You could drown in the numbers on this if you wanted to, but a study that stuck out to me was one from 2012 that found uneducated black men had an AIDS mortality rate 30 times higher than educated white men. Among uneducated black women, it found that the introduction of HAART barely dropped mortality rates at all. In 2011, AIDS was the ninth-highest cause of death for blacks and twenty-fourth for whites.

Higher levels of stigma, poor infrastructure for treatment in rural areas, abstinence-only education—Reif says they all contribute to the higher rates of diagnoses and deaths. Syringe exchanges are still illegal in almost every Southern state. An estimated 60,000 uninsured or low-income people with HIV live in states that have rejected the Medicaid expansion under Obamacare.

“Each state has a different Medicaid program in terms of whether you’re eligible and what your co-pays are,” she says. “Some Medicaid programs will only cover a certain number of drugs. So you get five. And you have to pick which five.”

Just as explaining the differences between Europe and America requires accounting for the weight of their histories and social structures, so does explaining the differences between the South and the rest of the United States. “The disease burden in the South is high for other diseases, too,” Reif says. “A lot of it goes back to institutionalized racism, poverty, the legacy of Tuskegee. There’s a lack of trust in health care. The states say they don’t have the money [to expand Medicaid]—and there’s some truth to that.”

No health care system in the world has solved the problem of AIDS. The United Kingdom and Germany have gaps in their cascades, too. They struggle to control costs and reach marginalized populations the same as the States. They just have less margin to reach.

But in trying to explain these numbers, I don’t want to excuse them. Some of the reasons the AIDS epidemic has been so devastating in the United States were chosen for us by history. Others we have chosen ourselves.

“At the end of the day, it’s best understood as a function of health disparities writ large,” says Chris Beyrer, the director of the Johns Hopkins Fogarty AIDS International Training and Research Program. The core difference between the United States and Western Europe, he says, is that “we’re a much bigger, much more complex, and much more unjust country.”

Clarification: This piece has been updated to note that federal funding for needle exchange, permitted after 2009, was banned again in 2011.