HIV is surging in the South, which the U.S. Centers for Disease Control and Prevention has designated “the epicenter” of an emerging crisis particularly affecting seven states spanning from Texas to North Carolina.
As last month’s gubernatorial election approached in Mississippi — which has the sixth-highest rate of HIV diagnoses in the nation — community healthcare workers had high hopes that help in the form of Medicaid expansion could be on the way.
Medicaid is the largest source of health insurance coverage for adults living with HIV. And expanding Medicaid could bring more funds to southern hospitals treating patients with HIV. A September poll found that 9 of every 10 Mississippians wanted to improve the state’s struggling hospital system, and 7 of 10 were in favor of expanding Medicaid.
But Republican Tate Reeves, who has maintained that the state cannot afford Medicaid expansion, defeated Democrat Brandon Presley. During his campaign, Presley argued that Mississippi cannot afford not to expand Medicaid.
It was an unusually close contest in an otherwise predictably red state. Reeves won with only 51% of the vote, barely avoiding a runoff. His re-election lessened the likelihood of any quick decision to expand Medicaid, or that Mississippi alongside other states would reach a 2019 goal set by the Department of Health and Human Services to reduce HIV infections 75% by 2025.
If Mississippi alongside the other six southern states affected by the surge in HIV cases expanded Medicaid, the program would provide more federal funds for the poorest people, including making pre-exposure prophylaxis, or PrEP, more widely available, a daily pill that’s been touted as a game changer because it’s so effective at preventing HIV.
The decision to not expand Medicaid, which is the nation’s largest public health insurance program for low-income people, in Mississippi as well as other parts of the South has become mixed with a stew of politics: red state versus blue state, urban versus rural, rich versus poor, straight versus gay and white versus everyone else.
One in five Mississippians live in poverty, which is more concentrated in rural areas and associated with poorer health outcomes, such as a higher risk of chronic diseases like heart disease and diabetes. Forty-two percent of the state’s rural hospitals are at risk of closing. Missisisppi rivals Louisiana as the poorest state in the nation. In the South, HIV is more of a suburban and rural problem than in other regions of the country, according to the CDC.
Hinds County is the epicenter of HIV infections in Mississippi. In 2021, Hinds, which includes the state capital of Jackson, had the highest number of new HIV diagnoses in the state, more than three and six times as many diagnoses as in neighboring Rankin and Madison counties, both majority white and the wealthiest in Mississippi.
Presley’s loss was a big disappointment for Alicia Barnes, chief operating officer of Open Arms Healthcare, a nonprofit clinic that provides sexual and reproductive healthcare for the Jackson area, Hattiesburg and Gulfport. Barnes was hopeful about Presley’s candidacy because he supported Medicaid expansion and appeared to understand the challenges low-income patients face in accessing health care.
“We’re in an epidemic and it’s not going to go away until something is done and it’s going to have to happen on a policy level,” Barnes said. “We’re doing what we can on a community level, but policy has to change.”
Nationwide, one of seven adults is covered by Medicaid. But for adults living with HIV, four of 10 are covered by Medicaid. And yet, they represent a small part of the overall Medicaid population: Less than one of every 100 people, according to the Kaiser Family Foundation.
In Mississippi, 22% of people living with HIV could gain Medicaid coverage if the state were to expand.
Gov. Reeves’ office did not respond to a request for comment.
The Ryan White HIV/AIDS Program, administered by the Health Resources and Services Administration with federal funding, fills the insurance coverage gap for people living with HIV who fall in the Medicaid coverage gap in non-expansion states. But it wasn’t intended to be that way.
The program serves more than half of the people diagnosed with HIV. It follows Medicare and Medicaid as the largest source of federal funding for HIV care, according to the Kaiser Family Foundation.
Uninsured people with HIV may access primary care and antiretroviral medications through the program or direct from pharmaceutical manufacturers with patient assistance programs, said Stephanie Hengst, manager for policy and research at The AIDS Institute. But the Ryan White program is not intended to be a primary source of financial coverage for insurance.
“It’s supposed to be filling the little gaps here and there, but not to become basically a payer for those in [non-expansion] states,” Hengst said. “Those resources could be better used for other needs.”
Those needs include substance abuse programming and housing, said Kathie Hiers, CEO of AIDS Alabama, a social service organization that provides health care services, insurance assistance and other support to people living with HIV/AIDS. States that have expanded Medicaid can offer a broader array of supportive services through the Ryan White program, Hiers said.
Roughly half of people living with HIV are age 50 and over. They might be facing chronic illnesses associated with aging that the Ryan White program may not be able to address because it’s an HIV/AIDS program. Alabama and Mississippi, for example, have the highest rates of death due to heart disease, a common comorbidity for people with HIV.
“People are not going to be able to live as long as their HIV medications would allow them to because they’re unable to get care for their heart disease,” said Vanessa Tate Finney, director of policy and advocacy at AIDS Alabama.
Medicaid expansion would increase access to PrEP, which the CDC reports is being underutilized in the South. Although Open Arms provides high-risk patients access to PrEP, uninsured patients may contract HIV because they cannot afford the daily pill, Barnes said.
“Although African Americans and people of color are at high risk of people who need Medicaid, it’s not just us,’ Barnes said. ‘HIV does not have a color when it comes to the disease.’