Why Your Address May Be Your Greatest HIV Risk

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HIV risk factors are simply the characteristics that place an individual at greater or lesser risk of getting (or passing on) HIV. We generally take that to mean one of four things:

  • A person’s ethnicity
  • Sexual orientation
  • Sexual practices (e.g., receptive anal sex, oral sex)
  • Other behaviors that can either increase or decrease the likelihood of infection (e.g., condoms, injecting drug use, antiretroviral therapy)

HIV risk factors are not meant to predict whether a person will get infected; rather they aim to highlight a person’s vulnerability to HIV so that he or she can take steps to reduce risk. And even when certain factors are not changeable—like race or sexual orientation—they can help us make an informed judgment based on how the virus is spread within our specific population or group.

One of the risk factors we don’t often discuss, at least on an individual basis, is how where you live has a direct impact on your risk of HIV, both directly and indirectly.

HIV Predominantly an Urban Disease

HIV remains, by and large, an urban disease. It is typically concentrated in densely populated cities of over 500,000 and primarily in communities that are vulnerable not only to HIV but to other communicable infections.

While the dynamics of infection can vary from region to region, epidemics are most often fueled by poverty, a lack of HIV-specific services, and an inadequate public health response to the local epidemic.

In the U.S., the highest rate of new HIV infection is in the South, where 18.5 of every 100,000 people are infected. This is followed closely by the Northeast (14.2) and the West (11.2).

More worryingly, the nine states that comprise the South also account for 40% of all new infections despite representing only 28% of the U.S. population.

According to the Centers for Disease Control and Prevention (CDC), the metropolitan districts with the highest HIV incidence (i.e., number of new HIV cases) are:

  1. Baton Rouge, Louisiana
  2. Miami-Fort Lauderdale-West Palm Beach, Florida
  3. New Orleans, Louisiana
  4. Jackson, Mississippi
  5. Orlando, Florida
  6. Memphis, Tennessee
  7. Atlanta, Georgia
  8. Columbus, South Carolina
  9. Jacksonville, Florida
  10. Baltimore, Maryland
  11. Houston, Texas
  12. San Juan, Puerto Rico
  13. Tampa-St. Petersburg, Florida
  14. New York City-Newark-Jersey City, New York-New Jersey
  15. Little Rock, Arkansas
  16. Washington-Arlington-Alexandria, DC-Maryland-West Virginia
  17. Dallas-Fort Worth, Texas
  18. Charleston, South Carolina
  19. Las Vegas, Nevada
  20. Los Angeles, California

The picture changes slightly when you look at the HIV prevalence within U.S. cities. Unlike the incidence rate, this figure tells us how many people out a 100,000 are infected within a specific metropolitan region.

The U.S. cities with the highest HIV prevalence (number of cases per 100,000 residents) are:

  1. Miami (1,046)
  2. San Francisco (1,032)
  3. Fort Lauderdale (925.8)
  4. Philadelphia (881.9)
  5. New York City (859.7)
  6. Baltimore (678.5)
  7. New Orleans (673.3)
  8. Washington, DC (622.8)
  9. Newark (605.7)
  10. Jackson, Mississippi (589.7)
  11. San Juan, Puerto Rico (583.2)
  12. West Palm Beach (579.4)
  13. Baton Rouge (560)
  14. Memphis (543.5)
  15. Columbus, South Carolina (509.1)
  16. Atlanta (506.6)
  17. Los Angeles (465.2)
  18. Orlando (460.7)
  19. Jacksonville (451.4)
  20. Detroit (410.7)

How a City’s Response Can Increase, Decrease HIV Rates

It’s important to note that HIV prevalence doesn’t necessarily translate to a higher number of new infections. Even in cities with some of the highest concentrations of HIV infections, an effective public health response can greatly diminish the risk of onward transmission.

Take San Francisco, for example, a city which responded to the epidemic by becoming the first to call for universal testing and treatment in 2010. Despite having the second-highest HIV prevalence in the U.S., the city’s aggressive response resulted in a dramatic drop in new infections, hitting an all-time low of only 302 new cases by 2015. It is believed that the widespread use of HIV PrEP (pre-exposure prophylaxis) could cut rates even further.

By contrast, the lack of a cohesive response can fuel an outbreak even in smaller, non-urban communities. We saw this in 2015 in the town of Austin, Indiana (population 4,295), where over 100 cases of HIV were reported among injecting drug users who had shared needles while taking the drug oxymorphone. The outbreak was attributed in large part to the state’s ban on needle exchange program (NEPs) designed to prevent such infections.

Not surprisingly, the states with some of the highest HIV rates are also those that also ban NEPs (including Alabama, Arkansas, Mississippi, South Carolina, Texas), and this despite a wealth of scientific evidence showing NEPs effectiveness in preventing blood-borne disease transmission.

Similarly, the states that have not adopted Medicaid expansion, designed to provide greater health care access to low-income residents, are among those with spiking HIV rates (Alabama, Florida, Georgia, Mississippi, South Carolina, Texas).​

According to the Centers for Budget and Policy Priorities, the adoption of Medicaid expansion provides people living with HIV greater access to not only treatment but to uninterrupted, long-term health care.

In the state of Massachusetts, by way of example, comprehensive health reforms expanded HIV care and treatment to 91% of the residents living with HIV, reducing hospitalizations and HIV-related health care costs by some $1.5 billion.

By contrast, the state of Alabama had to take 25% of its ADAP (AIDS Drug Assistance Program) budget from state funds in 2011—much of which could have channeled to other public health programs since 81% of those on ADAP were Medicaid eligible.

All told, more than half of the uninsured and low-income people living with HIV reside in states that have refused Medicaid expansion. Most agree that ongoing resistance to expansion places those most at need—among them, African-Americans and gay and bisexual men—at even greater risk of infection, illness, and death.

Cities With the Lowest HIV Rates

According to the CDC, the prevalence of HIV within non-metropolitan districts of the U.S. runs at around 112.1 cases per 100,000. Of the 107 cities included in its 2015 report, only six fell beneath this threshold:

  1. Boise, Idaho (71.7)
  2. Rapid City, Michigan (100.1)
  3. Fayetteville, Arkansas (108.8); Madison,
  4. Wisconsin (110)
  5. Ogden, Utah (48.6)
  6. Provo, Utah (26.9)

By contrast, the 10 U.S. cities with the lowest rate of new HIV infections are:

  1. Provo, Utah
  2. Spokane, Washington
  3. Ogden, Utah
  4. Boise, Idaho
  5. Modesto, California
  6. Worcester, Massachusetts
  7. Fayetteville-Springdale-Rogers, Arkansas-Missouri
  8. Madison, Wisconsin
  9. Scranton-Wilkes-Barre, Pennsylvania
  10. Knoxville, Tennessee
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