HIV in the
American South

I live in St. Petersburg, Florida. I've been HIV-positive for 16 years and an advocate for over a decade. I built this site in part because of a Florida ADAP crisis — a funding collapse that threatened to cut tens of thousands of Floridians off their HIV medications — and because I watched how invisible it was to people outside the advocacy world.

The South's HIV crisis is not invisible because it isn't real. It's invisible because the South is easy to ignore from the coasts. From inside it, the scale is impossible to look away from. This page is my attempt to put everything I know — from advocacy work, from research, from lived experience — into one place. Not for people who write reports about the South. For people who live here.

The numbers: an epidemic within the epidemic

Read those numbers again. More than half of all new U.S. HIV diagnoses occur in a region that holds less than 40% of the population.^[1] The South is not the hardest-hit region of an American epidemic — it is an epidemic of its own, embedded inside a national one that increasingly doesn't see it.

The South’s PrEP-to-need ratio was 12 PrEP users per new HIV diagnosis in 2024, the lowest regional ratio reported by AIDSVu. This compares PrEP use with diagnoses; it does not count everyone who could benefit from PrEP. It highlights a prevention-access gap, even while many Southern programs are providing PrEP. ^[2]

Estimated new HIV infections in the South declined 16% from 2018 to 2022. That is encouraging progress, with substantial work remaining. The national EHE goals were a 75% reduction by 2025 and a 90% reduction by 2030, measured against a 2017 baseline; those targets use a different time period from this regional 2018–2022 comparison. ^[15][3]

Why the South? The honest answer.

The Southern HIV crisis is not an accident or a mystery. It is the predictable result of a specific combination of structural conditions that compound each other in ways that are very difficult to untangle. Understanding them is the prerequisite for changing them.

The Deep South states

The Southern AIDS Coalition’s 2024 Manifesto focuses on nine Deep South states: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas. Each has a distinct mix of local services and coverage policies.^[7]

HIV care deserts

An HIV care desert is a place where accessible, appropriate HIV services are difficult to obtain. Distance is one barrier; affordability, appointment availability, language access, and transportation matter too. The practical question is whether a person can reach and continue the care they need. ^[7]

Chartis’s 2026 analysis classified 42% of Mississippi’s rural hospitals as vulnerable to closure. This is a financial-risk estimate, not a count of hospitals that have closed. Service disruptions and long journeys can complicate HIV care. If an appointment or refill is at risk, contact the clinic or case manager early to plan continued treatment; a missed visit does not automatically mean viral rebound.^[9]

Local clinicians can provide HIV care and PrEP with appropriate training and support. AETC programs offer education and consultation, including virtual case-based learning in participating programs. Ask the clinic how it coordinates specialist advice when needed. ^[22]

The reality of driving for HIV care

In large coastal cities — New York, San Francisco, Los Angeles — HIV care is often accessible by subway, bus, or a short cab ride. In the rural South, it can mean an entire day.

For someone who lives far from a clinic, an appointment can involve arranging transport, time away from work, childcare, blood tests, and prescriptions. That is an example of a possible burden, not a standard travel time or visit schedule. HIV visit and laboratory schedules should follow the individual care plan. ^[23]

When the cost or logistics of care become difficult to sustain, ask for help early. A case manager may be able to coordinate transport, refill delivery, local laboratory services, or a virtual visit. Availability and eligibility differ by program. ^[23]

Race and the Southern epidemic

Black people accounted for about 48% of new HIV diagnoses in the South in 2022. AIDSVu reports that Black people represented 23% of Southern PrEP users in 2024. The years and measures differ, but the figures identify an important disparity to address in prevention access. ^[2][10]

The history of segregation and disinvestment matters when examining access to care. County HIV patterns, poverty, transport, and health-service availability should be assessed together, without assuming that their maps match exactly or that a county-level pattern explains an individual’s experience. ^[7]

Hispanic/Latino people accounted for about 26% of new HIV diagnoses in the South in 2022: CDC’s Table 2a reports 5,126 of 19,822 diagnoses. AIDSVu reports 19% of Southern PrEP users were Hispanic in 2024. Programs should address language access, immigration concerns, affordability, and stigma according to local needs. ^[2][11]

Community organizations led by Black and Latino people can help shape services around local priorities. Investment should include language access, trusted outreach, peer support, and evaluation of who is reached and who remains underserved. The Southern States Manifesto provides a community advocacy framework for this work. ^[7]

