This guide brings together voices and ideas from those working in HIV/STD prevention in and for rural America. The suggestions shared in this guide illustrate the creativity and dedication of national, state, and local HIV/STD prevention specialists. Those voices bring understanding of rural realities to those charged with developing and implementing policies for rural HIV/STD prevention. They provide encouragement for others just beginning to address HIV/STD prevention in their rural communities. And they express the frustration that comes with being asked to do important work with limited resources in an environment loaded with challenges.

Most likely in the next decade, HIV and other STDs will continue to be a public health challenge in both rural and urban areas of the country. Most likely, there will not be a windfall of resources for rural HIV/STD prevention. Yet, this guide highlights a third prediction as well - that by sharing the resources, ingenuity, and knowledge that we do have, realistic opportunities exist to keep rural HIV and other STDs from becoming more prevalent.

Opportunity 1: Challenge rural HIV/STD complacency

At the time this document was created, the U.S. had recorded over 51,000 cases of AIDS in rural America. Although the cases have accumulated slowly, almost unnoticeably, the magnitude of the number (51,000) cannot be ignored. Indeed, rural America may have a false sense of security as a result of the relatively low annual HIV incidence in rural counties. That sense of security is buoyed by denial of the existence of rural HIV since stigma and homophobia force many with HIV into the shadows of rural communities. Community denial, then, becomes the fuel for complacency which in turn sets the stage for the next 51,000 cases and the resulting morbidity and mortality. Many of those “next 51,000 cases” could be averted by replacing complacency with ongoing surveillance, increased public awareness, and attention to other STD infection rates. There is the opportunity to eliminate denial and complacency, one rural community at time, now and during the next decade.

One approach to challenging “rural HIV complacency” is to call attention to the existence of HIV risk by focusing on more common STDs. That may involve a more vigorous public health response to STDs such as syphilis, chlamydia, and gonorrhea in rural counties. If STDs are viewed as harbingers of HIV, then attention to the early detection and treatment of STDs along with HIV testing may raise community awareness of HIV risk and begin to erode rural complacency. Rural outbreaks of hepatitis B and C among rural methamphetamine users present additional opportunities to sensitize a rural community to the potential of an HIV outbreak. However, more vigorous responses will require a delicate balancing act between protecting the confidentiality of persons diagnosed with an STD and the obligation to inform the public about legitimate risks posed by these pathogens in their communities. This same dilemma might not apply as much to urban areas since having a much larger population might preclude speculation about “Who has the STD?”

Opportunity 2: Reduce stigma toward HIV and those at heightened risk

Nearly all rural advisors for this guide noted the need to “de-stigmatize” HIV in rural America so that people at risk for infection and those already infected by HIV can access confidential testing, risk reduction counseling and high quality care without fear of discrimination or violence. Removing stigma can also open the door to greater social support that may indeed impact survival and quality of life for those infected and affected by HIV. However, this requires changes in public attitudes about HIV, STDs, male-to-male sex, injection drug use, having multiple partners, and other substance use that increases the frequency of unprotected sex. It involves changing attitudes toward people who are often marginalized in society in general. Changing those attitudes does not happen spontaneously. Change requires a genuine understanding of the community’s values and existing attitudes, intentionally crafted messages, and time. As people living with HIV/AIDS live longer, more productive lives there are increasing opportunities to put a positive “face” on the disease. As opportunities to communicate with the public emerge through the Internet (e,g, The Positive Project, YouTube, MySpace), mobile devices, and text messaging, rural areas can take advantage of lower-cost opportunities to inspire a change in attitudes toward HIV/STD and toward those affected by it.

Opportunity 3: Develop effective rural HIV/STD prevention interventions

Although this guide has provided many examples of existing rural HIV/STD prevention practices, ongoing efforts are needed to identify rural-specific strategies that promote safer sex behaviors as well as safer injecting practices among various populations of rural Americans. Indeed, there is an urgent need to develop and test HIV/STD prevention programs designed specifically for those populations of rural Americans at greatest risk for HIV/STD. Understandably, the current evidence-based interventions being promoted are tested almost entirely on urban populations. Most do not take into consideration the travel distances and isolation imposed by rural settings, the limited financial resources of rural areas, or the heightened challenge of maintaining confidentiality in a small town. Rural programs are forced to either adapt urban-based strategies to address rural realities or create their own interventions. It is unclear at this time how effective these adaptations and local interventions are. However, some empirical evidence is currently being gathered to begin to answer this question. This is a first step toward the development of HIV/STD prevention interventions tailored for rural areas. As these develop, attention will need to focus on at least five different rural populations: 1) white men who have sex with men; 2) men of color who have sex with men; 3) black women residing in the rural South; 4) injection drug users in rural communities; and 5) migrant workers and new immigrants.

Opportunity 4: Take advantage of broad social and scientific advances

Current technologies such as telemedicine, the Internet, increasingly available mobile phones, text messaging, and inexpensive long distance services may provide some innovative avenues for providing state-of-the-art medical care, social services, and risk reduction counseling to rural residents. The Internet and cellular phone technology may be useful tools for spanning substantial rural distances to bring those with expertise together with those in need of the latest knowledge and skills, and to connect people looking for confidential social support. Chat rooms, MySpace, and other Internet-based social networks allow people to “come together” in a way that transcends geography. Whether this creates overall added risk by making “hook ups” quite easy or decreases risk by improving intervention accessibility will be a question resolved in the next ten years as technology becomes integrated into rural prevention.

Opportunity 5: Collaborate to take advantage of what you’ve got

Rural prevention efforts need to keep in mind that rural areas have limited resources, minimal funding options, and a difficult time initiating rapid change. However, rural HIV/STD prevention specialists point out that volunteers and partnerships are resources that may be more available in rural areas to augment prevention efforts. Having broad community representation at the table to plan how to address HIV/STD concerns multiplies the opportunities for new partners and resources. For instance, it may be easier to tap the relatively small pool of core providers to participate in a collaborative network in a rural area. Such collaborations increase the likelihood of finding ways to promote HIV/STD prevention messages with other health promotion campaigns that are important to the community. Collaborations also serve to clarify community values and the different perspectives that are available for discussing HIV/STD with diverse groups in the community. That said, it is important to remember that even though it may be easier to get people to the table in a rural area, that does not necessarily mean the collaboration will be without factions or friction and good group facilitation will be needed.

Conclusion

Indeed, there are no simple solutions that will magically end rural HIV or other STDs. But there are opportunities to make a difference. Despite unique challenges and limited resources, rural America has inherent strengths that can be harnessed to prevent HIV and STDs among rural youth and adults. By knowing the community, assessing who is at risk of infection, understanding the context of that risk, and bringing together the broader community to think, talk, plan and act on HIV/STD issues, a path can emerge to address rural HIV/STD prevention in a way that fits the community. Now is the time to come together to tear down the fences that divide communities, isolate individuals, prevent collaboration, and allow HIV and other STDs to flourish. As fences collapse, new ideas and partnerships will arise to strengthen HIV/STD prevention in rural America.

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