amfAR, The Foundation for AIDS Research

HIV/AIDS in Florida: Epidemic Clouds the Sunshine State

March 3, 2004—Beneath the sunshine and the swaying palms, Florida is struggling to check an HIV epidemic that ranks third in the nation, behind only New York and California.

HIV and AIDS rates have been high in Florida since the first years of HIV/AIDS in the U.S. Close to 95,000 people in Florida currently live with HIV or AIDS, representing 10 to 11 percent of the national total. The three counties that rim the southeast edge of the peninsula, Miami-Dade, Palm Beach, and Broward, have been hardest hit, especially among men who have sex with men and minority populations. Meanwhile, the groups that are worst affected are also diverse, often transient, and culturally and geographically disconnected, making a uniform prevention message impossible.

Diversity of Factors

Thomas Liberti 

Thomas Liberti, Chief, Bureau of HIV/AIDS in the Florida Department of Health, speaks at the 2003 National HIV/AIDS Update Conference.

South Florida is a mosaic of diverse cultures. The city's Hispanic population, composed of Cubans, Venezuelans, and others from all over South and Central America, make up 50 percent of Miami's residents. This community has been hard hit by the epidemic: statewide, 16 percent of HIV cases are in Hispanics and that number jumps to 32 percent in Miami-Dade. Blacks—comprising African Americans, Haitians, and other Caribbeans—account for roughly half of all HIV/AIDS cases in the state and in Miami-Dade, even though they make up only 14 percent of Florida's population and a quarter of Miami's. Black women, in particular, are bearing a huge burden: a staggering 72 percent of both HIV and AIDS cases in Florida's black population affect women. In fact, an estimated 1 in 47 black Floridians have HIV/AIDS, compared with 1 in 176 Hispanics, and 1 in 346 whites, according to the Florida Department of Health.

 

Added to the population of minority groups and new immigrants is a steady influx of retirees from around the U.S. and young people attracted to the lively tourist spots. "One of the factors that may be unique to Florida's epidemic to some extent is that the population is transitory," says Dr. Gene Copello, Executive Director of the Tampa-based AIDS Institute and a professor of public policy at the University of South Florida’s College of Medicine. "It's a vacation state and so there is a relatively large number of people who come in and go out."

The connection to the southern hemisphere is a strong one, and a source of concern to Luis Penelas, a gay activist and Executive Director of Union Positiva, which provides outreach services to Miami-Dade's Hispanic communities.

"We go to the doctor when it hurts, but for HIV/AIDS, it's too late. You've already spread it and if you wait until symptoms develop it's a lot harder to control the disease."—Luis Penelas, Executive Director of Union Positivas 

"We are a bridge to South and Central America here. And the exchange of people is just constant," he says. The concern is that these are regions where HIV prevalence is high and testing rates are low. "There are places in the Caribbean and Central America where the incidence of AIDS is second only to sub-Saharan Africa," he says.

But immigration is not the sole culprit in the HIV epidemic. Poverty, drug use, risky sexual behavior, and a culture of denial in many minority communities are fueling a steady climb in HIV rates in these populations.

Penelas sees some cultural "idiosyncrasies" in his own community hindering his group's HIV prevention message. "The concept of preventive medicine is something that we haven't totally embraced overall as Hispanics," he says. "We go to the doctor when it hurts, but for HIV/AIDS, it's too late. You've already spread it and if you wait until symptoms develop it's a lot harder to control the disease."

Penelas is also concerned that the Catholic Church's condemnation of condoms is particularly harmful in the Hispanic community. "Hispanics tend to look up to the Church and get guidance from the Church," he says. "We do have to talk about abstinence, monogamy, and being faithful and honest with your partner, but we also have to talk about using a condom correctly."

And in communities where machismo is admired and homosexuality is a taboo, sex between men "on the down low" (in secret) is rampant, leaving women in the dark and at high risk for contracting HIV.

"The numbers really vary, but one recent survey [from University of California – San Francisco] I read said it's as much as 25 percent of married men engage in sex with other men. And our community is totally in denial about that," says Penelas.

 

AIDS Memorial Quilt

Florida Panels from the AIDS Memorial Quilt.

Rising Risk Behavior

High-risk behaviors—particularly unprotected sex and drug use—have been rising across the country and Florida is no exception. Rising HIV rates among men who have sex with men (MSM) and minority women, soaring syphilis rates, and surveys indicating condom use is down all point to a disturbing trend in riskier behavior, says Thomas Liberti, Chief of the Bureau of HIV/AIDS in the Florida Department of Health.

