Serene open spaces, farms, quaint churches, and self-sufficient hardworking young families are common stereotypical images of rural America. Rural communities are seen as good places to raise children away from “city problems.” Although these images still apply to some rural settings, for the most part today’s rural America is in credibly diverse. Rural settings vary from forests and mountains to plains and deserts. Only 6.5% of the rural labor force is engaged in farming while manufacturing, tourism, and energy production gain prominence. Even though the vast majority of the rural population remains white, African Americans, Latinos, and Native Americans have a substantial presence today, especially in the rural Southeast, Southwest, and northern Great Plains. Over the past decade, migration of ethnic minorities has fueled population growth in rural areas, even though young adults under age thirty still tend to leave rural areas for urban opportunities.[1] Despite their stereotypical “safe” image, today’s rural communities are not immune to problems associated with cities such as drug and alcohol abuse, risky sexual behavior, and diseases such as human immunodeficiency virus (HIV) infection, acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases (STDs).

This document shares concerns and ideas generated by those living and working in rural areas to prevent, detect, treat, and manage HIV and other STDs. It describes the state of HIV and STD infections in rural America, unique prevention challenges, approaches to HIV/STD education, and strategies for meeting the needs of those diagnosed with HIV infection or AIDS. In addition, this guide shares ideas for reaching hard to reach populations and describes programs that are currently being implemented in rural areas that may work to prevent the transmission of HIV and other STDs in rural settings.

The intent is to help those who create and implement policy to understand the unique issues that rural communities face and to help those who live and work in rural communities harness their strengths, address inherent challenges, and prevent HIV and other STDs in their communities.

What Does Rural Mean?

In 2000, as shown in Figure 1, non-metropolitan counties in the United States outnumbered metropolitan counties by two to one.[2] Does this mean that the majority of the country is rural? That depends on how rural is defined. Currently, there is no national consensus on how and where to draw the line between rural and urban. Federal and state agencies, researchers and policy makers apply different definitions for different purposes.

Many agencies define “urban” and everything outside of that definition is labeled “rural” by default. For example, the U.S. Census Bureau defines urban areas as continuously built up areas with a population nucleus of 50,000 or more and a population density greater than 1,000 people per square mile. Based on this definition, the Census Bureau reported in 2000 that 59 million people (21% of the population) were living in rural settings.[2]  

Prepared by the Economic Research Service, USDA (U.S. Census Bureau)

In contrast, the White House’s Office of Management and Budget (OMB) concluded from the same Census 2000 data that 55.9 million people (20% of the total population) should be considered rural.[3] Then, in 2003 the OMB revised the definitions to reflect today’s economic and social ties between rural and urban communities. As illustrated in Figure 2, OMB currently defines metro counties as those with one or more urbanized area of 50,000 or more. Metro areas may include outlying counties that show economic and social ties to the central county indicated by frequent commuting between the two. Non-metro areas are subdivided into micropolitan areas, those with a population center of 10,000 to 50,000, and noncore counties with smaller or no population centers. Using this newest definition, the OMB reports that in 2005, micropolitan areas and noncore counties covered 75% of America’s and area and were home to nearly 49 million people, just over 17% of the country’s population.[4]

Going one step further, the U.S. Department of Agriculture’s Economic Research Service (USDA ERS) uses a 9-code urban-rural continuum that defines urban areas by size of the population cluster and rural areas by population size plus proximity to metropolitan areas. Codes range from “1” for the largest population cluster to “9” for the smallest. The six codes applied to rural areas range from areas with towns of 20,000 or more that are adjacent to a metropolitan area to those with towns 2,500 or less that are not adjacent to a metro area.[5] Using this 9-code definition, rural America would include 57.6 million people.[5] Although the USDA ERS coding is perhaps the most precise, for this report, we use the OMB and Centers for Disease Control and Prevention definition which establishes a base of 48.8 million rural Americans.[6]

HIV, AIDS, and STD rates may vary depending on the definition of rural used to establish the number of people included in the denominator.

