On the surface, Indiana and Florida could not be more different. Be it size (Florida is the 3rd most populous state, while Indiana is the 38th); location (Midwest vs Deep South) or diversity of the population (Indiana is 84.3% white while Florida is over 46% minority), one might assume their challenges to be very different. However, each state's struggle with their own outbreaks of HIV only serves to reminds us of power of one of the virus' closest allies; poverty.
Most HIV activists agree that poverty plays a major role in the intransigence of the epidemic. According to the International Labor Office of UNAIDS: "HIV/AIDS is both a manifestation of poverty conditions that exist…, and the result of the unmitigated impact of the epidemic on social and economic conditions. HIV/AIDS is at the same time a cause and an outcome of poverty, and poverty is both a cause and an outcome of HIV/AIDS." So there is no coincidence that as each state struggles with growing poverty, so too has HIV increased.
Much has been written about Indiana's HIV outbreak-largely because it seemed to come out of nowhere. Starting in February 2015 through April 2016, 190 cases have been documented. Long known as a religiously and socially conservative state, it seemed ill suited to generate headlines for one town, Austin (population 4,200) now has a higher incidence of HIV than "any country in Sub Saharan Africa." says CDC Director Tom Frieden. "They've had more people infected through IV drug use than all of New York City last year." Indiana's poverty rate of almost 21% is also above both the national average (15.9%) and for that of Midwestern states (14.1%)
Florida too, has both soaring rates of poverty and HIV. Roughly 1 in 6 Floridians live in poverty and, according to the Business Insider, has three of the top 15 cities where poverty is increasing the fastest. Florida also has the highest number of new HIV diagnoses in the nation, with a 23% increase in 2015 alone.
Despite the largely different primary modes of infection in Austin, Indiana and Florida (IV drug use vs MSM), both states' increases in HIV can be linked to a lack of sustained effort to promote safer sex. In Florida, prevention funding has been flat or cut, and still has prohibitions on talking explicitly about sexuality in sex education classes. Austin IN, like much of rural America, has few medical providers. There is only one doctor and the Planned Parenthood clinic in the county that used to provide HIV testing and referrals closed in 2013, as government funding declined. There is a great fear among HIV surveillance experts of a growing prevalence of HIV in many other rural counties- especially in the south- but also in areas such as Idaho, which had two rural outbreaks in 2008.
The ongoing debates about income equality and jobs carry a much greater importance that just determining the type of housing in which one lives or the schools our children attend: it has a direct impact on our health. Poverty is the ultimate social determinant and until we have the will to aggressively address it, we will continue to have these pervasive health disparities, like HIV disease. In the meantime, we know what works against HIV. Access to HIV testing and treatment; condoms; needle exchange programs and prevention education can make a real impact on preventing or halting the outbreaks. When the Indiana state health department aggressively moved in and offered HIV testing and treatment as well as setting up a needle exchange in Austin, it effectively stopped its outbreak. Sadly however, "the horse was already out of the barn' and reactive policies are just that, often too little too late.
State governments and health departments, such as those in Indiana and Florida need to shelve their conservative rhetoric and provide a real plan to prevent HIV infection and to address their burgeoning IV drug use epidemics. Otherwise, we will continue to see a resurgence of this eminently manageable disease, all over the country.
