HIV and Poverty: A Slide Show

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This Saturday, April 28th, I’ll be joining documentary filmmaker Lisa Biagiotti and Stephen Inrig, a professor at UT Southwestern Medical Center, on a panel session at the annual meeting of the American Association for the History of Medicine. Our talk will focus on HIV in the Southern U.S., with my portion focusing in particular on the connection between HIV and poverty in the region.

In creating some slides to show during the talk, I was struck yet again by the starkness of this connection, and of the deeply engrained link between socioeconomic status and health. Because I know many people feel likewise alarmed and simultaneously glad to be aware and reminded about these connections, here is an extract of the slide set, with some explanations here and there.

The U.S. Census Bureau includes the following states/regions in its definition of the southern U.S.: Washington D.C., plus Alaska, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Texas, Tennessee, Virginia, West Virginia.

Here’s a look at the distribution of wealth in the U.S. According to the U.S. Census Bureau, of the 12 states with >30% of its population living in poverty, 12 are in the South:

Viewed from another angle, the five states with the lowest personal income per capita in 2007 (which I realize is several years ago now) are all in the southern U.S:

When HIV was first found in the United States in 1981, it was concentrated mainly in coastal cities, and did not turn up in any particular population in terms of race or economic status:

This moving image created by Scientific American, in conjunction with an article I wrote for that magazine about HIV in the South (Poor Man’s Burden, with much credit to editor Christine Gorman), chronicles the shift in geography that HIV has undergone in the United States since 1981. Here is the 2009 view:

Scroll back and forth between those two images to see how the orange circles have changed location.

Over time, HIV has come to be concentrated in areas stricken by poverty. To be sure, there are other factors that have contributed to the rise in HIV in the southern U.S.—social stigmas, for example—but economics is a major issue, and one that is tightly linked to race. Here are some statistics about HIV in the southern U.S.:

Here is a particularly stark view, showing HIV levels in several countries:

And let’s remember, the U.S. is the country that spends the most on healthcare in the entire world.

Here’s one more look at the link between HIV and income levels. Note the quote from the CDC’s report, “Communities in Crisis,” stating the inverse link between poverty and annual household income.

The connection with race is also clear, as in this chart and the statistics noted below:

In case it’s hard to read, here are some statistics:
• More than half of all poor and black households are in the south
• Blacks are 13% of the U.S. population and 51% of people living with HIV/AIDS
• The estimated lifetime risk of HIV is:
- 1 in 16 for black males
- 1 in 30 for black females
- 1 in 104 for white males
- 1 in 588 for white females

Of course, HIV isn’t the only illness linked to poverty. Diseases of poverty also include heart disease, diabetes, obesity, and some types of cancer (as former director of the NCI Samuel Broder once said, “poverty is a carcinogen.”). Here’s a look at the distribution of diabetes in the United States:

There are numerous reasons why poverty is linked to disease, and HIV in particular. Poverty is associated with inadequate education, limited healthcare, and inadequate career opportunities. The limit on career opportunities can prevent people from obtaining the independence needed to resist risky behavior. Poverty is also associated with higher rates of incarceration, which has a dramatic impact on the surrounding community. The quote in the slide below says so much:

Regarding the access to healthcare, poverty restricts it. In many states, Medicaid eligibility sets federal poverty level limits that leave many people ineligible, but yet unable to afford private insurance. Here is a look at the percentages of uninsured people under 65 and children under 18 in the United States in 2008:

Another problem with Medicaid is that routine HIV screening is not covered in many areas. The CDC reports that only 4 of 16 states in the South routinely cover HIV screening, even though this approach is recommended, especially considering that among the 1.2 million people currently living with HIV/AIDS, about 1 in 5 don’t know they are infected. Here is a look at where routine HIV screening is and isn’t covered by Medicaid (dark blue = yes, light blue = no):

In several states, Medicaid has limits on the number of prescription drugs allowed (often not enough to cover all drugs needed for proper HIV care) and other healthcare factors.

Access to primary care physicians is also a problem, though not as dramatic as in rural areas. Here’s a look at “health professional shortage areas,” specifically primary care, according to HRSA:

Poverty rates in the south are rising faster than in other regions of the country. The slides above are a sampling from my talk, which in itself offers only a glimpse at the many issues involved (I’m not an expert, it should be said). But hopefully they provide some insights into a complicated and very serious problem.

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