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.
August 20 is Southern HIV/AIDS Awareness Day (SHAAD). It was established to focus national attention on a regional crisis that gets dramatically less coverage than its scale deserves. Mark it. Use it. Share this page on it.
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 PrEP-to-need ratio is perhaps the most damning single statistic. 12 PrEP users for every new HIV diagnosis — the lowest in the country. The national average is better. The Northeast is dramatically better. In the South, the most powerful HIV prevention tool available to HIV-negative people is essentially missing from the communities that need it most. That isn't a medical failure. It's a policy failure.
Progress has happened — new HIV infections in the South declined 16% between 2018 and 2022, and that real progress reflects the work of hundreds of community organizations, Ryan White clinics, and advocates who refused to let the crisis proceed without a fight. But 16% progress in a region that needed 75% progress to meet the national EHE target tells you everything about how far there is still to go.[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 "Deep South" — the nine states where the epidemic is most concentrated — accounts for the majority of Southern HIV diagnoses.[7] Each state has its own specific landscape of care infrastructure, policy barriers, and community response.
HIV care deserts
A healthcare desert — or specifically an HIV care desert — is a geographic area where people living with HIV have no meaningful access to HIV-competent care within a reasonable distance. In the South, these deserts are not metaphorical. They are places where the nearest HIV specialist is two, three, or four hours away. Where the nearest clinic that offers PrEP is in another county — or another county over from that.
The problem compounds in rural areas in specific ways. Rural Southern hospitals — already under financial pressure from uncompensated care — have closed at alarming rates. Forty-two percent of Mississippi's rural hospitals are vulnerable to closure, according to the Chartis Center for Rural Health's 2026 analysis — an improvement from 49% the prior year but still among the highest rates in the country.[9] When the rural hospital closes, everything attached to it — the lab, the pharmacy, the specialist referral network — closes with it. An HIV-positive person in a rural Mississippi county might need to take a day off work, arrange childcare, and travel four hours round-trip for a routine quarterly lab visit. For someone working a low-wage job without paid leave, that appointment doesn't happen. For someone without a reliable car, that appointment doesn't happen. Missed appointments become interrupted treatment. Interrupted treatment becomes viral rebound. Viral rebound means HIV is transmissible again and the person's immune system is under attack.
Provider shortage is the other dimension. There are not enough HIV doctors in the South. Not in the cities. Nowhere near enough in rural areas. The HIV provider workforce nationally has declined even as demand has grown — and the South, which starts from a lower baseline of healthcare infrastructure, has been hit hardest. A primary care physician in rural Alabama may have never prescribed PrEP, may not feel qualified to manage HIV, and may not know where to refer. Older providers sometimes carry stigma from the early epidemic years. Newer providers may simply not have received adequate HIV training in medical school. The result: people in HIV care deserts are either driving hours for care, going without, or receiving substandard care from providers who aren't HIV specialists.
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.
Consider what a quarterly HIV care visit actually requires for a person in a rural Southern county with no local HIV specialist: waking early enough to drive two or more hours, arriving for a blood draw and a provider appointment, waiting for results, possibly picking up prescriptions, and driving two or more hours home. If you're working an hourly job, you've lost a full day of wages. If you don't have reliable transportation, you're dependent on someone else's schedule. If you're trying to keep your HIV status private from your employer, coworkers, or family, the time you're gone is unexplained.
Researchers and providers who work in the rural South describe this driving burden in terms that make the care cascade numbers make sense. People who fall out of care — who miss appointments, who go months without labs, who eventually can't be found for follow-up — are often people who simply couldn't sustain the logistics and cost of getting to care consistently. This isn't irresponsibility. It's the predictable outcome of asking people to do something that the system has made genuinely very hard.
Mobile clinics and outreach matter here more than anywhere. Organizations that bring HIV testing, PrEP prescribing, and case management services to rural communities — rather than expecting rural communities to come to them — are doing work that is qualitatively different from clinic-based care. It is harder, more expensive per patient, and more effective. It deserves dedicated funding that it rarely receives.
Race and the Southern epidemic
The racial dimensions of the Southern HIV epidemic are impossible to understand without the history of the region. Black individuals carry a disproportionate share of the Southern epidemic — approximately half of new HIV diagnoses in the region are among Black people, who make up a much smaller share of PrEP users.[10] That gap — nearly half of diagnoses, less than a quarter of prevention — is not explained by behavior. It is explained by structure.
