HIV IN THE SOUTHERN UNITED STATES
A HUMAN RIGHTS & PUBLIC HEALTH
IMPERATIVE FOR ACTION
The southern United States has more people living with – and dying of – HIV/AIDS than any other region in the country.
In many states in the South, deep poverty combines with harmful state laws and policies to undermine HIV prevention,
deny services to those who need them the most, promote stigma and discrimination, and violate human rights.
A Center of the US HIV Epidemic
While the South comprises 37 percent of the US population, it accounts for:
• approximately 50 percent of new HIV infections,
• approximately 50 percent of new AIDS diagnoses and all 10 cities
with the highest AIDS diagnosis,
• 43 percent of people living with HIV,
• the most AIDS deaths of any region; many people are diagnosed with
HIV late in the progression of the disease, at or near the point of fullblown AIDS, when treatment is less effective.
HIV Has Had a Particularly Devastating Impact on Minorities in the South
In some southern states such as Alabama, Louisiana, Georgia and Mississippi, African-Americans comprise
approximately 30 percent of the population but 65 to 75 percent of the cases of HIV. Of the 10 states with the highest
rates of new HIV diagnoses for Latinos, 7 were in the South.
HIV & Human Rights in the South: An Environment of Risk
Socio-economic conditions and harmful laws and policies create a high-risk environment for HIV.
Poverty
The South is the poorest region in the United States. Poverty and poverty-related issues such as lack of public
transportation, unstable housing, and food security are key barriers to HIV prevention, treatment and care. In comparison
to other regions, southern states have:
- more individuals and families living below the federal poverty level;
- more children living in poverty;
- the lowest median household income in the nation.
Incarceration
Each year, one in six persons living with HIV spends time in a correctional facility in the United States. Arrest and
incarceration causes delays and interruption of HIV treatment and has been shown to increase risk of HIV for injection
drug users. Incarceration can also contribute to HIV transmission in communities because social networks and
partnerships are disrupted. Southern states incarcerate more of their residents than any other region in the US. Louisiana
leads the nation in rates of incarceration, with 893 prisoners per 100,000 population.
Harmful Laws and Policies
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Criminalization of HIV Exposure: 32 states in the US, including 12 southern states, impose criminal punishment
for behavior related to HIV exposure or transmission. The majority of these laws impose liability only on persons
who are aware of their status and fail to disclose it to a sexual partner. Criminalization of HIV exposure can
discourage HIV testing, negatively impact an individual’s willingness to access treatment, and promote
misinformation. Prosecutions are disproportionately applied to marginalized groups such as sex workers and drug
users.
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Failure to provide evidence-based HIV prevention: Seven southern states do not require sex education at all; and
of the 10 states that mandate sex or HIV/AIDS education in schools, 4 do not require that contraception be
addressed and 9 require that abstinence before marriage be “stressed.”
Pervasive stigma and discrimination makes men who have sex with men a hard to reach population for testing and
prevention programs - a significant risk to their health. Discriminatory criminal and family laws fuel statesponsored homophobia: eight southern states still have anti-sodomy statutes, despite their being ruled
unconstitutional by the US Supreme Court.
The practice by police of using possession of condoms as evidence to support prostitution-related charges in some
southern states places some members of the groups most vulnerable to HIV (sex workers, transgender women,
and LGBT youth) at significant risk because they fear carrying condoms and sometimes engage in sex without
protection as a result.
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Lack of access to syringe exchange programs for drug users: The sharing of needles during injecting drug use is a
major risk factor for the transmission of HIV. States with syringe exchange and other effective harm reduction
measures have shown long-term, consistent decline in injecting drug use as a mode of HIV transmission. Yet
criminalization and legal uncertainty surrounding drug paraphernalia in most southern states have resulted in a
significant unmet need for clean syringes among drug users and lack of access to health services.
Access to Health Care
Residents of southern states are less likely to have health insurance than those in other regions of the US. In the South,
states have established the most restrictive Medicaid income eligibility and offer the most limited benefits of any region in
the country, leaving many of those at highest risk of HIV without health insurance and creating serious gaps in care for
people living with HIV/AIDS. Under the Affordable Care Act, states can choose to expand eligibility for Medicaid to all
persons with household incomes below 133 percent of the federal poverty level. Eleven of the 17 southern states are
currently not moving forward with Medicaid expansion under the Affordable Care Act.
Failure to Invest
As the demand for a wide range of services related to HIV continues to increase, many states in the South invest little
on prevention, care and essential services (such as housing) for people living with HIV and rely almost exclusively
on limited and incomplete federal programs.
Human Rights
Obligations
Federal, state and local governments
are obligated under international law
to address the HIV crisis:
• Right to highest attainable
standard of health
o Right to disease
prevention, information
o Right to treatment and
services
o Right to an adequate
standard of living
• Right to be free from racial
discrimination
o Right to equal access to
public health services
Recommendations
Addressing HIV in the South is a public health and human rights
imperative. Human Rights Watch urges states in the southern United
States to:
• Expand Medicaid under the Affordable Care Act.
