Flat federal funding for HIV prevention and care over the past decade along with growing urban demands for HIV prevention and services have in essence decreased the funds available to rural areas for HIV prevention and care.[1] This has been particularly evident in the South which has the largest rural HIV burden and has historically received the least federal HIV funding.[2] Despite calls to action for increased funding,1,2 rural areas may be slow to see more money and need ways to provide HIV/STD prevention with minimal funding. Given the limited resources for rural HIV/STD prevention, a major strategy for reducing the spread of infection needs to be based on the steps health care providers, health department staff, and others involved in HIV/STD prevention take in response to newly reported cases of HIV or other STDs.

How a New Case of HIV Infection or Other STD is Identified

A new diagnosis of HIV or another STD can be a sentinel event for preventing additional infections in a rural community. One new hepatitis B or C infection may lead to the identification of multiple infections within a drug sharing network. The detection of a case of syphilis in a rural community may lead to the discovery of others infected with syphilis, other STDs, or HIV. As such, it is essential for health departments to plan how they respond to newly identified HIV and STD cases.

State health departments require that physicians, health care facilities, and laboratories report positive test results for a variety of STDs including HIV, syphilis, congenital syphilis, gonorrhea, and chlamydia.[3] The process for notifying local health departments may vary from state to state. Once a newly reported infection is identified, it is important to determine whether the individual has any sex or drug-injection partners in his or her home community. If so, the partners might also be infected, but not be aware of their infection; thus, they may be at risk for unknowingly transmitting the infection to others.

Generally, Disease Investigation and Intervention Specialists (DIS) will contact individuals whose infections were diagnosed in health department sites to talk about their partners. However, many patients learn of their infection through sites not directly connected to a health department such as a doctor’s office, community-based testing program, out-patient clinic, or emergency department. If an individual is diagnosed at such a site, there may not be anyone clearly designated to talk to the patient about the need for his or her sex and drug-injection partners to be notified of their potential exposure to HIV or another STD. If an individual is diagnosed with HIV infection or another STD infection in a doctor’s office, the doctor or other health care provider may talk directly to the patient about his/her infection, ways to decrease the risk for transmission to partners, and the need to notify sex and drug-injection partners of potential exposure to the infection. However, some doctors and other health care providers may feel uncomfortable or unprepared to have this conversation with patients, or may not be aware of the importance of discussing these topics.[4]

The possibility that some clinicians may be unwilling or unable to talk frankly to their patients about sex can be a significant obstacle to preventing HIV infection and other STDs in rural areas. One person with an undiagnosed HIV infection or other STD in a rural community could transmit the infection to one or more individuals, who in turn, could infect others. For this reason, rural communities need a strategy to educate doctors, clinic staff, and others who might diagnose HIV infection or other STDs about the need for sexual risk assessments, appropriate testing, motivational risk-reduction counseling and referral to Partner Services (previously called Partner Counseling and Referral Services) provided by state and local health departments.

A proactive approach could include mailings or emails to all health care providers or at least to those known to have seen STD or HIV patients in their practices. State health departments could periodically mail or email updates about reporting requirements, training opportunities, how to utilize Partner Services, and the availability of staff to provide Partner Services in a sensitive and confidential manner.

Some state health departments have assigned DIS to particular regions while others house their DIS centrally and send them out on an as-needed basis. There are advantages to each approach. For one, DIS who are responsible for a particular geographic area become familiar with resources in the area. The downside is that they could become identified as the “STD man (or woman).” When their car is seen at someone’s house, others suspect why they are there. It should be noted that this is not to imply that having regional DIS is a bad strategy. The DIS may cover such a broad area that he or she is not readily identified and many drive their own cars (versus a car with health department or government markings). The advantage of having a DIS work on an as-needed basis is that they are not likely to be recognized as being from the health department.

A more serious concern is when there is no DIS available to talk to the client. Local public health nurses or other staff may be trained to perform this function. The STD/HIV Prevention Training Centers are funded by the CDC to provide such training. One option for partner notification that may work for rural areas takes advantage of the Internet. As of 2008, nine U.S. cities and ten states (California, Colorado, Florida, Idaho, Indiana, Kentucky, Louisiana, Massachusetts, Minnesota, and Wisconsin) have employed the Internet to allow infected individuals to anonymously notify partners using clever e-mailed “postcards” through commercial programs such as inSPOT or using internally developed programs such as Stop the Spread Online. Although such programs do not offer individual counseling, they at least offer a means for notifying partners of potential exposure to HIV or another STD. As shown on the Stop the Spread Online website, these online notification programs can also link those who have been notified of exposure to web sites with HIV/STD prevention and testing information.

Suggested Strategies to Follow

There are a number of very different approaches that could or should be taken depending on the infection involved (HIV, syphilis, chlamydia, or gonorrhea) and how an infected individual responds to questions about partners. It is beyond the scope of this document to describe such approaches in detail. However, in general, the DIS or health care provider should talk to the infected individual to identify partners who may also be infected, to identify and address ongoing risk behaviors, and to identify sexual and drug sharing networks. This discussion should also identify sexual and drug sharing networks in which disease transmission may be occurring. A more complete description of these processes is described in the 2008 Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection.[3]

STDs are a part of life. One reason they’re so common has nothing to do with sex, and everything to do with silence.
- inSPOT 2008

A community plan might include recommendations concerning media response to reports of new infections. Inappropriate media reporting can easily result in a breach of confidentiality, creating the unintended consequence of increasing stigma, discrimination, and possibly violence toward those who are infected or are suspected of engaging in risky behaviors. This, in turn, may discourage others from coming forth for testing or care. It may not be possible to make decisions about media coverage in advance, but having an advisory group in place through the planning process will provide a means for careful consideration of the consequences of media coverage by people who have taken time to assess community needs and attitudes towards HIV and other STDs.

A recent HIV outbreak in rural Wisconsin provides an example of how state and local health departments and AIDS service organizations can work together to understand the epidemiology of an HIV outbreak, particularly the sexual behaviors and social networks. The online report also describes how health officials and community organizations mounted a joint community response to alert the gay community to the increase in cases, expand testing opportunities, and strengthen prevention messages and community partnerships.

Summary

The steps a community takes when new infections are identified do matter. It also matters that rural communities may have limited financial resources for HIV/STD testing and responding to people newly diagnosed with HIV or other STDs. However, having a plan in place will allow rural communities to accomplish three things:

1) ensure that people infected with HIV and other STDs are diagnosed as early as possible to prevent further transmission and to get them into care as early as possible to improve their own health outcomes;

2) have ongoing surveillance to quickly identify a potential outbreak of HIV or an STD such as syphilis that may indicate the presence of unidentified HIV cases; and

3) respond to newly identified cases as rapidly and effectively as possible.

The planning process can be used to involve the community, to generate their support for HIV/STD prevention, and to reduce stigma and denial in the process. However, the critical piece is identifying a lead person or agency to direct this planning process. State health departments may provide guidance and support for rural planning for and responding to new cases of HIV and other STDs.

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