Prepared by the Economic Research Service, USDA (U.S. Census Bureau)

Thus, the way rural is defined matters because it helps define disease epidemiology, which inturn influences public policy, resource allocation, and access to services. The definition also matters because simple rural and urban categories do not adequately describe the diversity of rural America. Being labeled “rural” does not mean that those living in a rural setting are all the same or even similar. What unites the 49 million rural Americans are the challenges that come from living in a rural setting such as isolation, poverty, and limited access to health care, mental health care, and social services. Beyond any definition, it is the diversity of rural America, the realities of living in a rural setting, and the disparities between urban and rural policies that contribute to the unique challenge of rural HIV/STD prevention.

Health Disparities in Rural America

Evidence shows that rural Americans experience a broad range of health disparities, especially in comparison to persons living in suburban areas. For example, infant mortality rates in both urban and rural areas typically exceed the rates reported for suburban areas.[7]Other indicators suggest that rural Americans experience more illness and mortality compared to their urban counterparts. For example, findings from a study conducted in the late 1990s show that rates of premature mortality from all causes were highest among rural Americans.[8] Similar disparities have been observed for heart disease, chronic obstructive pulmonary disease, suicide, and unintentional injuries.[7]

Disparities in HIV/AIDS, and STD morbidity and mortality are particularly evident in the rural South. Two-thirds of newly diagnosed rural HIV cases were located in the rural South in 2007 and the greatest number of deaths from AIDS now occurs in the South.[9] Yet the South receives the least funding for HIV testing and treatment compared to other regions of the country.[10]

The reasons that rural Americans experience greater disease and premature death are not fully understood but may be a function, in part, of general characteristics of rural populations in the U.S. For example, in contrast to their urban and suburban counterparts, rural Americans are more likely to be classified as low-income.[11,12] They are nearly twice as likely as their suburban counterparts to lack health insurance with 21% of rural Americans lacking health insurance as compared to 12% of suburban Americans.[11]

Another difference between rural America and the rest of the country pertains to mental health. Rural residents are more likely to stigmatize mental illness, be under-diagnosed, and receive inadequate treatment for mental illness. This may contribute to behaviors such as drug use, early initiation of sexual activity, or unprotected sex with multiple partners that put individuals at greater risk for HIV infection and other STDs.[14-16]

Health disparities experienced by rural Americans are complicated by a number of factors. One factor is that rural areas often lack the resources for early detection and cutting-edge treatment of diseases including HIV/AIDS. With limited resources, acute care and mandated prevention efforts such as childhood immunizations may take priority over less urgent and less obvious needs such as HIV/STD prevention. Another complication arises from the fact that rural social networks may be close-knit and highly stratified, with distinct groups of insiders and outsiders. Although some rural residents embrace the isolation inherent in rural settings, others are involuntarily isolated by closed social networks in small communities. This means that there are unique challenges for mobilizing rural communities to respond to public health threats such as HIV and for implementing and adapting innovations developed in urban settings for those at increased risk who must remain “hidden” in rural areas.

Challenges in HIV/STD Prevention & Management for Rural America

Given all the disparities that exist for rural America, it is not surprising that the social issues that characterize the HIV/AIDS epidemic in the U.S. may be very different in rural settings and present unique challenges to HIV prevention. For instance, several studies identified that rural residents commonly deny that HIV exists in their community.[15-17] This makes community awareness of HIV risks a priority for rural prevention. Similarly, stigma surrounding HIV/AIDS and other STDs appears to be very prevalent in rural areas, creating a substantial barrier to HIV/STD prevention, testing, and treatment.[17-21]

Traditional values may contribute to negative views toward homosexuality, injection drug use, and HIV/STD in rural areas, especially in southern states.[10,16,20,21] Although it is not clear whether rural residents have more negative views of these behaviors than urban residents, it is clear is that men who have sex with men are more likely to conceal those behaviors in rural areas in response to high levels of stigma.[22] The need to remain “hidden” in a rural community, combined with a lack of rural venues for men to meet and socialize with male partners, encourages rural men and teens to travel to urban areas to find sexual partners.[23,24] The increased availability of Internet sites to locate sexual partners in other locales contributes to the rural-urban pathway as well. Since urban areas tend to have a higher prevalence of HIV and STDs than rural areas, rural men may unknowingly bring an infection back to theirrural community where they do not have a safe, confidential place to access HIV/STD testing.