The Black Belt — the arc of majority-Black counties stretching from Virginia through the Carolinas, across Georgia and Alabama, into Mississippi and Louisiana — corresponds almost exactly with counties that have the highest poverty rates, the highest rates of uninsurance, the lowest access to HIV care, and some of the highest HIV diagnosis rates in the country. This is not coincidence. It is the ongoing legacy of segregation, redlining, disinvestment, and the deliberate concentration of poverty in Black communities.
Latino communities are also disproportionately affected. In 2022, Hispanic/Latino people made up an estimated 19% of the Southern population but accounted for 42% of new HIV diagnoses and 34% of people living with HIV in the region.[11] Latino PLHIV face compounded barriers: language access, immigration enforcement fear, cultural stigma, and a healthcare system that is often not built for their navigation.
Addressing the racial dimensions of the Southern epidemic requires race-conscious interventions — not just generic HIV programs that happen to serve diverse populations. Trusted community messengers. Culturally relevant outreach. Black-led and Latino-led organizations. Investment in community health workers who look like, speak like, and come from the communities they serve. This is what the data consistently shows works. It is also what is most often underfunded.
The Medicaid non-expansion crisis
If you want to understand the Southern HIV epidemic in a single policy lens, this is it. Medicaid is the largest payer for HIV care in the United States. Expanding Medicaid to cover low-income adults without children — which the ACA authorized in 2010 — would allow PLHIV in the South to access coverage before they develop AIDS-defining conditions. It would allow HIV-negative people to access PrEP through Medicaid. It would provide insurance coverage to the millions of low-income Southerners currently in the coverage gap.
Seven of the ten states that have not expanded Medicaid are in the South. Florida is one of them. Mississippi is one of them. Georgia, Texas, Alabama, South Carolina, and Louisiana are others. The reasons given vary — ideology, concerns about cost, political positioning — but the outcomes are measurable: higher rates of uninsurance, higher rates of late HIV diagnosis, higher HIV-related mortality in non-expansion states compared to expansion states.
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.
2025 update: The "One Big Beautiful Bill Act," signed in July 2025, reduced Medicaid expansion eligibility thresholds and added work requirements for Medicaid recipients — changes that directly affect PLHIV in expansion states and compound the existing crisis in non-expansion Southern states. HIVMA and other clinical groups have warned that Medicaid work requirements and eligibility rollbacks under H.R. 1 will disrupt care for people with HIV — a group for which Medicaid is the single largest insurer.[12]
Stigma and faith in the South
Stigma doesn't operate the same way in every part of the country. In large metropolitan areas with visible LGBTQ+ communities and decades of public HIV education, HIV stigma still exists — but it coexists with counter-narratives that have been building for forty years. In rural Southern communities, those counter-narratives are often absent.
In a small town in Alabama or Mississippi, everyone knows everyone. Going to the county health department for an HIV test means being seen by your neighbor's cousin. Being referred to an HIV clinic in a nearby city means explaining where you've been. Having HIV medications visible at home means having a conversation you may not be ready to have. The social costs of visibility in small communities are real and specific — and they shape behavior in ways that aggregate into epidemic dynamics.
Faith culture adds another layer. The South is the most religiously observant region in the country, and for many Southerners, their pastor, priest, or deacon is among the most trusted people in their lives — sometimes more trusted than their doctor. Historically, many Southern faith communities responded to the AIDS epidemic with silence, condemnation, or active hostility. People died alone in their families' homes with their HIV diagnosis a secret that could not be spoken in church. The damage from those years of silence persists as distrust of healthcare systems and HIV organizations that are perceived as aligned with urban, secular, LGBTQ+-affirming culture.
But the story isn't entirely one of hostility. There are Black Southern churches that have become HIV testing sites, support group hosts, and PrEP advocacy platforms. There are rural Catholic health systems doing HIV outreach in communities that no secular organization could access. There are faith-based organizations across the Deep South doing some of the most culturally competent HIV work in the country — precisely because they understand that trust in these communities flows through faith, and they've earned it.
— A refrain heard often from Southern HIV clinicians and advocates
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 straightforward answer is that the South is the largest HIV market in the country. 52% of new diagnoses means 52% of potential patients for HIV treatment and prevention products. The gap between the HIV burden and the PrEP uptake in the South represents an enormous unmet market for PrEP products. The pharmaceutical industry's investment in Southern HIV work is, at least in part, an investment in expanding its market.