• Amend criminal laws to permit syringe exchange programs to
operate legally.
• Ensure adequate HIV care and support services including
affordable housing.
• Take a "prevention, not punishment" approach to sex work and
individual drug possession.
• Eliminate state-sponsored homophobia by taking all sodomy
laws off the books, repealing bans on same-sex marriage, and
passing anti-discrimination laws for LGBT people.
• Repeal laws that criminalize failure to disclose one's HIV
status.
HIV in the South: Human Rights Watch Reports
In Harm's Way: State Response to Sex Workers, Drug Users and HIV in New Orleans
December 2013
Mississippi Moving Forward: Progress and Challenges in State Response to HIV
March 2013
We Know What to Do: Harm Reduction and Human Rights in North Carolina
September 2011
Rights at Risk: State Response to HIV in Mississippi
March 2011
Southern Exposure: Human Rights and HIV in the Southern United States
November 2010
Sentenced to Stigma: Segregation of HIV-Positive Prisoners in Alabama and South Carolina
April 2010
List of Resources
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US Centers for Disease Control (CDC), “HIV Surveillance Report: Diagnoses of HIV Infection in the United States and
Dependent Areas, 2012,” November 2014,
http://www.cdc.gov/hiv/pdf/statistics_2012_HIV_Surveillance_Report_vol_24.pdf (accessed November 26, 2014).
US Census Bureau, “Income and Poverty in the United States: 2013,” September 2014,
https://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-249.pdf (accessed November 26, 2014)
The Children’s Defense Fund, “The State of America’s Children: 2014,” undated, http://www.childrensdefense.org/childresearch-data-publications/data/2014-soac.pdf (accessed November 26, 2014).
Anne C. Spaulding et al., “HIV/AIDS Among Inmates of and Releases from US Correctional Facilities, 2006: Declining
Share of Epidemic but Persistent Public Health Opportunity,” PLoS One (2009).
Bureau of Justice Statistics, “Prisoners in 2012 – Advance Counts,” July 2013, http://www.bjs.gov/content/pub/pdf/p12ac.pdf
(accessed November 26, 2014).
The Sentencing Project, “Fact Sheet: Trends in U.S. Corrections,” September 2014,
http://sentencingproject.org/doc/publications/inc_Trends_in_Corrections_Fact_sheet.pdf (accessed November 26, 2014).
The Center for HIV, Law and Policy, “State-by-State Chart of HIV-Specific Statutes and Prosecutorial Tools,” October 2013,
http://hivlawandpolicy.org/sites/www.hivlawandpolicy.org/files/State%20By%20State%20HIV%20Laws%20Chart%20upda
ted%2010-21-13.pdf (accessed November 26, 2014).
The Center for HIV, Law and Policy, Positive Justice Project, “Ending and Defending Against HIV Criminalization, A
Manual for Advocates: State and Federal Laws and Prosecutions,” May 2014,
http://hivlawandpolicy.org/sites/www.hivlawandpolicy.org/files/Criminalization%20Manual%20%28Revised%2010.20.14%
29_0.pdf (accessed November 26, 2014).
Guttmacher Institute, “State Policies in Brief: Sex and HIV Education,” November 2014,
http://www.guttmacher.org/statecenter/spibs/spib_SE.pdf (accessed November 26, 2014).
US Centers for Disease Control (CDC), “HIV Surveillance in Injection Drug Users,”
http://www.cdc.gov/hiv/pdf/statistics_surveillance_HIV_injection_drug_users.pdf (accessed November 26, 2014).
Kaiser Family Foundation, statehealthfacts.org, “Sterile Syringe Exchange Programs, 2013,” http://kff.org/hivaids/stateindicator/syringe-exchange-programs (accessed November 26, 2014).
Kaiser Family Foundation, statehealthfacts.org, “State Sex and HIV Education Policy, 2014,” http://kff.org/hivaids/stateindicator/sexhiv-education-policy (accessed November 26, 2014).
Kaiser Family Foundation, “Health Insurance Coverage of the Total Population, 2013,” http://kff.org/other/stateindicator/total-population (accessed November 26, 2014).
Kaiser Family Foundation, “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An
Update,” November 2014, http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-donot-expand-medicaid-an-update (accessed November 26, 2014)
Kaiser Family Foundation, “Status of State Action on the Medicaid Expansion Decision, 2014,” undated,
http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act (accessed
November 26, 2014).
The Council of Economic Advisers, “Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid,”
July 2014, http://www.whitehouse.gov//sites/default/files/docs/missed_opportunities_medicaid_0.pdf (accessed November
26, 2014).