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.
This map shows the prevalence of people living with an HIV or AIDS diagnosis in the Southeastern U.S. in 2010 (the most recent data available).AIDSVu, Emory University, Rollins School of Public Health
Nearly 50 percent of all new cases of HIV infection in the U.S. are in the South, even though that region makes up only a third of the U.S. population. African-American men and women living in the South are hardest hit by far. Only a quarter of the population of Alabama is black, but nearly 75 percent of HIV patients there are.
Lawayne Childrey, 53, was a young man in Birmingham during the initial outbreak of AIDS in the 1980s. When he was diagnosed with HIV, he told his mother and his partner. His partner continued to say he was negative “up until three months before he died,” Childrey said, and never told his family he had HIV.
Childrey now works as a journalist in the South and has done numerous stories covering HIV. He said stigma and misinformation around the disease haven't decreased.
“Even now, I heard of three incidents where people have been put out of their families' homes after their families found out that they have HIV,” he said, “because they thought they could get [HIV] on the toilet seat or by sharing glasses.”
On top of a reluctance to talk about HIV and AIDS, Childrey said there is the stigma of being gay, especially in the African-American community, with men preferring to stay on the “down low.” Researchers and health professionals have long noticed that many black men will not openly identify as gay, so the CDC developed the phrase “men who have sex with men,” or MSM, to try to remove the stigma from the terminology.
Childrey said he once interviewed a doctor who explained that in the South, if you tell people you have diabetes, they will say, “I am so sorry to hear that.” Or if you have heart disease, “I am so, so sorry.”
“But if you have AIDS,” Childrey recalled the doctor saying, “the first thing people want to know is, ‘How did you get it?’ And then you are going to have to tell them you are gay.”
“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.
The Rev. Dale Braxton doesn't shy away from sermons about HIV/AIDS. "As long as we are afraid to talk about it, it will continue to spread," he said.Ashley Cleek
The rural town of Mount Willing has a population of 500, and more than half are members of Snow Hill Christian Church. In the church’s main hall, a dozen kids attend summer classes on entrepreneurship while a pair of elderly women piece together a necktie quilt.
The Rev. Dale Braxton, Snow Hill’s pastor for 30 years, grew up in Lowndes during the bloodiest parts of the civil rights movement. He said the first time he went to the bedside of a person dying from AIDS was in the early 1980s.
“It was a shock to me, but it was teaching me how to deal with families,” Braxton said, smoothing out his linen shirt. “I have studied since then to try to be able to ease the pain of what the family and the person is going through.”
Braxton is excited about Foster's study. A few years ago, he started preaching an annual sermon about HIV/AIDS in which he explains that “the church is a hospital” where all are welcome. He plans to offer his church as an HIV-testing center during national testing days, and said he’ll volunteer to be the first tested.
Braxton doesn’t shy away from such topics as HIV, STDs and safe sex, even though it has caused division among his congregants.
"I try to let them know that if you are without knowledge you will perish," he said. "As long as we are afraid to talk about it, it will continue to spread."