Noxubee County is situated in a remote rural region of eastern Mississippi adjacent to the Alabama state line. It boasts thousands of acres of pristine forest and is home to part of the Sam D. Hamilton Noxubee National Wildlife Refuge, which provides a gorgeous, picturesque home to bald eagles, American alligators, storks, deer and quail. Noxubee County is also disproportionately low-income and African American and, like many other rural counties, lacks significant health care infrastructure.

When one of its residents is diagnosed as HIV positive—which happens routinely given that the county’s HIV prevalence rate is about 318 per 100,000 people, higher than Zambia or Botswana, which have among the highest national rates across the globe—he or she very likely must drive two hours to Jackson, the state’s capital, for specialty care. This is because Noxubee is one of the 10 counties in Mississippi Public Health District 4 that currently lacks a health care provider who can serve people living with HIV/AIDS, according to the Southern AIDS Coalition.

The nine counties of the neighboring Public Health District 6, just to the south, including hard-hit Lauderdale County, also lack any HIV specialists. People living with HIV in these counties must also drive several hours to Jackson or elsewhere for specialty care.

Mississippi’s official population is only around 2.9 million, which is slightly more than Brooklyn’s. It is also one of the poorest and most rural states in the nation. About 51 percent of its residents live in rural areas, per the U.S. Census Bureau. Mississippi is one of only four states—including Maine, Vermont and West Virginia—where more than half of the population lives in rural, non-urbanized areas. The state also boasts the largest proportion of African American residents—37 percent—of the 50 states.

The Magnolia State also has one of the nation’s highest rates of new HIV infections—the nation’s ninth highest—which are disproportionately concentrated among African-American gay and bisexual men. The rural isolation, poverty, lack of access to health care and patchwork health care infrastructure have exacerbated health and HIV disparities among Mississippi’s significant African-American population. The lack of medical providers capable of providing HIV care and a lack of access to transportation to reach HIV care providers, have been cited by the Mississippi State Department of Health as the two most significant structural barriers to access, care and treatment for its rural residents living with HIV.

“If you travel around Mississippi you [will] realize that there are relatively few hospitals and clinics. There is a lack of availability of care,” says DeMarc Hickson, PhD, the chief operating officer of the Jackson-based My Brother’s Keeper, an HIV/AIDS community organization with locations across Mississippi. “So sometimes an entire family must get in the car, drive to Jackson for shopping and then visit the doctors.”

Transportation is also a significant barrier. The state’s only public transportation system is based in and around Jackson, near the center of the state.

“If you are in the Delta and are HIV positive, you may have to drive all the way to Tupelo or Jackson for care,” says Andrew Bates, a 24-year-old community outreach specialist at the Hattiesburg, Mississippi–based AIDS United. “That is two or three hours one way.”

Lack of rural health care infrastructure is not unique to Mississippi or the Deep South. But the nationwide rural health care crisis that began around 2010 has exacerbated the HIV crisis in the South, which is the now the epicenter of the domestic epidemic. “Over the past six years, 76 rural hospitals have closed in America,” reported Amarillo, Texas–based High Plains Public Radio in late November 2016. “Many of the rural closings have come in states that have refused to expand Medicaid under the Affordable Care Act.”

Mississippi is one of 19 states that have refused to expand Medicaid eligibility requirements as part of the Affordable Care Act [ACA, or Obamacare]. Arkansas, Kentucky and Louisiana are the only Southern states that have done so. This means that hundreds of thousands of low- and moderate-income working people across the South could have access to health insurance but do not.

Meanwhile, “At least nine rural Mississippi hospitals are at risk of closure” and “22 more are considered generally at risk,” reported The Clarion-Ledger, the state’s largest and most respected newspaper, in November 2015, quoting a study conducted by Mississippi State University academics and health care and policy professionals.

The South has the nation’s highest prevalence of infections in rural areas and a larger proportion of counties without HIV specialists, according to the Southern HIV/AIDS Strategy Initiative. The many African-American–majority counties across the Mississippi Delta—the northwest section of the state that lies between the Mississippi and Yazoo Rivers—are among the nation’s poorest and have among the highest HIV burdens in the country.

Coahama County’s HIV prevalence is about 852 per 100,000 residents, according to the Robert Wood Johnson Foundation’s County Rankings and Roadmaps. Tunica County’s is 744 per 100,000. Bolivar County’s is 452 per 100,000 residents. Rural counties across the South also have the nation’s lowest five-year survival rates after diagnosis: Nearly one third of those diagnosed with AIDS in Mississippi die within five years.

For perspective, consider this: There are about 1,242,000 people living with HIV in the United States. The South—the 17 states extending from Oklahoma and Texas to the District of Columbia—comprises about 37 percent of the nation’s population and about 44 percent of the nation’s HIV caseload. But the overall HIV prevalence across the South is only about 17 cases per 100,000 people, according to the Centers for Disease Control and Prevention. About 60 percent of the HIV cases among all African American gay and bisexual men are also in the South. For more, see POZ’s January/February 2017 cover story “Southern Exposure.”

Stigma—fueled by homophobia and a religious, socially conservative culture—is an additional stressor and a significant public health challenge to the epidemic among rural Black gay and bisexual men in the South. Like almost every other structural and social barrier, stigma is more challenging in rural areas.

Same-sex relations are very stigmatized in many rural areas, says My Brother’s Keeper’s DeMarc Hickson. MBK is one of the few health care providers in the state to offer culturally competent care to African-American gay, bisexual, same-gender-loving and transgender men and women. “Many of these men are feeling very isolated and alone. This is why it’s so important to have knowledgeable, caring and culturally sensitive providers.”