Why Is There an HIV Crisis in the South?

Shawn, whose real name has been changed to protect his privacy, is a 31-year-old gay black man who lives in Tallahassee, Fla. There, he works as a substitute middle school teacher and aspires to be a hip-hop artist. He is also HIV-positive. Shawn discovered his status in August 2013, and the news, while devastating, did not surprise him.

“I was pissed and sad. But I live in Tallahassee, Fla., where the odds are stacked against me," he says. "It’s a very small gay community and I’ve slept with my share of men. Sometimes I was safe and others I wasn’t. I guess [HIV] finally caught up with me.”

That the news of a HIV diagnosis would come as no shock is a sad reality for many gay and bisexual black men. According to numbers from the Centers for Disease Control and Prevention, around six in 10 members of this group will seroconvert by the age of 40.

The South is particularly stricken by the HIV epidemic. Half of all new HIV infections in the United States occur in the South, although the region has only a little more than a third of the country’s population. African-Americans account for more than half of these diagnoses, with men who have sex with men (MSM) bearing the brunt of the epidemic.

Activists have been preaching for years that HIV is no longer a death sentence. In the United States, we have the medical tools at our disposal to detect and control the virus. Yet here, people are still dying. According to the Southern AIDS Strategy Initiative, the South has the lowest five-year survival rate for those diagnosed with HIV or AIDS. Of those diagnosed with HIV, 15 percent of people will die (or 19 percent, should one live in the most affected state, Louisiana). If they are diagnosed with AIDS, that number jumps to 27 percent (or 33 percent in Louisiana). Black people have the highest death rate.

So why is it that in a country like United States — where one Ebola infection makes national headlines — there are still places where the rates of HIV infection rival those of the hardest-hit places in Africa? Why are black people dying of a virus that can be managed? What is the matter with the South?

To be fair, HIV is not confined to this region, and other regions and cities have their own battles in the fight against the virus. Yet below the Mason-Dixon line, there are a number of factors that create a perfect storm for HIV infection among black men who have sex with men, among them issues tied to systemic racial discrimination such as low income and poverty, lack of access to adequate health care, limited HIV testing and education, and stigma attached to the virus.

Poverty has been identified by the United Nations Population Fund as a critical factor in the spread and treatment of HIV. For many gay and bisexual men of color, economic inequalities add to the pernicious effects of oppression and homophobia. A seven-city study of HIV prevalence among young gay and bisexual men in the South found HIV rates of 16 percent for black men, 6.9 percent for Latino men, and 3.3 percent for white men, despite the fact that white men reported potentially risky sex and drug-using behaviors with greater frequency.

For those Southern gay men of color who are socio-economically disadvantaged, access to health resources is limited for a number of reasons. First, there already tend to be physician and hospital shortages in minority communities, affecting health outcomes of all black people in the South and making them extremely vulnerable to a virus like HIV. Second, many of these men live far from tony city centers where many LGBT cultural, health, and social resources are clustered. Third, mental health issues like depression and feelings of isolation create invisible barriers that keep these men out of the reach of health care.

While organizations dedicated to queer people of color are located in almost every major city in the South, with workers spending countless hours canvassing communities of color to offer free HIV education and testing, HIV rates are not dwindling. And stigma remains a very real barrier. Many men fear visiting a clinic for testing or treatment, because they are either afraid to know the result, or they worry that doing so would out their status or their sexuality to others.

“This can cause many gay men to be ashamed,” said Mel Prince, group director of Selma, Ala.’s AIDS Information and Referral, in an interview with The Washington Post. “We have patients who are scared to death to come to our clinic because they don’t want people to find out about their condition. People in the South are still in the dark ages about HIV.”

“There are many, many people in this state who have been diagnosed but are not in care,” added Harold Henderson, who directs an HIV clinic at the University of Mississippi Medical Center in Jackson. 

But there are a number of other obstacles to care that are specific to the black gay and bi men who live in this region.

First among them is mental health. Southern black gay and bi men are suffering from a self-esteem issue. And not only is it not being discussed, it’s killing them. A 2009 study showed the powerful effects of homophobia perpetrated by family and community members. These researchers compared lesbian, gay, and bisexual young adults who were rejected with those who were supported by their families. Rejected LGB youth were 8.4 times more likely to have tried to commit suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to have risky sex.

There is also a link between homelessness and HIV. According to the Congressional Research Center, 32 percent of homeless youth in the South are black, more than double the proportion of black youth in the total population. Moreover, studies indicate that LGBT kids tend to be particularly vulnerable, accounting for up to 40 percent of this group.

Institutions that are cornerstones of black community and culture in the South — such as religion and music — are perpetuating this stigma attached to their sexual orientation. This in turn robs them of crucial support networks that would allow them to reach help and care. 

The black church, which plays a pivotal role in shaping attitudes of black people in the South, is foremost among these offenders. According to a 2008 study from the Pew Research Center, roughly 58 percent of evangelical African-Americans say homosexuality should be discouraged, a message preached to them by religious leaders who hatemonger under the guise of “God’s work.” This message chips away at the self-worth and mental health of the gay and bi black men who attend services. Many are forced to either stay in the closet or flee the church due to its negative preaching. 

And after fleeing bigotry as well as the social support networks of the African-American community, where are LGBT black men to turn? Whether real or perceived, the South’s history of racism and its ongoing fight to pass homophobic laws under the guise of religious freedom has created an atmosphere of intolerance. The gay community isn’t always an option for support. Racism within this group has been shown to limit the dating and social networks of gay and black men, as evidenced in articles like The Daily Beast’s “‘No Blacks’ Is Not a Sexual Preference, It’s Racism.”

“If you’re a gay man, phrases like ‘no blacks’… aren’t just words that you’d find on old signs in a civil rights museum, they are an unavoidable and current feature of your online dating experience,” the writer states, pointing to apps like Grindr and Scruff where such phrases are unfortunately not uncommon on profiles.

These kinds of rejection can have devastating consequences in the real world, where even relatively minor rejections can really affect the mental health of an individual. Life experiences with oppression and homophobia often become internalized and can have detrimental effects on the development of positive sexual identity for Southern black gay men. Being fetishized or belittled by the gay community takes its toll, and not just on mental health. Studies have shown that limited dating pools lead to a greater risk of contracting HIV. As Shawn expressed earlier, these men “live in a small gay community,” and eventually, HIV “caught up with me.”

Shawn has been receiving treatment since his HIV diagnosis, but he admits he is still engaging in consensual unprotected sex with partners who are unaware of his status. “I was told since I’m undetectable that it’s harder to pass the virus on. Plus those guys I take home from the club know the risk just as I did,” he said.

Of course, Shawn is one of the lucky ones. He knows he is positive and is receiving treatment for the virus. But many Southern gay and bisexual black men are walking around blind to their positive status and unable to access lifesaving health resources. This is not just a Southern epidemic. It is an American epidemic, and it needs to be addressed. 

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KARAMO BROWN is a Texas-born gay man, a former cast member of MTV's The Real World and the proud father of two sons. See him on HuffPost Live and BET. Follow him on Twitter and Instagram @KaramoBrown.