Part I of this series explored the historical and social factors that have contributed to the high prevalence of HIV in the South. 

Part II of this series discusses Medicaid expansion and the provision of HIV preventative care under the Affordable Care Act (ACA). This Expert Column also concludes by bringing together the themes and calling for change.

Lack of Medicaid Expansion

Eight of the 11 states in the country that have not expanded Medicaid are in the South. This statistic should be concerning for HIV advocates, given that Medicaid is the largest source of coverage for people who have HIV in the United States, and nearly 50% of the uninsured reside in the South.

Medicaid does not cover everyone, and there are still people in the South who are uninsured due to lack of employer health insurance and ineligibility for Medicaid based on income. Medicaid income eligibility criteria are more restrictive in the South, especially in some Deep South states, like Louisiana and Alabama. However, studies have shown that those with Medicaid coverage generally experience better access to the health care system and preventive care, as well as improved health outcomes. They also experience less financial strain from medical bills.

Over the last few decades, the Ryan White HIV/AIDS Program has tried to close the gaps in care between those with and without Medicaid coverage. The program aims to do so by providing antiretrovirals and other essential drugs for uninsured/underinsured people living with HIV. Authorized under Title II of the Ryan White Act Comprehensive AIDS Resources Emergency (CARE) Act, the AIDS Drug Assistance Program (ADAP) operates in all 50 states and U.S. territories. ADAP also provides HIV-related prescription drugs to under- and uninsured persons within the United States.  

Currently, Southern states contribute less than the national average — 16% of the state’s ADAP funding — with some not contributing at all. This deficit matters because the ADAP program funding depends on not just congressional appropriations; it requires state funding to close gaps. Without sufficient funding, fewer people will have access to care, and the waitlist will only grow longer, which could lead to increasingly more new HIV cases and hinder viral suppression goals. In times of economic hardship, such as the recession in the early 2000s, which saw increased demand for ADAP and reduced tax revenues, Southern state legislatures cut ADAP benefits and capped enrollment. These cuts left several thousand people waiting for antiretroviral therapy.

In 2011, at the height of the crisis, more than 90% of the 9298 people on waiting lists lived in Southern states.

This delayed access to antiretrovirals and therapy increases the morbidity, mortality, and transmission of HIV. These issues are then compounded by the fact that the Ryan White Program is not well-advertised to patients or those most at risk, which typically include Black women and Black gay men. Further, data shows that 63.6% of African American Ryan White clients are male, 33.7% are female, and 2.7% of clients are transgender. The proportion of Black male clients is lower than the national average, while the proportion of Black female clients is 8.3% higher than the national average, or 25.4%.

To address these gaps, the Ryan White programs in the South must provide more culturally competent care to Black communities and better communicate through faith communities and health practices, similar to other programs, such as HRSA Health Centers and TargetHIV. In Memphis, Tennessee, a Ryan White program has begun partnering with faith leaders to bolster the program’s use by eliminating or lessening the stigma associated with HIV. Additionally, the programs must develop and adopt more nimble and innovative care practices for Black patients with HIV. There also needs to be more racially focused Ryan White programs and messaging to help bridge the gap between Black patients and care.

Current Litigation Efforts to Prevent HIV Preventative Care Under the ACA

Despite its goal of providing health care coverage to millions of Americans, Medicaid expansion is under attack by Southern states. In 2023, a Texas district court ruled on Braidwood Mgmt. v. Becerra, a case aimed at stopping the enforcement of preventive care coverage requirements under the ACA. The Braidwood plaintiffs objected to providing health care that “encourages” same-sex relations, prostitution, sexual promiscuity, and intravenous drug use. The court found that their religious objections did have standing under the Religious Freedom Restoration Act (RFRA), which prohibits the U.S. government from substantially burdening a person’s exercise of religion. Most of the plaintiffs objecting to the ACA’s requirement argued that their religious objections would have made them forgo purchasing health insurance as a whole or even providing it to their employees.

The district court further held that the remedy for the Appointments Clause violation, which occurs when a federal official is appointed without adhering to the constitutional procedures, would be to cancel all agency action taken to implement or enforce the preventive care coverage requirements. Thus, any preventive services issued on or after March 23, 2010, by the U.S. Preventive Services Task Force (USPSTF) are unenforceable. This ruling also means that the ACA’s provision is unenforceable. Ultimately, almost all required HIV care could be stripped away from all health insurance plans in the nation, as the USPSTF has listed some HIV prevention measures as required preventative care.

Because of its concern that this ruling would gut HIV and other preventative care, the Biden administration has since appealed, stating that they are also working on a preventative care workaround if the decision is affirmed.


The legacy of racism and oppression in the South has had devastating and pervasive consequences on health equity and outcomes in the region today.

Systemic racism and unjust power structures prevalent in our health system have drastically affected health literacy in the Black community. African Americans have been systematically limited by discriminatory policies and practices that have blocked them from accessing resources and skills needed to receive, understand, and apply health information. The disparate rates of HIV in the South’s Black communities are one of countless examples of the lingering effects of this region’s troubled past.

To improve health outcomes for their people, Southern political leaders must make genuine and thoughtful efforts to rebuild their trust in the health care system. They can no longer be excused from racist and classist political maneuvering that affects their most vulnerable populations. HIV care is health care and, as such, should be available for all.