The Medicaid non-expansion crisis

Medicaid expansion is an important coverage issue in the South. Full ACA expansion generally covers eligible adults with incomes up to 138% of the federal poverty level, including adults without dependent children. It provides a route to coverage without requiring an AIDS diagnosis or a disability determination. ^[5]

As of September 20, 2026, the seven Southern states without full ACA expansion are Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee, and Texas. Louisiana expanded in July 2016; North Carolina followed in December 2023. Georgia’s limited Pathways program is separate from full ACA expansion. ^[5][17][13]

In non-expansion states, a person living with HIV who does not qualify for existing Medicaid categories (typically because they don't have dependent children or a recognized disability) often has no insurance at all. They may qualify for Ryan White and ADAP, which cover HIV-specific care and medications — but Ryan White doesn't cover the full range of medical care PLHIV need, and ADAP funds have their own eligibility limits and funding pressures. The coverage gap is real, wide, and filled with people living with HIV who are either paying out of pocket, going without care, or being served by an already-stretched safety net.

Stigma and faith in the South

HIV stigma can affect people in cities, suburbs, and rural communities. Local visibility, available support, and concerns about privacy shape different experiences. Southern community organizations are working to expand informed, affirming responses. ^[7]

In a small community, someone may worry about being recognized at a clinic or about discussing medications at home. Ask the provider about discreet communication, billing, delivery options, and private appointment arrangements. The right approach depends on the person’s circumstances. ^[23]

Faith can be a source of comfort, advocacy, or difficult experiences with stigma. A person deserves respectful support regardless of belief or identity. COMPASS’s faith-based programs support education and collaboration with congregations and faith leaders. ^[19]

Some Southern faith organizations provide HIV education, testing partnerships, and community support. COMPASS describes faith-based advocacy and organizational-capacity grants; check current programs and funding dates with the coordinating centers. ^[19]

Who's fighting back: Southern HIV initiatives

The South is not passively experiencing its epidemic. It is home to some of the most creative, community-centered, and tenacious HIV advocacy in the country — organizations that have been working with inadequate resources against structural headwinds for decades and have not stopped.

Why pharma invests in the South

It is worth naming directly: pharmaceutical companies — Gilead, ViiV Healthcare, Merck, and others — have made substantial investments in Southern HIV advocacy, community organizations, and awareness campaigns. This raises legitimate questions about motivations that deserve honest discussion.

The South’s large share of diagnoses makes it important to both public-health programs and HIV medicine manufacturers. Commercial interests deserve scrutiny, but a share of new diagnoses is not a measure of the treatment or prevention market. Prevention serves people without HIV; treatment serves people living with HIV. ^[2]

Industry-supported programs can fund organizational capacity, outreach, and care navigation. COMPASS and PASI describe those activities. Assess each program by its results, transparency, and responsiveness to community priorities rather than assuming that funding alone proves a health outcome. ^[19][20]

What it means is that the South's HIV organizations carry a particular responsibility to maintain their independence — to advocate for policies (like Medicaid expansion) that might not serve pharma's narrow interests, to be critical when drug prices are too high, to center community voice over funder preference. The Southern HIV community has navigated this tension for decades. It continues to.

As someone who has received consulting support from pharmaceutical companies in the past — and who discloses that on this site — I don't say any of this from a position of purity. I say it because the relationship between the pharmaceutical industry and Southern HIV advocacy is real, complicated, and worth understanding clearly if you're going to be part of this work.

Telehealth and bridging the distance

Telehealth can support HIV treatment and prevention when travel is difficult. HHS provides guidance for coordinating virtual care, testing, and follow-up. Whether it works well depends on the person’s needs, access to technology, privacy, and local services. ^[23]

Telehealth cannot provide every part of care remotely. Arrange any needed specimen collection, examinations, or injections, and confirm technology and privacy needs before a visit. Ask the clinic which services can be delivered virtually and where in-person care is available. ^[23]

A coordinated plan may combine virtual appointments with local laboratories, outreach visits, or clinic care. HHS describes ways to organize this care. The best arrangement is the one that meets the individual’s clinical needs and can be sustained. ^[23]

Florida: coverage and care in the South

What actually works — and what the South needs

There are practical ways to improve access, including coverage, local services, prevention choices, and community leadership. Programs need sustained support and evaluation to identify what works in each setting.