Stigma goes hand in hand with the lack of anonymity that rural Americans experience in contrast to their urban counterparts. The threat of being noticed and identified buying condoms or seeking HIV/STD testing, substance abuse treatment, or HIV/STD treatment is real enough in a small rural town to dissuade some people from getting services in their local community if at all. Stigma, racism, and other forms of discrimination create pressures that drive rural folks who engage in risky behaviors underground,[17-21] making HIV/STD prevention interventions targeted to high risk groups especially problematic.

In the past decade, pervasive rural methamphetamine use has increased rural risk of HIV, hepatitis B and C, and other STDs. Increased risk occurs when drug users measure or inject meth using a contaminated syringe or shared rinse water. Risk also increases from prolonged unprotected sexual intercourse associated with methamphetamine use. Rural communities hit hard by methamphetamine abuse are struggling to reduce and treat meth use and have few resources left over to devote to HIV/STD risk reduction and prevention.[18,25]

Rural America is far from culturally monolithic. Consequently, cultural differences abound and create additional HIV prevention and treatment challenges. For example, rural culture and attitudes toward HIV/STD prevention in Appalachia will be greatly different from those in the plains states and both of these cultures may have very little resemblance to the culture found in the Deep South. Thus, "one size fits all" HIV/STD prevention efforts are clearly not realistic for multi-cultural rural America. Nevertheless, there are some cultural commonalities. For many communities, especially Black, Native American, and immigrant communities, there is a long-standing culture of distrust of the government and health care system that may impede HIV/STD efforts.[10,26] Another rural cultural commonality is the value placed on local control. This means that local control may result in different interpretations of state policies or a decision to disregard them altogether. This has been observed in the case of state mandated HIV/STD in-school education where local groups choose to ignore the state mandate or initiate an untested home-grown program for their youth.

Structural disparity influences rural HIV/STD prevention as well. Perhaps the greatest structural disparity between rural and urban settings is the poverty and limited economic opportunity faced in some rural areas. Settings that are isolated from major transportation routes and urban centers have fewer job opportunities, a smaller tax base, and must struggle to recruit well-trained stable health care providers. They often have no public transportation and may not have health, mental health, or substance abuse treatment available without traveling long distances. For individuals and families living in sparsely populated areas, there are few community infrastructures for mobilizing or leveraging resources.[21] In the economic context of extremely limited federal funding for HIV/STD prevention in rural America, these complex and diverse rural realities suggest that rural HIV/STD prevention challenges may exceed those found in urban America.

A recent study identified three other structural differences associated with HIV prevention success in states that are predominantly rural. First, less successful HIV prevention was associated with having a higher proportion of religious adherents in a state. Second, states with more venues and programs for individuals who engage in male-to male sex and/or identify as gay, lesbian, bisexual, or transgender were more likely to have HIV prevention programs rated as successful. The authors noted a particular lack of programs and services for men of color who have sex with men in all 13 states defined as rural in the study even though some states had large proportions of ethnic and racial minorities. Third, the study found that the amount of state resources spent on HIV prevention was not associated with successful prevention programs. However, allocating more funds to community-based organizations and programs that support men who have sex with men (MSM) was associated with more successful HIV prevention.[27]

Multiple factors contribute to the challenge of HIV/STD prevention in rural areas with the mix and force of factors varying among communities. However, even one factor may be formidable. For instance, rural isolation may mean that rural residents simply do not have access to services taken for granted by metropolitan residents, for instance, high speed Internet, stores that stock a wide variety of condoms, and free or low-cost HIV/STD testing.

Summary

Much like rural America itself, the road to effective HIV/STD prevention and control may be unpaved and winding, yet the moral obligation to develop and smooth this road is clearly evident. The challenges are inherently difficult and the available research and financial support are modest at best. Innovative, collaborative responses and solutions are required to contain and reduce HIV and other STDs in rural locations. After describing the epidemiology of HIV/STD in rural America, this guide will elaborate on various strategies that may work within the rural setting to reduce HIV/STD.

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