More than 30 years into the AIDS epidemic, a combination of safe-sex education and a new generation of pharmaceuticals has left many Americans convinced that HIV/AIDS is a problem that has been, if not solved, at least addressed. But that's certainly not true in the American South, which accounts for nearly 50% of all new HIV infections in the United States.
The South has the highest rate of AIDS deaths of any U.S. region. It also has the largest numbers of adolescents and adults living with HIV and the fewest resources to fight the epidemic.
The disease there is concentrated largely in poor minority communities. Diagnoses tend to be late and often only after the infection has progressed to AIDS. Treatment is less effective at that stage, and that's assuming it is even available. Thousands of those living with the human immunodeficiency virus are unable to get the medications they need, waiting in limbo for slots to open up in state AIDS drug assistance programs. President Obama recently pledged to eliminate these waiting lists, and I hope he does.
In Mississippi, the AIDS death rate is 60% higher than the national average, and about 50% of the people who know they are living with HIV are not receiving care, about the same percentage of nontreatment as in Ethiopia.
Bronwen Lichtenstein, a professor at the University of Alabama who has closely examined the epidemic in her state, sees the dire situation as inextricably linked to the region's history. "It's much deeper than poverty," she said. "The Southeast was a colony with slaves, and the region can't get over its racial history. Things haven't changed, they've just gone underground because the social structure is the same."
Places with high infection rates in the South also tend to have high rates of incarceration, teen pregnancies and unemployment. Access to healthcare is usually limited if it exists at all. Young black men who have sex with men bear the burden of new infections, with a 60% chance of being infected by age 40.
I have spent time with and interviewed many black gay men living with HIV in the South, and they tend to tell similar stories. Their families have shamed and shunned them; their churches have condemned them. The schools they attended failed to provide even the most basic sex education.
The culture, they say, has forced them into hiding. Some marry; some have girlfriends. They try to be invisible in a culture that can accept black men as prisoners, drug dealers, gangsters, adulterers, absent fathers — but not as gay.
The underlying problems of stigma, discrimination and homophobia are palpable, and they exacerbate the crisis. One black pastor I filmed urged his flock to see HIV/AIDS as a punishment: "Some say that homosexuality is not a sin," he intoned. "It is. AIDS is God's curse to a homosexual life."
Obama pioneered a national HIV/AIDS strategy that has focused on 12 cities. But its implementation has overlooked the rural South. I question whether urban successes will translate to rural areas.
The region doesn't have the population density, and thus the disease concentration, to meet the program's funding requirements. And because there is so little education and outreach and so many people with HIV/AIDS who don't receive treatment, the virus continues to spread.
Lichtenstein likens HIV to gangs and crime. "Prisoners have a better chance of not going back to prison if they leave their neighborhood. It's the same for this disease," she said. "You'd have a better chance of not contracting HIV if you left, moved away, broke the cycle. The ways out are the military, jobs or college, but most black men don't go to college, and decent jobs can be hard to find."
Josh, the main subject of my film, left his hometown and found the support of a "gay father" and 20-plus "gay brothers" in Jackson, two hours away. Gay families have become informal support systems for the South's abandoned gay sons.
But that isn't nearly enough. This week in Washington, public health workers and researchers from around the world are meeting for the annual International AIDS Conference. This is the first time in 22 years that the gathering has been held in the United States. I hope the attendees spare some thought for the region stretching south from America's capital city.
Lisa Biagiotti is a journalist and filmmaker. Her documentary "deepsouth," about HIV in the rural South, premiered this week. deepsouthfilm.com.