Medicaid expansion

Full ACA Medicaid expansion provides an additional coverage pathway for eligible low-income adults. It can reduce the coverage gap, but enrollment, benefits, provider access, and continuity of care also matter. Advocates can use current state coverage information to focus their work. ^[5]

Community-led, culturally specific outreach

Outreach should reflect the communities it serves and involve them in design and evaluation. Black-led and Latino-led organizations, peers, and trusted local partners can help identify barriers and workable responses. The Southern States Manifesto sets out community priorities for this work. ^[7]

Mobile services

Mobile services can bring testing, prevention, and support closer to people. Programs should also plan privacy, follow-up, laboratory access, and medication continuity. Some people prefer an outreach setting; others prefer a clinic. ^[7]

Long-acting PrEP

Twice-yearly injectable lenacapavir was FDA-approved for PrEP in June 2025. It requires initiation doses that include oral tablets, HIV testing, and ongoing follow-up. Long-acting options may help some people avoid daily pills, but reliable injection access, affordability, and a plan for missed doses remain essential. Discuss the available choices with a PrEP provider. ^[24]

Decriminalization

Advocates seek laws that reflect current HIV science and avoid unjust penalties. CDC reviews the mismatch between some laws and transmission evidence. Legal duties differ by jurisdiction and can change; do not assume that a scientific principle such as U=U automatically exempts a person under current law. ^[16]

Sustained investment in Southern organizations

Southern AIDS Coalition’s Manifesto calls for sustained investment in community organizations, care, and prevention. Use current local service gaps and program results to make the case for funding and accountability. ^[7]

References & Sources

1. Centers for Disease Control and Prevention. Diagnoses, deaths, and prevalence of HIV in the United States and 6 territories and freely associated states, 2022. HIV Surveillance Report, 2024. stacks.cdc.gov ↩ ↩
2. AIDSVu. Southern HIV/AIDS Awareness Day Toolkit 2025; 2022 diagnosis/undiagnosed data and 2024 PrEP data. Source. ↩↩↩↩
3. CDC. Estimated HIV incidence and prevalence; South 2018–2022 trend. Source. ↩
4. Chartis. 2026 Rural Health State of the State. Source. ↩
5. KFF. Status of State Medicaid Expansion Decisions. Source. ↩
6. HIV Medicine Association. House Moves to Strip Health Coverage from Millions of Americans, Including Many People With HIV — more than 40% of people with HIV have Medicaid coverage, making it the largest single insurer for PLHIV. HIVMA, 2025. hivma.org ↩
7. Southern AIDS Coalition. Southern States Manifesto 2024 — defines the Deep South as Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas. southernaidscoalition.org ↩
8. Florida Department of Health. HIV/AIDS management and current ADAP eligibility, July 2026. Source. ↩
9. Chartis. 2026 Rural Health State of the State; Mississippi 42% closure vulnerability. Source. ↩
10. CDC. HIV Surveillance Report, 2022 diagnoses, Table 2a: race/ethnicity by region. Source. ↩
11. CDC. HIV Surveillance Report, 2022 diagnoses, Table 2a: South Hispanic/Latino 5126 of 19822 diagnoses. Source. ↩
12. CMS. Medicaid community-engagement interim final rule fact sheet, June 1, 2026. Source. ↩
13. North Carolina Department of Health and Human Services. Medicaid Expansion in North Carolina — expansion launched December 1, 2023. medicaid.ncdhhs.gov ↩
14. Southern AIDS Coalition. About / Home. Community-led regional advocacy organization founded in 2001. southernaidscoalition.org ↩
15. CDC. National HIV initiatives and EHE targets. Source. Checked September 20, 2026. ↩
16. CDC. HIV criminalization and ending the HIV epidemic. Source. Checked September 20, 2026. ↩
17. Louisiana Department of Health. Medicaid expansion began July 1, 2016. Source. Checked September 20, 2026. ↩
18. CMS. Community-engagement requirements, exemptions, and implementation dates. Source. Checked September 20, 2026. ↩
19. Gilead COMPASS. Grant programs and final Transformative round through September 2025; ten-year initiative. Source. Gilead’s corporate-giving commitment. Checked September 20, 2026. ↩
20. ViiV Healthcare. PASI launched 2010; 33 organizations supported in 2021. Source. Checked September 20, 2026. ↩
21. AIDS United. Southern HIV Impact Fund 2024–2025 grant announcement, June 24, 2024. Source. Checked September 20, 2026. ↩
22. AETC National Coordinating Resource Center. Program directory. Source. Checked September 20, 2026. ↩
23. HHS. Telehealth for HIV care. Source. Checked September 20, 2026. ↩
24. CDC. Clinical recommendation for injectable lenacapavir PrEP, MMWR 2025. Source. Checked September 20, 2026. ↩
25. CDC. HIV treatment as prevention and U=U. Source. Checked September 20, 2026. ↩