Introduction

The ultimate solution to HIV/STD infection lies beyond medical advances. Preventing new infections depends not only on individuals’ practicing safe sexual and drug use behaviors, but also on public awareness of HIV/STD risks, and developing systems for early detection and treatment of HIV and other STDs. Such prevention strategies rely on HIV/STD education of individuals, networks of friends, health care providers, and the community as a whole. Often, HIV/STD education has been poorly planned, implemented, and evaluated. However, as the epidemic has evolved, research has identified effective educational approaches. Education is an essential frontline defense against HIV and other STDs even though measuring its impact is often impossible. Education may be an especially strong prevention strategy for rural communities with limited or no resources designated for HIV/STD prevention. Although lack of funding is a major barrier to rural HIV/STD prevention, the smaller size of rural communities enables them to draw on their human resources and existing community institutions such as schools, faith-based organizations, service organizations, and local media for affordable prevention education. This chapter will focus on education strategies that utilize the existing and often rich assets of rural communities.

For rural communities in particular, effective HIV/STD prevention education starts with a solid understanding of the values and competing health concerns of the community. It engages people who influence public opinion. Because different groups of people are motivated by different messages and respond to different educational approaches, multiple messages and approaches optimize the probability of success. This means that approaches and messages should be tailored to the audience. It also means that for a wide-spread impact, rural prevention education should target many different venues including schools, community-based organizations, faith-based organizations, and health-care facilities.

Education, like any other intervention, is typically a response to a perceived need. In urban America, the relatively high annual incidence of HIV/AIDS cases warrants and inspires ongoing educational efforts to stem the rising tide of the epidemic. The same cannot be said about rural communities. Instead, HIV prevention education in rural America may often occur as a direct result of an event that triggers fear about the spread of HIV. These precipitating events may be grounded in a new case of HIV/AIDS recently found in the community or having someone living with HIV/AIDS move into a given rural community. A precipitating event may be the catalyst needed to engage the community, address misconceptions about HIV/AIDS, and form a community committee to direct prevention education efforts. Such committees, whether large or small, are vital to planning and designing education efforts tailored for a specific rural community.

Schools

Because schools reach nearly all youth, they have the opportunity and obligation to provide young people with the knowledge and skills to avoid HIV and other STDs during their lifetime.

Schools can be an important partner in HIV/STD prevention education efforts. As of 2008, 70% of states mandate schools to teach HIV/STD prevention. A 2004 national survey showed that 93% of U.S. adults support school-based sexuality education.[1] However, controversy remains at the local level about what this education should include and what role parents should play. State guidelines about content are weighted toward stressing abstinence and no states require that contraception be stressed.[2] A review of hundreds of sexuality education programs found those that effectively decrease sexual risk behaviors among teens require age appropriate, medically accurate instruction delivered by a non-judgmental instructor over adequate time with attention to skill development.[3 ,4] There are many prevention curricula and after school programs that effectively delay initiation of sex, improve refusal skills, and increase condom use that have been show to be effective. Lists and descriptions of effective programs are available online through the CDC compendium, Advocates for Youth, The National Campaign to Prevent Teen and Unplanned Pregnancy and ETR Associates.

Many obstacles stand in the way of rural schools implementing effective HIV/STD education. Because rural Americans generally hold more traditional values,[5] some may be resistant to sexuality education. Rural communities may need to create a community advocacy group consisting of parents, students, clergy, PTA members, faith community representatives, health professionals, educators, community leaders, and other community members to mobilize support for HIV/STD education. Presentations of local data that highlight youth risk behaviors from the Youth Risk Behavior Surveillance System, county rates of STDs among youth, and local teen pregnancy or birth rates may move policy-makers to action. Educators and health care providers who work in rural settings suggest framing HIV/STD education less as sexuality education and more as disease prevention education. Focusing on how to stay healthy and prevent diseases through decision-making, refusal, and negotiation skills may provide an acceptable starting point for rural communities that embrace more traditional values. Emerging Answers, a document distributed by The National Campaign to Prevent Teen and Unplanned Pregnancy, provides a list of youth development programs shown to decrease sexual risk behaviors without any focus on sexuality education. These have been found to be well-accepted in rural areas and lend themselves to implementation in after school programs or in youth-serving organizations that already exist in rural communities such as 4-H, Boys and Girls Clubs, or GED programs. Understanding a community’s potentially conflicting values and identifying those individuals who influence youth policies provide the basis for selecting the program that is right for a specific community at a given time.