That doesn't automatically make the work harmful. COMPASS built real organizational capacity in communities that desperately needed it. PASI connected real people to real care. The organizations doing the work — the community nonprofits, the advocacy groups, the faith-based organizations receiving those grants — are doing it because they believe in it, not because they're pharma proxies. The funding enabled work that wouldn't otherwise have happened. The work saved lives.
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
The COVID-19 pandemic forced a rapid expansion of telehealth for HIV care across the South — and what the data showed was encouraging. People who had been falling out of care because they couldn't make the drive were able to maintain quarterly appointments via video. Viral suppression rates improved in some programs. Providers reported that patients seemed more comfortable discussing sensitive topics from home than in clinical settings.
Telehealth doesn't solve everything. The rural South has significant broadband access gaps — you can't do a video appointment without reliable internet, and reliable internet is still not universal in the same rural communities that most need HIV care access. Lab work still requires in-person visits. Some patients have privacy concerns about telehealth at home — if they're not out about their HIV status to family members, a home video appointment carries its own risks.
The most effective Southern HIV telehealth models combine virtual care for routine visits with mobile clinic visits for lab draws — teams that travel to rural communities with a phlebotomist, medications, and a laptop, so patients get both their in-person needs met and can have their follow-up visit virtually. These hybrid models require investment and coordination but have produced some of the best retention-in-care outcomes of any approach tested in rural Southern settings.
Florida: the Southern epidemic's largest state
🌴 Florida: Ground Zero in the South
Florida is the second-highest HIV-burden state in the country and home to more PLHIV than any other Southern state. Miami-Dade County consistently ranks among the highest-burden counties in the nation — with HIV rates that rival cities in sub-Saharan Africa in some community comparisons. Broward, Palm Beach, Hillsborough (Tampa), Orange (Orlando), and Duval (Jacksonville) all have significant concentrated epidemics.
Florida's refusal to expand Medicaid — despite being the third-largest state by population — is one of the most consequential state-level policy decisions in the country for PLHIV. Hundreds of thousands of Floridians fall in the coverage gap. The March 1, 2026 ADAP eligibility cuts — reducing income eligibility from 400% to 130% FPL — removed approximately 16,000 Floridians from HIV medication coverage, triggering the most significant state-level HIV care crisis in the state in recent memory.[8]
Florida's HIV criminalization statute is among the most aggressive in the country and has not been updated to reflect modern science or the U=U consensus. It creates legal fear that compounds stigma in ways that drive PLHIV away from testing and care.
And yet: Florida has one of the strongest HIV service infrastructures in the South. Ryan White-funded clinics in every major metro. CAN Community Health with 19 Florida locations. AHF Healthcare Centers statewide. The Florida Consortium for HIV/AIDS Research (FCAR). Academic research programs at University of Miami, USF, and UF. The capacity exists. The funding and policy environment is what's failing it.
If you're in Florida and living with HIV or seeking HIV prevention services, use our Florida care locator — 195+ organizations across all 67 counties.
For rural Florida specifically, the page HIV in Rural Florida covers the geography of the epidemic and what services exist outside the major metros.
What actually works — and what the South needs
The solutions to the Southern HIV epidemic are not mysteries. They have been documented, studied, piloted, and in many cases proven. What's missing is the political will and consistent funding to implement them at scale.
Medicaid expansion
This is the single highest-impact policy lever available. Every analysis agrees: expanding Medicaid in the remaining non-expansion Southern states would reduce new HIV infections, reduce HIV-related deaths, reduce late-stage diagnoses, and expand PrEP access. It would do this for HIV specifically, and it would do it alongside improving outcomes for every other chronic condition in those communities. The barrier is political, not economic — the federal government pays the vast majority of expansion costs. The communities bearing the consequences of non-expansion have the least political power to change it.
Community-led, culturally specific outreach
Programs that center Black and Latino leadership, that use messengers who reflect the communities they serve, that meet people where they are — in barbershops, churches, community centers, LGBTQ+ venues — consistently outperform clinic-based outreach in reaching people who have been hardest to reach. This is not a controversial finding. It is consistently documented and consistently underfunded relative to its effectiveness.
