REIF ET AL. RESPOND

Abstract

Doherty et al. highlight several important social dynamics that likely contribute to the disproportionate HIV incidence rates in the southern United States. Although we touched on most of the areas Doherty et al. mention, including racial disparities in health care and economic conditions, intriguing new information regarding determinants of HIV infection in the South has emerged since our original submission.1–5 We welcome the increased attention to the HIV and sexually transmitted infection (STI) epidemics in the South as signaled by their letter as well as by recent special issues of Sexually Transmitted Diseases (July 2006) and AIDS Care (September 2006). Doherty et al. correctly observe that emerging information regarding the influence of the war on drugs and other contextual factors on sexual networks in the African American community is critical to the dialogue on HIV/AIDS in the South. In the special issue of Sexually Transmitted Diseases, Adimora et al. synthesized research regarding social networks and STI transmission and concluded that areas of elevated STI rates are characterized by high levels of concurrent relationships and “sexual bridging between the general population and high-risk, high-prevalence subgroups,” facilitating the spread of HIV and STIs.1(pS44) They further concluded that these relationship patterns are fostered in the African American community by discrimination, lack of economic opportunities, and the low male-to-female ratios created, in part, by high levels of incarceration. In a state-level ecological analysis in the recent AIDS Care supplement on HIV/AIDS in the South, Qian et al. found that US states with higher proportions of African American residents experienced greater recent increases in HIV/AIDS.2 In addition, states in the South had greater increases in HIV/AIDS than states in other regions, and this disparity was only partially explained by regional differences in the proportion of African American residents. These results suggest that there are other factors in addition to the specific concerns of the African American community that are fueling the rising epidemic in the South. Although the latest research on issues pertinent to HIV/AIDS in the South has furthered our knowledge of the epidemic, our understanding of how to intervene remains incomplete. We maintain that for a region of the country with the highest absolute numbers of HIV-infected individuals and the largest proportionate increases, research and attention has been relatively scant. In particular, further research is needed examining interventions that target the social forces facilitating the spread of HIV/AIDS, some of which may involve societal change.1