Another barrier is that rural schools may also lack trained health educators with the knowledge, skills, and comfort level needed for effective delivery of HIV/STD prevention education. Overcoming this obstacle requires a school to identify a teacher, guidance counselor, or health professional in the school or community-at-large with the nonjudgmental and open attitude needed to engage students in prevention education. If that person does not have adequate training in HIV/STD prevention education for youth, such training is available through state departments of health or education and a national network of state organizations that prevent teen pregnancy and HIV/STD. Having a trusted HIV/STD prevention educator from within the school is preferable since this allows students to ask questions and receive message reinforcement throughout the school year. However, another option is to recruit a health or counseling professional from the community to provide school-based HIV/STD education. State and local health departments, local AIDS Service Organizations, the American Red Cross, and local family planning clinics may be able to provide or suggest a local health educator. Although it may be more difficult for an outsider to develop a trusted relationship with the youth, this approach is reasonable if that is the most knowledgeable and approachable person available. In fact, sometimes the anonymity of the outside person increases perceived confidentiality.

Although there is broad consensus that abstinence is the best way for young people to protect themselves from HIV/STDs and unintended pregnancy, federally funded abstinence-only-until-marriage programs have strict performance specifications, called the A through H guidelines, of what information can and cannot be included in presentations.[6] While most abstinence-until-marriage programs do discuss HIV and other STDs as good reasons to abstain from sex, they cannot include prevention specific information or demonstrations about condom use. In 2007, a rigorous federally funded evaluation of four school-based abstinence-until-marriage programs following Title V’s A through H guidelines showed these programs were not effective in delaying sexual initiation over time or preparing young people to protect themselves from HIV, STDs, and/or unintended pregnancy when they became sexually active.[7] This may suggest that parents and concerned community members may want to be involved in the selection and ongoing support of HIV/STD prevention education in their local school. At a minimum, prevention education for youth should teach young people the benefits of abstaining from sexual intercourse, how to take responsibility for their health, how to protect themselves from HIV/STD infection, how to identify the signs and symptoms of infection, how and where to get tested, and how to talk with partners about preventing HIV/STD.

Community

Rural communities may lack funding resources, but may be rich in human resources, especially those added through volunteers. Although volunteers are a valuable asset, they cannot be solely responsible for HIV/STD prevention, and state and local health departments should remain mindful of this limitation.

Rural communities have unique HIV/STD prevention needs. Groups at elevated risk for HIV and STDs vary from one community to another and may include those imprisoned in correctional facilities, men who have male to male sex, migrant workers, victims of partner violence, or methamphetamine drug users. Another rural challenge is that it is often unclear who in the community is responsible for HIV/STD prevention. Local health departments are often under-staffed and minimally funded. Private rural health care providers may shy away from these stigmatized diseases. Service organizations and faith based organizations have other missions. And community leaders face other pressing concerns. That means that the first task for community leaders, organizations, churches, schools, and health care facilities is to identify the populations most in need of HIV/STD prevention information and in need of changing behaviors. Getting to “know your community” through a defined process guides resource allocation and establishes some measures that will be useful to judge the impact of community education efforts. The process should include a review of risk behaviors in the literature, a review of local data, and interviews or focus groups with professionals knowledgeable about HIV/STDs and high risk groups, gatekeepers (such as owners of bars or adult bookstores), and individuals from the target population. The intent should be to identify structures, policies, attitudes, economic factors, and behaviors that put local people at increased risk for HIV and other STDs.

In American Indian and Native Alaskan communities, it is especially important to consider the impact of historical trauma on these communities and make education programs congruent with cultural values and traditions. This holds true for programs for African-Americans who have also been traumatized over the course of American history. For Latino communities, education programs need to incorporate the values of the culture and not just be translated into Spanish. Equally important is the identification of assets and non-traditional resources the community can draw on. A Community Tool Box to help community groups conduct local assessments is available online through the University of Kansas.

