According to the Centers for Disease Control and Prevention (CDC, 2012), Texas experiences some of the highest rates of HIV/AIDS in the US and ranks 4th in the nation for AIDS diagnosis. However, the patterns of HIV/AIDS infection in Texas are not uniformly distributed. East Texas exhibits the highest rates of HIV infection and the virus is spreading more rapidly here than any other region (Texas Department of State Health Services, 2010). Nationally, HIV/AIDS rates are highest in areas of extreme poverty. In fact, the CDC asserts that HIV infection is closely related to poverty (CDC, 2011). This paper seeks to analyze the spatial distribution of HIV/AIDS in East Texas and to gain an understanding of the underlying explanatory variables. Specifically, this research focuses on the role of poverty in HIV infection in the urban/rural divide of east Texas.
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About 1.1 million Americans were living with HIV in 2010 (CDC, 2010 c), and over 619,400 people have died from the disease since the beginning of the epidemic (CDC, 2012). Due to increased access to antiretroviral treatments, education and diagnosis at a younger age, people with the disease are living longer. Because these treatments prolong the lives of those who are infected and significantly reduce death rates, more people become infected with HIV than die from the disease each year. Consequently, the opportunity for transmission to others increases as well (CDC, 2008).
Certain geographic areas and populations experience comparatively greater disease burdens (AVERT 2011). AIDS mortality rates vary as well, both nationally and within Texas, with Texas ranked fourth highest among US states in cumulative AIDS cases from the 1980’s to 2008, with 77,070 total cases (CDC, 2010 c).
Geographic distribution of health outcomes are neither random nor uniform, but rather vary spatially, producing heterogeneous spaces of risk for disease (Oppong & Harold, 2009). The human ecology of disease provides an excellent framework for investigating the geography of human health. It attributes the uneven distribution of diseases to genetics, environment, and behavior (Meade & Emch, 2010). Environment is defined as the combination of natural, built, and social structures. For example, the geographic distribution of HIV/AIDS illustrates how the social environment impacts the risk and spread of disease. Sexual behavior norms differ spatially, creating a variable risk of exposure to disease (Oppong & Harold, 2009).
A person’s social environment, including cultural and social groups and individual relationships, can significantly affect their vulnerability to a disease (Oppong & Harold, 2009). Differences in income, gender, culture, and education comprise aspects of the social environment. Socially constructed environments play an important role in creating the circumstances necessary for exposure to disease inducing agents. On a global scale, this is seen in low-income countries that face widespread poverty, lack of access to healthcare, poor nutrition and diet, and inadequate sanitation (Oppong & Harold, 2009). The World Health Organization estimates that 45% of diseases are associated with poverty in the poorest countries in the world (Stevens, 2004).
The built environment also contributes to variability to risk for disease. This includes structures that humans have created such as houses, office buildings, factories, and highways, as well as building and zoning codes. Because humans spend much of their time indoors, examining the exposure risks of these spaces is important. The urban built environment can promote good health in terms of access to education, social support, health care, and resources. However, it may present certain risks, such as crowding, social disorder, poor sanitation, pollution, and industrial accidents. The built environments in areas of low socioeconomic status reflect the lack of developmental infrastructure such as sanitation, resulting in challenges for control of diseases. Low-income families are also more likely to face difficulties in paying for HIV testing and antiretroviral medications (Oppong & Harold, 2009).
Vulnerability to a disease within a population may be tied to specific places where risk behaviors and place characteristics facilitate disease spread. The behaviors of vulnerable people, in turn, lessen their resilience, resulting in poor health. Socio-economically disadvantaged people tend to live in places that result in greater vulnerability. In contrast, people that are not considered vulnerable to disease live in more affluent areas where access to health care is greater and poor sanitation does not pose a comparative problem (Oppong & Harold, 2009).
The geographic concentration of vulnerable places creates an environment where risk for disease may be greater. Those with lower socio-economic status may be less likely to oppose environmentally unsafe development whereas the wealthy possess the means to mitigate or avoid these types of developments. This is the reason for an increase in the spatial concentration of vulnerable people. It is clear that the environment is a huge factor in where and why diseases spread, and it is critical to identify and address both social and built components of environment. Consequently, the overwhelming weight of evidence suggests that physical, service, and social characteristics of places influence health in important ways, including by shaping choices and behaviors (Oppong & Harold, 2009).
