Fact Sheet: Number 8 (1996)

HIV/AIDS in Rural America

The U.S. Centers for Disease Control and Prevention (CDC) reports that 5.36% of all AIDS cases have occurred in rural areas (less than 50,000 persons). Small metropolitan statistical areas (MSAs) of 50,000 to 499,999 persons account for 9.76% of all AIDS cases, and MSAs of at least 500,000 persons account for 84.5% of all AIDS cases. Patterns of HIV infection indicate the spread of the AIDS epidemic into rural America is rising. (1)

The Incidence of HIV Infection
A recent study indicated that HIV is increasingly affecting women, adolescents, and minorities. (2) The study estimates rates of HIV infection to be as high as 2.29% among Black males, as low as .05% among White females, and to average .47% for the entire population.

Estimating HIV infection, based on AIDS cases, is complicated by the tendency of rural residents to seek diagnosis in urban areas. Because HIV test results for adolescents and adults are currently reported by only 26 states, it is not possible to nationally quantify current HIV infection patterns in rural areas. Consequently, estimates of HIV infected individuals who have not yet developed AIDS are based on population samples drawn from Job Corp volunteers, patients of STD clinics, childbearing women, and military applicants. Collectively, these methods have provided several consistent findings relevant to the spread of HIV in rural America.

1. Age. The majority of HIV infections occur between the ages of 15 and 29. (3) Thus, HIV, like other STDs, is found disproportionately among young adults.
2. Co-factors. Syphilis epidemics in parts of the rural South during the late 1980s and early 1990s, coupled with epidemic use rates of crack/cocaine, have frequently been cited as leading cofactors in both rural and urban areas of the United States. (4)
3. Mode of transmission. As the AIDS epidemic evolves, heterosexual transmission of HIV continues to increase. Between 1989 and 1995, annual reported rates of heterosexual HIV transmission nearly doubled (5.8% - 11.0%). Rates of heterosexual transmission are particularly high in rural areas of the South. (5)
4. Gender. As heterosexual transmission increases and women continue to share drug injection equipment with HIV positive partners, the rate of HIV infection for females continues to rise. Reported increases for female HIV infection are consistent regardless of rural or urban location in both Georgia and Mississippi. (6,7) Two recent studies have provided evidence showing the increase of HIV infection among rural women.
   
   *Estimates of HIV infection as high as 3.5% have been calculated for women living in rural areas of South Carolina. (5) This figure is more than 21 times greater than national estimates for women based on CDC AIDS case reports.
   
   *A study of Job Corp applicants showed that those that were 16 or 17 years old, who tested positive for HIV, were more likely to be female than male. Additionally, this study found the rate of HIV infection in rural applicants to be nearly 50% of the rate in urban applicants, which is much higher than national estimates based on CDC AIDS case reports. (8)
   
   
5. Race. Patterns of HIV infection show disproportionately high prevalence rates in Hispanics and Blacks. Blacks living in rural America are particularly likely to be infected by HIV. For example:
   
   *A recent study of pregnant women living in rural Florida reports that 8.3% of all Black female participants were HIV positive. This figure is 11 times greater than national estimates of HIV infection for Black women and 166 times greater than the estimated national average for White women. (9)
   
   *A recent analysis of over 1.6 million blood specimens from childbearing women shows HIV infection rates to be up to 35 times higher in Black women regardless of urban or rural location. This study concluded that HIV infection is widespread in non-urban locations, particularly in the South. (5)
   
   *A study of nearly 10,000 adolescents shows that Black males were equally likely to be HIV positive as Black females, regardless of urban or rural location. (7)
   
   
6. Size of the statistical area. Although some researchers report findings based on urban or non-urban location, the CDC has used the categories of rural, small MSAs, and MSAs since 1990. Figure one illustrates increases of AIDS case rates, per 100,000 persons, between the years of 1991 and 1995 for the three types of statistical reporting areas. Due to under-reporting and shifting patterns of HIV infection, these figures underestimate the extent of the HIV epidemic. However, the figures still provide a basis for making a relative comparison between the three types of statistical areas.
   

From 1991 to 1995, reported AIDS cases in rural areas of the U.S. rose from 4.9 to 8.8 cases per 100,000. This 80% increase is far greater than the 64% increase and the 47% increase observed over the same time span for small MSAs and MSAs, respectively. Additional indications that rural HIV infection rates will continue to rise are provided by the following studies.

• In a recent report of AIDS cases in all U.S. counties, most of the top 25 counties experiencing rapid increases in AIDS cases were predominantly rural. The study concluded that, "the epidemic has...entered a dangerous phase of spreading to rural America". (10)
• In 1990, the National Commission on AIDS (NCOA) reported that, "The number of new AIDS cases diagnosed in rural communities across the country is growing at an alarming rate...there has been a 37% increase in diagnosed AIDS cases in rural areas compared to a 5% increase in metropolitan areas..." (11)
• A 1996 study stated that: "An obvious area of needed epidemiological research and public health intervention is to define indigenous HIV infection in small cities and rural areas, particularly in the South." (12)

Prevention
Effective prevention of HIV transmission in rural America requires innovative educational methods and materials designed to reach the target audiences. Community partnerships involving organizations such as schools, churches, and youth organizations appear to be an effective means of promoting HIV preventive behavior.

Local use of the Cooperative State Research, Education and Extension Service of the United States Department of Agriculture can be one effective means of facilitating the educational services for protecting rural Americans from HIV infection.

Sources of information
The information for this Fact Sheet was derived from sources including the CDC and journal articles.

1. CDC (1995). First 500,000 AIDS cases-- United States, 1995. MMWR, 44(46) 849-852.
2. Rosenberg, P. S. (1995). Scope of the AIDS epidemic in the United States. Science, 270, 1372-1375.
3. CDC (1995). HIV/AIDS Surveillance Report: Year end ed., 7 (2).
4. Forney, M. A., & Holloway, T. (1990). Crack, syphilis, and AIDS: The triple threat to rural Georgia. GAFP Journal(2), 5-6.
5. Wasser, S. C., Gwinn, M., & Flemming, D. (1993). Non-urban distribution of HIV infection in childbearing women in the United States. Journal of Acquired Immune Deficiency Syndromes, 6, 1035-1042.
6. Whyte, B. M., & Carr, J. C. (1992). Comparison of AIDS in Women in rural and urban Georgia. Southern Medical Journal, 86, 571-578.
7. Young, R. A., et al. (1992). Seroprevalence of human immunodeficiency virus among adolescent attendees of Mississippi sexually transmitted disease clinics: A rural epidemic. Southern Medical Journal, 85(5), 460-463.
8. St. Louis, M. E., et al. (1991). Human immunodeficiency virus infection in disadvantaged adolescents: Findings from the U.S. Job Corps. Journal of the American Medical Association, 266(17), 2387-2391.
9. Ellerbrock, T. V., et al. (1992). Heterosexually transmitted human immunodeficiency virus infection among pregnant women in a rural Florida community. The New England Journal of Medicine, 327(24), 1704-1709.
10. Lam, N. S., & Liu, K. (1994). Spread of AIDS in rural America, 1982-1990. Journal of Acquired Immune Deficiency Syndromes, 7,485-490.
11. National Commission on AIDS (1990). Report Number Three: Research, the Workforce and the HIV Epidemic in Rural America.
12. Holmberg, S. D. (1996). The estimated prevalence and incidence of HIV in 96 large U.S. metropolitan areas. American Journal of Public Health, 86,642-654.

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