The Florida Department of Health reports that most HIV exposures—52 percent in 2002—resulted from sex between men, while intravenous drug use and heterosexual sex accounted for 14 percent and 11 percent of transmissions, respectively. Among women, heterosexual sex accounted for 49 percent of transmissions and intravenous drug use 24 percent.

In South Beach, the narrow strip of land along Miami's shore that is home to a thriving gay party scene, use of methamphetamine is a growing epidemic, says Kevin Garrity, Executive Director of the South Beach AIDS Project in Miami. "There are reams of scientific evidence that say if you do crystal, you [are] six times more likely to engage in unprotected sex," he says.

Another side effect of methamphetamine use, Garrity says, is a noticeable drop in attendance at bars—a favorite place for organizations like his to carry out interventions and outreach—because people are binging on crystal meth and finding sex partners online. "These are people that we're not going to reach with any kind of message at a bar because they're not there," he says.

That's why Garrity's group, like many others, is taking its message online, where counselors answer questions and offer advice in chat rooms. "Fully 30 percent of our testing clients are now coming off those chat rooms," he says.

A Graying Epidemic 

While HIV/AIDS rates are highest in the 24- to 44-year-old set, older Floridians are not exempt. And in a state where 27 percent of the population is over 55, this oft-overlooked group is finally getting the attention of AIDS outreach organizations.

Early on in the epidemic, AIDS organizations assumed seniors didn't really need HIV prevention outreach. "As we expanded, we found out that everything that people thought was probably false," says Liberti. In truth, he says, older Floridians are entering the dating scene anew, and facing risks that didn't exist when they were young. "When they were younger,

"We need to be cognizant of not throwing the baby out with the bath water in terms of focusing on HIV positives. There's a happy medium. We still need to have a major focus on high-risk HIV negatives at the same time we're focusing on positives. It's not a contradiction. There's room for both."—Kevin Garrity, Executive Director of The South Beach AIDS Project 

condom use was for preventing pregnancy, period," says Liberti. Now, he says, "you actually have to educate seniors about the use of condoms for the prevention of disease." Added to that is "the Viagra effect." Newly potent men are now engaging in sex with multiple partners in retirement communities. But the myths persist. When older people see their doctor, Liberti says, "it's the last thing on the doctor's mind to ask about sexually transmitted disease."

Balancing Budget and Prevention 

Florida received $230 million in Ryan White CARE Act dollars in 2003. In addition, the hardest hit cities, such as Miami and Fort Lauderdale, qualify for direct federal funding from the Act as well. But funding has either leveled off or even dropped in some counties, even though prevalence rates are rising. For instance, the Miami Herald reported that while prevalence of HIV rose 44 percent in Palm Beach County, 30 percent in Broward, and 18 percent in Miami-Dade (according to the Kaiser Family Foundation), funding rose by only 7 percent in Palm Beach and actually dropped slightly in the other two counties. Although the state provided some money to fill the gaps this year, few believe this solution is anything more than a short-term fix.

The effects of these shortfalls could be severe for people living with HIV/AIDS. Although the state is making every effort to maintain dollars for the AIDS Drug Assistance Program that provides medications to about 13,500 people without insurance who are ineligible for Medicaid, the social service and support programs are getting pinched.

"There are a lot of other factors that are just as important as the drugs and yet because of the funding crunches, most if not all of our money is going to go to drugs. We're cutting transportation, we're cutting psychosocial services, we're cutting drug abuse prevention programs. And that's not good," says Penalas.

Expanded testing—a centerpiece of Florida's HIV/AIDS program—is one of the state’s biggest success stories. With the roll-out of a rapid test program throughout the state, the Department of Health performed nearly 300,000 HIV tests in 2003.

Encouraging HIV testing is just one of the components of the Centers for Disease Control and Prevention's newest initiative, which shifts the focus from primary to secondary prevention. Many people have reservations about the CDC's new initiative, however. "What we fear is in danger is funding of our program for prevention for high-risk HIV negatives," says Garrity. "We have people out five nights a week in clubs recruiting people for HIV testing, doing individual interventions, risk assessments, and condom distribution. They haven't said they're going to cut it out completely. They're just going to cut it back."

"We need to be cognizant of not throwing the baby out with the bath water in terms of focusing on HIV positives," Garrity adds. "There's a happy medium. We still need to have a major focus on high-risk HIV negatives at the same time we're focusing on positives. It's not a contradiction. There's room for both."