Changing Modes of Exposure to HIV/AIDS
The United States HIV epidemic is concentrated among those who engage in high-risk behaviors such as men who have sex with men (MSM) (53% of new infections) and injection drug users (IDU) (12% of new infections) (CDC, 2010 b). In 2008, 20% of those living with AIDS in the US were infected through IDU. Despite prevention efforts such as needle exchange programs, HIV spread continues (AVERT, 2011). At the beginning of the epidemic, HIV infection was most frequent among gay and bisexual men. Today, MSM continues to be the leading mode of exposure and new HIV infections spread through MSM are rising every year primarily due to unprotected sex (AVERT, 2011) and the fact that approximately half of MSM living with HIV are unaware of their status (CDC, 2010 c). However, heterosexuals have been affected just as much in recent years, particularly the poor living in extreme poverty within urban neighborhoods. Approximately 31% of new HIV infections in the U.S. in 2010 were acquired through heterosexual transmission (CDC, 2010 a). According to the CDC roughly 2.1% of heterosexuals living in high-poverty urban areas are infected with HIV in the United States (CDC, 2011).
Socioeconomic status. HIV infection rates also vary with neighborhood characteristics and socioeconomic status. Rates tend to be higher in populations with the lowest socioeconomic status. This is due to the fact that more disadvantaged people tend to live in disadvantaged places and are therefore more vulnerable to experiencing poor health (Oppong & Harold, 2009). Consequently, the HIV epidemic has significantly affected the economically disadvantaged in urban areas. Moreover, the HIV prevalence rates in areas of extreme urban poverty do not significantly differ by ethnicity or race, unlike the patterns of ethnic differences found in rates for the overall U.S. population (CDC, 2010 a).
Income, extreme urban poverty. The environment in which one lives plays perhaps the most crucial role in HIV infection. According to the CDC, HIV prevalence rates in urban poverty areas are inversely related to socioeconomic status, meaning that HIV prevalence rates are higher in impoverished areas (CDC, 2010 a). The CDC also states that poverty plays a significant role in HIV infection and considers it the single most important demographic factor (CDC, 2010 b). Frequently, prevention efforts fail to reach HIV-infected and uninfected individuals in poverty stricken areas (CDC, 2008).
The CDC released a report in 2011 showing a powerful link between poverty and HIV risk where prevalence was especially high in areas with the lowest socioeconomic status. The analysis revealed that a greater risk was evident for individuals living below the poverty line than those living above the poverty line (2.4% vs. 1.2% risk) in low-income urban areas. The study concluded that the lower the socioeconomic status, the greater the HIV prevalence rate (CDC, 2010 b). These findings, which have significant implications for future research on HIV prevention, aim towards looking at the epidemic in isolation from the environment that people live, prioritizing prevention efforts where disadvantaged communities are most affected (CDC, 2010 b).
In the US, HIV prevalence in poor urban neighborhoods was four times the national average (AVERT, 2011). These high HIV rates were attributed not to race or ethnicity, but to limited access to healthcare and other services. The poorest segments of urban centers have the highest risk for HIV. Poor neighborhoods are common in urban centers, and the poorest residents live in the inner cities, a concentration of economically blighted neighborhoods with high rates of unemployment and a lack of public safety indicators. Drug abuse is commonly connected to the exchange of sexual behaviors, which can be a gateway of infections, including HIV and other STIs (Akuwe, 2000).
The incidence of HIV/AIDS in urban areas is higher probably because of high levels of STIs, IDU, poverty, and an influx of people. Poor neighborhoods are common in urban areas, a concentration of low-income housing, often of ethnic minorities, where a number of risk factors are prevalent among these poorest segments (Akuwe, 2000).
Many health problems are exacerbated by poverty in terms of access to care, transportation, education and individual and family well-being (CDC, 2008). Also, physicians may communicate less effectively with people of a lower socioeconomic status, and conversely, such people may lack trust in their provider, yet treatment is crucial in reducing the transmission of HIV (Horton, 2010). The lack of access to resources for persons infected with HIV, living in poverty, can play a role in their decreased survival rates. More affluent infected persons can increase their chance of survival through increased opportunities for treatment (American Psychological Association 2012).
Race/ethnicity. Race/ethnicity also plays an important role in the geography of HIV/AIDS. The CDC reports that the U.S. epidemic is characterized by distinct ethnic and racial disparities (CDC, 2010 b). In the U.S., AIDS has become a serious threat among Black communities and has taken the lives of over 200,000 Blacks since the epidemic began (Horton, 2010). For the overall U.S. population, the HIV prevalence rate for Blacks (1.7%) is eight times higher than Whites (0.2%), and the rate for Hispanics (0.6%) is three times the rate for Whites (CDC, 2010 c). Racial and ethnic disparities in disease burden can be attributed to many factors, but poverty plays a central role. For the overall U.S. population, almost 50% of Blacks live in areas of poverty compared to just 10% of Whites (CDC, 2010 a). There are also higher rates of other sexually transmitted infections (STIs) in Black communities that also experience limited access to health care and treatment, institutionalized racial discrimination, and high rates of incarceration which all contribute to risk of infection (CDC, 2009).
