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 AfricanAmerican 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 AfricanAmerican 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
i
MSAs with greater than 10 HIV diagnoses among African-American men
2
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
3
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.
Table 1: Ten MSAs with the highest HIV diagnosis rates 2008-2010
Population 2010 Ranking 2009 Ranking 2008
201010
(ref)
Miami FL
5,414,772
49.7
1
52
1
70.3
Baton
43
2
43.1
2
44
Rouge LA
774,327
New
1,134,029
36.9
3
37.1
6
41
Orleans LA
Jackson MS 537,285
34
4
39.2
3
33.9
Memphis
33.7
5
38.8
4
45.1
TN
1,285,732
Orlando FL 2,054,574
32.9
6
34.7
8
41
New York
32.3
7
34.2
9
36.7
City
19,006,798
Columbia SC 728,063
30.9
8
30.2
11
28.7
Atlanta GA
5,376,285
30
9
37.7
5
47
Jacksonville
29.3
10
36.4
7
44.1
FL
1,313,228
Charlotte
1,701,799
26.3
12
30.2
10
36.6
Ranking
1
5
7
10
3
6
8
15
2
4
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.
4
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 620.2 3
637.8
3
657.7 3
LA
Jackson MS
545.8 4
535.4
4
562.8 4
San
535
5
No data
No
Francisco
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
424.7 10
416.3
10
419.4 9
FL
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 AfricanAmerican 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.
ii
MSAs with greater than 10 HIV diagnoses among African-American men
5
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-StamfordNorwalk 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* Rate*Proportion
Proportion
Males
Female
female
MSM
Miami FL
Baton Rouge LA
New Orleans LA
Jackson MS
Memphis TN
Orlando FL
iii
93.1
70.1
69.8
66.8
65.6
61.7
27.5
35
21.3
20.1
20.3
18.1
.24
.34
.25
.25
.25
.23
.54
.43
.56
.56
.53
.60
Proportion
AfricanAmerican
female
.18
.31
.23
.22
.23
.15
Proportion
AfricanAmerican
MSM
.15
.34
.35
.48
.43
.18
MSAs with greater than 10 HIV diagnoses among African-American women
6
New York City
Columbia SC
Atlanta GA
Jacksonville FL
LA
San Francisco
60.5
62.3
61.4
48.7
54.5
51.6
18.5
13.8
14.3
23.1
6.1
5.8
.25
.20
.20
.34
.10
.10
.55
.62
.65
.45
.82
.70
.15
.16
.17
.26
.038
.043
.20
.43
.47
.24
.17
.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
10% decrease
25% decrease
diagnoses, diagnosis
in cases of HIV
in cases of HIV
rate and placement in diagnoses
diagnoses
top 10 for diagnosis
rate
Baton Rouge
339 (43.0/100,00)
34 fewer cases – 85 fewer cases
2nd
remains 2nd
moves to 7th
Jackson
184 (34.0/100,000)
18 fewer cases
46 fewer cases
4th
moves to 7th
moves to 12th
Columbia
230 (30.9/100,000)
23 fewer cases
58 fewer cases
8th
moves to 10th
moves to 18th
Memphis
440 (33.7/100,000)
44 fewer cases
110 fewer cases
5th
moves to 7th
moves to 12th
Conclusions:
7
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
8
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.
9
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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.
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.
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.
Center for Disease Control and Prevention. Estimated HIV Incidence in the
United States, 2007-2010. HIV Surveillance Report. 2012;17(4).
Bartley N. The Evolution of Southern Culture. Athens, GA: University of Georgia
Press; 1988.
Wilson D, Ferris W. Encyclopedia of Southern culture. 1989. Accessed 9/2011,
2011.
Centers for Disease Control and Prevention. HIV Surveillance Report, 2009.
2011; http://www.cdc.gov/hiv/surveillance/resources/reports/2009report/.
Centers for Disease Control and Prevention. HIV Surveillance Report, 2008.
2010;
http://www.cdc.gov/hiv/surveillance/resources/reports/2008report/pdf/2008Survei
llanceReport.pdf.
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.
U.S. Census Bureau. Census Regions and Divisions of the United States.
http://www.census.gov/geo/www/us_regdiv.pdf. Accessed November, 2011.
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.
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.
American Medical Association. AMA Redi-Counts. In: Redi-Direct Marketing I,
ed.
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.
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.
10
11