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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.104208
LETTER |
Irene A. Doherty and Peter A. Leone are with the School of Medicine, University of North Carolina, Chapel Hill. Sevgi O. Aral is with the Centers for Disease Control and Prevention, Atlanta, Ga.
Correspondence: Requests for reprints should be sent to Dr. Irene Doherty, 130 Mason Farm Rd, CB 7030, UNC School of Medicine, Chapel Hill, NC 27599-7030 (e-mail: doherty{at}med.unc.edu).
The commentary presented by Reif et al.1 summarizing the state of HIV in the southeastern United States did not fully address key determinants that explain, in part, how the interaction between individual-level factors, patterns of sexual partnerships and sexual networks, and societal forces affect HIV transmission.
The lack of viable employment, quality education, access to medical care, decent housing, pleasant neighborhoods, and overall community infrastructure perpetuates economic inequalities among African Americans.2 These contextual features promote health disparities, including HIV. For example, a population-based, case–control study of HIV in a rural community of Florida illustrates these points. In adjusted analysis that controlled for individual risk behaviors, residence in neighborhoods where prostitution and crack cocaine use occur was also associated with HIV.3
In addition, the crack epidemic over the past 20 years has fueled the "war on drugs," which has disproportionately affected African Americans.4 The threshold for incarceration for drug-associated offenses was lowered and sentencing laws for these offenses toughened. Although African Americans account for 12% of the population in the United States, approximately 40% of incarcerated persons are African American, and 12% of African American men 18–29 years-old were incarcerated in 2005.5 Ecological studies demonstrate that high incarceration rates are correlated with elevated rates of sexually transmitted infections and adolescent pregnancies, which are also characteristic of counties in the United States that experienced the highest rate increase in AIDS over the past decade.6,7
Furthermore, the loss of African American men from their communities, in part because of excess incarceration and mortality rates and the low ratio of African American men to women, has affected sexual partnerships and sexual networks in ways that exacerbate sexually transmitted infection transmission and heterosexual HIV infection.2 Incarceration disrupts sexual relationships. Qualitative data suggest that incarceration promotes concurrent sexual partnerships, which has been confirmed quantitatively in a study of African Americans in eastern North Carolina.8,9 Concurrent sexual partnerships are a feature of sexual networks that accelerate HIV transmission. The shortage of men also promotes discordant sexual mixing patterns between predominately lower-risk African American women and men at higher risk for HIV.2 Not surprisingly, young African American women in the South are the fastest growing population with heterosexually acquired HIV.10
Contrary to the authors’ suggestion that "little research has been published regarding the cause of the sharp increase in HIV/AIDS in the Deep South,"1(p972) we understand much more about the HIV epidemic in the South than was presented in this commentary.
References
1. Reif S, Geonnotti KL, Whetten K. HIV infection and AIDS in the Deep South. Am J Public Health. 2006; 96:970–973.
2. Adimora AA, Schoenbach VJ. Contextual factors and the black-white disparity in heterosexual HIV transmission. Epidemiology. 2002;13:707–712.[CrossRef][Web of Science][Medline]
3. Ellerbrock TV, Chamblee S, Bush TJ, et al. Human immunodeficiency virus infection in a rural community in the United States. Am J Epidemiol. 2004; 160:582–588.
4. Jensen EL, Gerber J, Mosher C. Social consequences of the war on drugs: the legacy of failed policy. Criminal Justice Policy Rev. 2004;15:100–121.[CrossRef]
5. Harrison PM, Beck AJ. Prison and Jail Inmates at Midyear 2005. Washington, DC: US Dept of Justice; 2006. Publication NCJ 213133.
6. Peterman TA, Lindsey CA, Selik RM. This place is killing me: a comparison of counties where the incidence rates of AIDS increased the most and the least. J Infect Dis. 2005;191(Suppl 1):S123–S126.
7. Thomas JC, Torrone E. Incarceration as forced migration: effects on selected community health outcomes. Am J Public Health. 2006;96:1762–1765.
8. Adimora AA, Schoenbach VJ, Martinson F, Donaldson KH, Stancil TR, Fullilove RE. Concurrent sexual partnerships among African Americans in the rural south. Ann Epidemiol. 2004;14:155–160.[CrossRef][Web of Science][Medline]
9. Gorbach PM, Stoner BP, Aral SO, Whittington WLH, Holmes KK. "It takes a village": understanding concurrent sexual partnerships in Seattle, Washington. Sex Transm Dis. 2002;29:453–462.[Web of Science][Medline]
10. Fleming PL, Lansky A, Lee LM, Nakashima AK. The epidemiology of HIV/AIDS in women in the southern United States. Sex Transm Dis. 2006;33 (7 Suppl):S32–S38.[CrossRef][Web of Science][Medline]
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