Mobile services
Mobile HIV testing, mobile PrEP prescribing, mobile case management — bringing services to communities rather than expecting communities to come to fixed sites — is the most direct response to HIV care deserts. Mobile services also navigate stigma differently: a van in a community parking lot or a church parking lot is less visible and less stigmatizing than a sign reading "HIV Clinic" on a building that people have to walk into.
Long-acting PrEP
Injectable PrEP — particularly twice-yearly lenacapavir when it receives full PrEP approval — has the potential to address some of the access barriers that daily oral PrEP cannot. If someone can receive a PrEP injection every six months at a mobile clinic or health fair, they don't need to fill a daily prescription, don't need consistent pharmacy access, and don't have medication visible at home. For the rural South, where daily pill adherence is complicated by logistics and privacy concerns, long-acting options could be transformative — if they're accessible, affordable, and actively promoted in the communities that need them most.
Decriminalization
HIV criminalization laws don't prevent HIV. They prevent HIV care. Repealing or modernizing criminalization statutes to reflect current science — specifically to exempt people with undetectable viral loads and to require intent and actual risk — would reduce the fear that drives PLHIV underground. North Carolina, Louisiana, and California have modernized their laws in recent years. The remaining states with punitive statutes, including Florida, have not.
Sustained investment in Southern organizations
The organizations doing this work — community nonprofits, faith-based organizations, peer navigators, mobile outreach teams — are chronically underfunded relative to the scale of the epidemic they're addressing. Federal HIV funding allocation has historically underweighted rural and Southern areas. The argument for rebalancing that allocation toward the region carrying the majority of the epidemic's burden is simple and compelling. It has not yet succeeded.
Southern HIV/AIDS Awareness Day is August 20.[2] Use it. Organizations across the South hold events, issue reports, and mobilize advocacy on and around this date. If you're in the South, show up. If you're outside the South, share. The epidemic's center of gravity is here — the national conversation should reflect that.
References & Sources
- 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 ↩ ↩
- AIDSVu. Southern HIV/AIDS Awareness Day Toolkit 2025. Emory Rollins School of Public Health. aidsvu.org ↩ ↩ ↩ ↩
- Centers for Disease Control and Prevention. CDC Publishes New HIV Surveillance Reports (Director's Letter, May 21, 2024) — estimated new HIV infections declined 16% in the South in 2022 compared with 2018. cdc.gov ↩
- Chartis Center for Rural Health. Unrelenting Pressure: Rural Hospital Vulnerability and 2025 rural health state of the state. Chartis, 2024–2025. chartis.com ↩
- Kaiser Family Foundation. Status of State Medicaid Expansion Decisions. KFF. kff.org ↩
- 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 ↩
- 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 ↩
- International Association of Providers of AIDS Care (IAPAC) & NASTAD. News Alert — Florida ADAP Changes (Jan 12, 2026): Florida DOH shifted direct ADAP coverage to individuals at or below 130% FPL effective March 1, 2026, affecting an estimated 16,000 Floridians. See also Florida DOH ADAP page. iapac.org ↩
- Becker's Hospital Review, summarizing Chartis Center for Rural Health. 417 Rural Hospitals at Risk of Closure — Mississippi's share of rural hospitals vulnerable to closure improved from 49% to 42% in Chartis's 2026 analysis. beckershospitalreview.com ↩
- Kaiser Family Foundation. The Impact of HIV on Black People in the United States. KFF, 2024 — the South accounts for 52% of new HIV diagnoses among Black people and 46% of Black people living with HIV nationally. kff.org ↩
- Kaiser Family Foundation. The Impact of HIV on Hispanic/Latino People in the United States. KFF, 2024 — in 2022, Hispanic/Latino people made up 19% of the Southern population but accounted for 42% of new HIV diagnoses in the region. kff.org ↩
- HIV Medicine Association. Medicaid Work Requirement Rule: Making a Harmful Law Worse for People with HIV. HIVMA, June 2026. See also HIVMA state advocacy brief on Medicaid work/community-engagement requirements under H.R. 1. hivma.org ↩
- North Carolina Department of Health and Human Services. Medicaid Expansion in North Carolina — expansion launched December 1, 2023. ncdhhs.gov ↩
- Southern AIDS Coalition. About / Home. Community-led regional advocacy organization founded in 2001. southernaidscoalition.org ↩