In Texas, HIV cases for Blacks in 2006 were five times higher than for Whites or Hispanics (Texas State Department of Health Services, 2010). This is reflective of high HIV cases for Blacks in America. Sixty-four percent of youths and teens in Texas with HIV infections in 2008 were Black (CDC, 2011).It is apparent that race/ethnicity plays a vital role in HIV infection, and that this phenomenon requires further research and targeted public health interventions.(CDC, 2009).
- Counties with high percentages of Blacks will have high rates of HIV/AIDS. Since the rate of HIV/AIDS is significantly higher in Texas for Blacks than for any other race, I predict that the same will be true for east Texas.
- Counties with high rates of poverty will have high rates of HIV/AIDS. The CDCs latest report that shows poverty is a factor in the spread of HIV.
- More urban areas have higher HIV/AIDS rates. Because of the influx of people in urban centers, the spread of disease is higher in areas where there are a lot of people.
- Counties with a high percentage of people that have less than a high school diploma will also have high rates of HIV/AIDS. Education is crucial to the prevention of HIV/AIDS, so where there is less education among the population, I predict we will find higher rates of HIV/AIDS.
Zip-code level data on all HIV/AIDS cases reported in each east Texas county from 1999-2008 were provided by the Texas State Department of Health Services. All county-level demographic data, including race/ethnicity, level of education (percentage of population 25 and older with less than a high school diploma), household socioeconomic status, and percent urban area, was derived from the 2010 Census. The 2010 Texas Epidemiologic Profile defined the area of east Texas that was used in this study. Pearson’s correlations were used to measure the strength of the relationship between the independent variables collected from the U.S. Census above and rates of HIV infection.
Background and Study Area Characteristics
For this study, east Texas is defined to include all counties east of Interstate 35 south to Harris County, which includes the Houston metro area. It includes the major metropolitan areas of Texas such as Austin, Dallas-Fort Worth, and Houston. East Texas is more urbanized, has a much higher percent of Blacks in the population, and has a higher median income and a higher income inequality, in comparison to the rest of Texas. The state median income in 2010 was $33,335.00 (2010 Census). The highest median income per capita is $39,493 in Collin county (2010 Census), and the county with the highest percentage of poverty is Brazos with 29.7% (Figure 6).
The results of the analysis are presented in Table 1. Poverty, percent of population that is Black, percent of population that is Hispanic, and percent of the area of the county that is urban had a positive, significant correlation with the rate of HIV/AIDS in a county. Percent White and percent rural had a negative, significant correlation with the rate of HIV/AIDS in a county (Table 1).
The rate of HIV/AIDS in east Texas appears to be elevated in the central portion of east Texas, particularly in urban areas. Harris county exhibits the highest rate at 443 cases per 100,000 (Figure 2). Counties with the highest rates (160-1016 cases per 100,000) include: Anderson, Bowie, Dallas, Ellis, Galveston, Gregg, Grimes, Harris, Houston, Jefferson, Marion, Matagorda, Navarro, Shelby, Tarrant, Travis, Trinity, Walker, Waller, and Wharton counties (Figure 2).
The northern and western portions and the central eastern region have the highest percent White population (Figure 3). Blacks are concentrated along the eastern border with Louisiana, the Dallas-Fort Worth Metroplex area, and the south central region (Figure 4). The southwestern border and northwestern counties in the Dallas-Fort Worth Metroplex area have the highest percent Hispanic population (Figure 5).
Percent poverty by county shows that the area most affected is the central portion of this region (Figure 6). These counties include: Marion, Shelby, San Augustine, Nacogdoches, Houston, Walker, Brazos, Falls, and San Saba. Percent urban by county shows that metropolitan areas in the northwest and southeast have the highest percentages and the highest include Dallas, Tarrant, and Harris counties. In these counties, there are high percentages of Whites and Blacks living in poverty (Figure 7). The counties with greatest percentage of the population lacking a high school diploma are located in the central and southern central region as well as eastern border counties (Figure 8).
The geography of HIV/AIDS in east Texas counties cannot be attributed to one factor alone. Some of the contributing factors, including those analyzed here, are high-density populations, percent minority population, and the influx of diseases from other locations. This research illustrates the fact that urban counties in Texas experience higher rates of HIV/AIDS. Where there are high concentrations of people, a disease is more likely to spread because people gather there as a result of travel or work, and the areas exhibit extreme rates of urban poverty. Acknowledging this comparatively higher disease burden, urban areas should have more testing centers that are free to the public and target specific populations within these cities in planning public health education campaigns. In terms of race/ethnicity, higher percentages of both Blacks and Hispanics live in and near urban areas (Figure 4 and Figure 5). The high rates of HIV/AIDS among these groups could be the outcome of living in areas of extreme urban poverty (Figure 7). It is shown that poverty is highest among the Black and Hispanic populations in Texas, which also represent the populations most affected by HIV/AIDS. This research clearly shows that where there are high rates of poverty and large Black and Hispanic populations, there are likely to be high rates of HIV/AIDS infection.
