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  • Marcus J. Hopkins

HIV in Appalachia: A Tale of Syndemics


By: Marcus J. Hopkins December 1st, 2022


On World AIDS Day 2022, the Appalachian Learning Initiative (APPLI, pronounced like "apply") is highlighting HIV in the Appalachian Region.


The first thing to understand about the HIV epidemic in Appalachia is that the region faces two different epidemics with two separate modes of transmission:

  1. HIV transmissions that occur primarily via sexual modes of transmission.

  2. HIV transmissions that occur as a result of Injection Drug Use (IDU).

The vast majority of new HIV diagnoses in Appalachia occur via sexual transmission—particularly in Men who have Sex with Men (MSM)—and five of the ten states with the highest rates of new HIV diagnoses in the United States in 2019 were Appalachian states (Centers for Disease Control and Prevention, 2022):

  • #2 - Georgia (23.1 new diagnoses per 100k residents)

  • #6 - Mississippi (16.0)

  • #7 - Maryland (15.2)

  • #9 - South Carolina (13.2)

  • #10 - North Carolina (13.1)


Rates of transmission in 2019 in most of Appalachia's 423 counties and 8 independent Virginia cities are below the national rate of new HIV diagnoses of 9.2 (per 100k), with just 45 jurisdictions having rates higher than the national rate. The county with the highest incidence rate in 2019 was Cabell County, West Virginia, with a rate of 85.0 (per 100k) (CDC, 2021).


While Cabell County is an extreme outlier in terms of new HIV diagnoses, it serves as a bellwether for the rest of the state. In West Virginia, there is a very different epidemic unfolding.

  • In 2019, out of 156 newly reported HIV diagnoses, 92 (59%) reported IDU as the primary risk category.

  • Comparatively, in 2020—despite a decrease of two-thirds in the number of HIV tests administered, West Virginia still identified 139 new cases, of which 110 (79.1%) reported IDU as the primary risk category (West Virginia Department of Health & Human Resources, 2022).


To put this into perspective, just 7% of all new HIV infections in the U.S. are the result of IDU.


Since 2018, West Virginia has been host to not one, but two separate HIV outbreaks in Cabell and Kanawha Counties. Both of these outbreaks are driven by IDU, but molecular surveillance has found them to be independent of one another, meaning that it isn't just one community of Persons Who Injection Drugs (PWIDs) crossing county lines, but two separate communities.


Efforts to combat the spread of HIV across the state have largely been led by community-based organizations and healthcare providers (including WV Health Right in Charleston, MP Health Right in Morgantown, and the Community Education Group based in Lost River, WV).


The county health departments in Kanawha and Cabell Counties have been doing exemplary work with what scant resources they've been allocated by state legislators and federal agencies, and the state Director of HIV Care and Prevent, Shawn Balleydier, has been instrumental in working to combat this epidemic, doing the work by personally going out and testing people for HIV alongside healthcare providers.



But, the story of living with HIV in Appalachia is about more than just rates of new diagnoses and modes of transmission; it is a story about the underlying absence of public health and social services infrastructures.


For those of us living with HIV in Appalachia—particularly in central and southern counties—accessing HIV testing, treatment, and supportive services is beset by geographic, financial, and stigma-related barriers:

  • We've faced a decade of rural hospital and clinic closures that have devastated access to testing and healthcare services

  • We've faced chronic underfunding of our public health infrastructures from state and federal legislators

  • We've endured decades of underfunded transportation infrastructure projects, both in terms of public transportation maintenance and expansion and in terms of private transportation options (e.g., road building, maintenance, and repair)

A key consideration to keep in mind, however, is that the barriers to accessing testing, care, and treatment are not the same in all parts of Appalachia. The circumstances in Alabama that hinder access to services may not be the same as those impacting West Virginians and Pennsylvanians. Just as Appalachia's topography varies from state to state, so too do the barriers and facilitators.


With that in mind, APPLI invites our readers to use the following widget to find HIV testing, services, and Pre-Exposure Prophylaxis (PrEP):



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