MONTGOMERY, Ala. — Dr. Laurie Dill pointed to a large map in the hallway of Medical AIDS Outreach of Alabama (MAO). It showed the number of people in each county living with HIV or AIDS in 2010. Where the counties pulsed red is the new, rural heart of the HIV/AIDS epidemic.
Dill pointed to a belt of deep red that cut across Alabama. “That's the Selma to Montgomery march,” she said. “Plus Tuskegee.”
Today the famous route where Martin Luther King Jr. led a civil rights pilgrimage in 1965 runs through a land in the midst of an HIV epidemic.
HIV/AIDS, long thought to be an urban disease, has migrated south to rural communities that lack the money, resources or education to combat the epidemic. In Alabama, one of the hardest-hit areas is the Black Belt. Originally known for its fertile, cotton-growing soil, the region is one of the poorest in the U.S.
Across the Black Belt, counties like Lowndes, Hale, Greene, Macon, Dallas and Montgomery routinely rank among the highest in new incidence rates for HIV in the state.
Lowndes County was the halfway mark on the five-day march from Selma to Montgomery and saw some of the worst racial violence of the 1960s. Today a quarter of its population lives below the poverty line. Across the county there are fewer than five doctors and no hospitals. Since 2010, Lowndes has had the highest incidence rate of HIV in the state (53.1 per 100,000), more than triple the national average (15.8) and higher than counties with 60 times the population.
The rate is so high in some counties that people are “at risk for HIV by geography,” Dill said.
“There is a synergy of plagues that put people at risk for HIV,” Dill said, borrowing a term from a paper by Dr. Paul Farmer on HIV. “One of them is racism. One is poverty. One is poor education. One is domestic violence. One is rural access. One is stigma.”
In rural Alabama, it's a perfect storm.
MAO is working to combat HIV by increasing technology and access to care. Telemedicine clinics — where patients can meet with a doctor, nutritionist or psychologist via video chat, avoiding lengthy or expensive commutes — allow MAO to treat 1,400 patients in clinics across the state. Bluetooth stethoscopes enable doctors to see and hear patients' heartbeats in real time.
Grants from the Elton John Foundation have also allowed MAO to hire a community health worker to target rural residents. It's a pilot program that has worked in developing countries like Haiti.
“It always sounds like we have taken care of [HIV] here [in the U.S.],” Dill said with a note of sarcasm. “You look at the numbers and go, ‘Oh, my gosh, what's with the South?’ You don’t get to a national AIDS-free generation without taking us with you.”
Despite the availability of world-class HIV care in clinics like MAO and the University of Alabama at Birmingham's 1917 clinic, the Deep South continues to have the highest mortality rate for people living with HIV in the U.S. Researchers think this is related to lack of access to care, patients dropping out of care, and HIV being so stigmatized that people are afraid to get tested or seek treatment for fear that someone may find out they have HIV.
Of the 14,574 Alabamians thought to be living with HIV or AIDS, more than 2,600 likely do not know they are infected.
When Dr. Pamela Payne Foster came to Alabama in 2004, she started an HIV/AIDS tour through the Black Belt to raise awareness and increase testing.
“We did town hall meetings and we wanted people to come out and get tested,” she said. “No one showed up.”
Foster now teaches at the University of Alabama and studies the spread of HIV in the South. She said that when she interviews people living with HIV in rural Alabama, they regularly list church as the place they feel most stigmatized.
“One of their greatest fears is that when they tell the pastor that they are HIV-positive that that information will spread throughout the congregation. They feel it should be confidential, so they say, ‘If you want to keep a secret don’t tell anybody in the church.’”
At the same time, Foster said, HIV-positive men and women report a deep desire for a connection to their church communities. In many of these isolated towns, churches also function as a social club, civic group, after-school program and food bank. “The church should be a place that is open for people living with HIV/AIDS,” she said.
A few years ago, Foster borrowed an anti-stigma curriculum that had been used in churches in Ghana and decided to test it in Alabama. It took her a year and a half to recruit 12 churches to participate in the study. She hopes the study will not only educate congregations about HIV/AIDS, but also reduce stigma around it.