Hiv/aids in Metropolitan Statistical Areas: 9 Southern States

Duke Center for Health Policy and Inequalities Research

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.
  
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  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.

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.

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 7^th 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 15^th highest diagnosis rate in 2008 to 11^th in 2009 and 8^th in 2010, while Atlanta went from 2^nd in 2008 to 9^th 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.

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.

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.

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%).

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.

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).

^Among adolescents and adults

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 2^nd 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 11^th highest HIV diagnosis rate, would then be among the 10 MSAs with the highest HIV diagnosis rate.

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 12^th 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 11^th and 12^th 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

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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/.

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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.