Previous studies have not shown percent Hispanics in a population to have a positive, significant correlation with the rate of HIV/AIDS. But since Hispanics seem to be located in and around urban and urban impoverished areas where there are high HIV rates, they are living in a vulnerable environment. The particularly high rate of Hispanic HIV/AIDS in East Texas is noteworthy. In previous research, this author has conducted, percent Hispanics in a population was associated with low levels of education and high rates of poverty, two important variables associated with HIV infection. Drawing attention to the HIV rate in the Hispanic population of Texas is important because frequently the seriousness of the crisis has been concealed among other groups such as Blacks. Now, Hispanics can be examined as a target population that is vulnerable to HIV/AIDS.
There are strong positive correlations between the rate of HIV/AIDS in a county and the percent of poverty, particularly in urban impoverished areas. There are also strong correlations between HIV/AIDS rates and percent Black and Hispanic in the population. This research shows that rates are highest among minorities and in impoverished and rural areas. The vulnerability framework provides a critical theoretical and analytic perspective, as the risk of exposure is high in poor urban areas, populated predominately by minorities. This can significantly impact their vulnerability to disease through the social and built environment. Socially constructed environments and poverty contribute to the circumstances necessary for the spread of disease. The built environment in low socioeconomic status areas reflects the poor public health infrastructure that limits protection against HIV/AIDS infection. The argument can be made that what might be occurring is that vulnerable people are creating vulnerable environments, resulting in impaired resilience and poor health. It is apparent that poverty has played a central role in HIV/AIDS infection patterns and rates and that minorities are disproportionately affected, but in order to understand these mechanisms, a deeper investigation is needed.
The spatial analysis of HIV/AIDS in east Texas shows us many things. First, geography alone does not determine rates of disease. Second, in order to pinpoint risk factors, a more in-depth analysis should occur. I would recommend further research into the Hispanic population in counties with high rates of HIV/AIDS, specifically, the mode of transmission. Another recommendation would be to investigate other factors that could be associated with such high percentages among the Black population. Perhaps a neighborhood-level spatial analysis of the counties with the highest rates of HIV/AIDS in east Texas would provide deeper insights into the dynamics of this disease.
- Akuwe, C. (2000). The need for an urban HIV/AIDS policy in the United States. Journal of Health and Social Policy, 23, 1-15.
- American Psychological Association (2012). HIV and socioeconomic status. Retrieved from http://www.apa.org/pi/ses/resources/publications/factsheet-hiv-aids.aspx
- AVERT: Averting HIV and AIDS. (2011). HIV/AIDS in America. Retrieved from http://www.avert.org/america.htm#contentTable1
- Center for Disease Control. (2010a). Is there a generalized HIV epidemic in impoverished urban areas of the United States. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/resources/other/poverty.htm
- —. (2010b). New study in low-income heterosexuals in America’s inner cities reveals high HIV rates. Retrieved from http://www.cdc.gov/nchhstp/newsroom/povertyandhivpressrelease.html
- —. (2010c). Texas 2010 HIV/AIDS epidemic profile. Retrieved from http://www.cdc.gov /nchhstp/stateprofiles/pdf/Texas_profile.pdf.
- —. (2008). CDC HIV/AIDS facts December 2008: dramatic declines indicate success in U.S. HIV prevention. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/pdf/transmission.pdf.
- —. (2009). Framing Health Matters. A review for the Center of Disease Control and Prevention’s response to the HIV/AIDS crisis among Blacks in the U.S., 1981-2009. American Journal of Public Health. Retrieved from http://www.cdc.gov/hiv/topics/aa/ resources/journals/sutton_et_al_ajph_2009.pdf
- Horton, A. (2010). AIDS in Black America: A ray of hope. The International Journal of Science in Society, 1, pp.13-28.
- Meade, M. & Emch, M. (2010). Medical geography, 3rd ed. New York: The Guilford Press.
- Oppong, J. R. and Adam Harold. (2010). Disease, ecology and environment. In Tim Brown, Sara McLafferty, and Graham Moon (eds.) A companion of medical geography. Wiley-Blackwell.
- Stevens, P. (2004). Diseases of Poverty and the 10/90 Gap. Southern African Regional Poverty Network (SARPN). Retrieved August 27, 2012 form http://scholar.google.com/scholar?q=Stevens+2004+World+Health+Organization
- Texas Department of State Health Services. (2010). Texas HIV epidemiological profile at a glance: Texas integrated epidemiologic profile for HIV/AIDS prevention and services planning. Retrieved from Texas Department of State Health Services website: http://www.dshs.state.tx.us/hivstd/reports/default.shtm
Table 1: Correlation Between Percent of the County Population With Risk Factors and Rate of HIV/AIDS in Population of the County
- *Significant at >1%
- **Significant at >3%