in US MSAs demonstrate a concentration of the highest HIV diagnosis rates in the targeted Southern states. These findings indicate the need for developing and implementing effective HIV prevention and care strategies to address the Southern HIV epidemic. HIV prevention and care interventions that have found to be effective in other regions of the US may not be as successful in the targeted states region due to the cultural distinction of this region. Current programs may need to be adapted and new programs created and tested that address the specific needs of this population. Differences in demographic and other characteristics of HIV-infected individuals between targeted state MSAs must also be considered in tailoring approaches to the specific areas within the targeted states region.

REFERENCES


1. Prejean J, Tang T, Hall I. HIV diagnoses and prevalence in the southern region of the United States, 2007-2010. Journal of Community Health. 2012;Epub.

2. Center for Disease Control and Prevention. Diagnosis of HIV infection and AIDS in the United States and Dependent Areas, 2010: HIV Surveillance Report. 2012; 22:http://www.cdc.gov/hiv/surveillance/resources/reports/2010report/index.htm. Accessed November, 2012.

3. Reif S, Whetten K, Wilson L, Gong W. HIV/AIDS Epidemic in the South Reaches Crisis Proportions in the Last Decade. 2011; http://globalhealth.duke.edu/news/2011/ResearchReportFinal3-12.pdf. Accessed July, 2012.

4. Center for Disease Control and Prevention. Estimated HIV Incidence in the United States, 2007-2010. HIV Surveillance Report. 2012;17(4).

5. Bartley N. The Evolution of Southern Culture. Athens, GA: University of Georgia Press; 1988.

6. Wilson D, Ferris W. Encyclopedia of Southern culture. 1989. Accessed 9/2011, 2011.

7. Centers for Disease Control and Prevention. HIV Surveillance Report, 2009. 2011; http://www.cdc.gov/hiv/surveillance/resources/reports/2009report/.

8. Centers for Disease Control and Prevention. HIV Surveillance Report, 2008. 2010; http://www.cdc.gov/hiv/surveillance/resources/reports/2008report/pdf/2008SurveillanceReport.pdf.

9. Center for Disease Control and Prevention. Diagnosed HIV infection among adults and adolescents in Metropolitan Statistical Areas - United States and Puerto Rico 2010. HIV Surveillance Report: Supplemental Report. 2013; http://www.cdc.gov/hiv/topics/surveillance/resources/reports/#supplemental, 18.

10. U.S. Census Bureau. Census Regions and Divisions of the United States. http://www.census.gov/geo/www/us_regdiv.pdf. Accessed November, 2011.

11. Human Rights Watch. Southern Exposure: Human Rights and HIV in the Southern United States. 2010; http://www.hrw.org/sites/default/files/related_material/BPapersouth1122_6.pdf. Accessed November, 2011.

12. Southern AIDS Coalition. Southern States Manifesto: Update 2012 Policy Brief and Recommendations. 2012; http://www.southernaidscoalition.org/Southern+States+Manifesto-+Update+2012.pdf. Accessed May 2013, 2012.

13. American Medical Association. AMA Redi-Counts. In: Redi-Direct Marketing I, ed.

14. Heckman T, Somlai A, Peters J, et al. Barriers to care among persons living with HIV/AIDS in urban and rural areas. AIDS Care. 1998;10:365-375.



15. Lishner D, Richardson M, Levine P, Patrick D. Access to primary health care among persons with disabilities in rural areas: a summary of the literature. Journal of Rural Health. 1996;12:45-53.


i MSAs with greater than 10 HIV diagnoses among African-American men

ii MSAs with greater than 10 HIV diagnoses among African-American men

iii MSAs with greater than 10 HIV diagnoses among African-American women


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