HIV stubbornly retains a foothold in major US cities, particularly those in the South. A lack of synergistic efforts among public health agencies can compound the problem, as can embedded attitudes and stigma.
We often think of the HIV epidemic as something that’s happening in places such as third-world African countries. And although it’s true that HIV is endemic in sub-Saharan Africa, Americans cannot afford to be blind to the fact that the disease continues to be a scourge affecting people right here in the United States. In fact, one hotbed of HIV is the cosmopolitan city of Atlanta.
Atlanta currently ranks number 3 out of all the metropolitan areas in the United
for HIV cases, based on the rate of diagnosis. According to the US Centers for Disease Control and Prevention (CDC), in 2017 the Atlanta-Sandy Springs-Roswell area had a rate of 27.3 diagnoses out of every 100,000 people, for a total of 1607 new diagnoses. For comparison purposes, Chicago’s rate of diagnosis was 11.6 out of 100,000 people; the New York-New Jersey-Pennsylvania area’s rate was 16.1 out of 100,000; and San Francisco’s was 13.4 out of 100,000. As of the end of 2016, the Atlanta metro area had 32,043 people living with HIV.
Carlos del Rio, MD, likens the situation in Atlanta to that of some communities in Africa, where infection rates are often north of 1% of the population. He cited a 2011 study that showed a particular cluster in the Atlanta metro area where rates of infection were at 1.34%. “[W]hile in the United
we don’t have a generalized epidemic, in downtown Atlanta we do,” Dr. del Rio, the chair of the Department of Global Health at the Rollins School of Public Health and professor of medicine in the Division of Infectious Diseases at Emory University School of Medicine, told Contagion®. “A generalized epidemic is something that we’ve only seen in Africa.”
As in other areas of the country, African-Americans are disproportionately affected by HIV in Atlanta. In 2016, African-Americans comprised a full 44% of HIV diagnoses nationwide even though they make up only 12% of the population. These diagnoses are weighted heavily toward younger men who have sex with men.
Why is Atlanta such a focal point for HIV, particularly in the African-American community and among young men? “There are many reasons, many of them systemic,” David Malebranche, MD, MPH, associate professor of medicine at Morehouse University in Atlanta, told Contagion®. “We are in the South, which is a very racist and sexually prejudiced area of the country. This permeates into every level of policy, research, and treatment and care pertaining to HIV, from HIV criminalization laws, funding for HIV prevention and treatment, lack of Medicaid expansion, voter suppression, etc. [And so,] it’s no coincidence that a city like Atlanta, in the state of Georgia, with implicit bias that is anti-black and anti-anything not heterosexual, has the rates it does that disproportionately impact black people and men who have sex with men.”
Some experts feel the problem is compounded by a lack of synergy among city agencies and health departments. “It contributes to the ability to have a coordinated response,” Dr. del Rio explained. “There’s no plan for the city of Atlanta.” The problem also stems from a dearth of statistics. “One of the things we lack, quick frankly, is good data,” he added. “It’s very hard to combat an epidemic without appropriate data.”
Dr. Malebranche agrees with the assessment that the government should be engaging in a more targeted effort to attack the problem. “At the city and county level, we have had a history of mismanagement of HIV prevention and treatment funding that should be focused on the groups most impacted according to the epidemiology, but unfortunately gets funneled to systems and agencies that don’t belong to or know how to work with black communities,” he said.
There are bright spots in the Atlanta HIV landscape, however. Fulton County, which includes most of Atlanta, is approaching the 3-year anniversary of its PrEP Clinic, which provides a once-a-day PrEP pill to residents at risk of HIV. Morehouse College, an historically black institution, recently began offering PrEP to students through its health center. And Dr. del Rio spoke about ongoing efforts by the CDC to recruit local, state, and federal authorities to address the problem.
“We’ve got the tools to do something,” Dr. del Rio said. “Our hands are not tied. But I think what is desperately needed is a coordinated citywide response.”