Community HIV/STD prevention education can serve several purposes. First it can increase general awareness of HIV and other STDs and how transmission can be prevented. Second, it can change community attitudes and norms, increasing tolerance of those who engage in risky behaviors and putting a human face on those diagnosed with HIV. Community education can help decrease stigma and homophobia which are leading barriers to rural HIV prevention.8 Decreasing stigma, in turn, increases the likelihood that people will come forward for diagnosis and treatment of HIV/STDs, engage in HIV/STD testing, and disclose their HIV/STD status to partners. Changes may also include the promotion of new attitudes and behaviors such as being abstinent, limiting the number of sex partners, remaining monogamous, using condoms, using sterile syringes, and not sharing works for injecting drugs. However, there can be a fine line between approaches that decrease stigma and ones that inadvertently increase stigma and discrimination. In general, in order to decrease stigma, community level HIV/STD awareness campaigns should be careful not to “point fingers” at certain populations. Campaigns aimed at specific high-risk groups must be mindful of potential unintentional consequences such as suggesting that if “those people” would only leave the community, then there would be no further HIV or STD risk.

It is difficult for rural communities to provide major and continuous attention to HIV/STD prevention in part because HIV infection is an unlikely event in comparison to other health conditions that rural communities “see” on a regular basis, such as pregnancy, diabetes, and heart disease. Other STDs, while generally more common than HIV/AIDS in rural areas, are often not publicized and remain hidden to the broader public. The focus on other more visible health concerns presents an opportunity for HIV prevention messages to be delivered in tandem with other health promotion efforts like prenatal visits, diabetes care, substance abuse treatment, and domestic violence counseling.

HIV/STD prevention messages may be quite effective when communicated by non-traditional partners such as pharmacists, hair stylists, barbers, and even tattoo artists. Rural prevention specialists have suggested sharing information in pre-existing social networks such as agricultural organizations, church auxiliaries, talking circles, platicas, parent-teacher associations, or bowling leagues. Each community needs to assess what groups exist that would be open to HIV/STD education and would be likely to disseminate the information further into the community. Finding groups that may link with less accessible but more at-risk groups, such as men who have male-to-male sex and drug users, is difficult but ideal. Bringing community members into the planning process will help to identify such groups.

The steps for conducting an effective media campaign are not difficult but are time-consuming. They include:

1. collecting data about and from the target audience to identify the best communication channels and guide tailoring of messages
2. using behavior change theory to identify the behavior or attitude being targeted
3. dividing the audience into groups based on similar qualities to determine the best way to reach each group
4. using message design theory to develop tailored messages and test those with target audience representatives in focus groups
5. strategically placing messages in media channels accessed by the target audience, and
6. monitoring and measuring whether the specified process was followed and whether the desired outcome was achieved.[10]

At the very minimum, rural communities should assess the HIV/STD prevention needs of their community, be actively involved in reducing HIV/STD stigma and denial, and coordinate HIV/STD and unintended pregnancy prevention efforts between organizations and agencies. Community educational efforts need to be tailored to accommodate different learning styles, languages, and literacy levels. More importantly, programs should be culturally appropriate and build upon the existing value system of the community. Rural communities may lack funding resources, but may be rich in human resources especially those added through volunteers. Although volunteers are a valuable asset, they cannot be solely responsible for HIV/STD prevention, and state and local health departments should remain mindful of this limitation. By leveraging resources from agencies such as health departments and the Rural Center for AIDS/STD Prevention and partnering with existing community institutions and media channels, rural communities have the potential to be creative and tap existing resources in innovative ways to effectively bring an awareness of HIV/STD prevention to their communities.

The Faith Community

“The church has been silent for too long about sexuality.”

-David Satcher, M.D., 16th U.S. Surgeon General

The majority of rural Americans are strongly connected to their faith community. Thus, faith-based organizations (FBOs) can draw on their spiritual connection to people to promote HIV/STD prevention and reach vulnerable populations in rural America. Communities of faith have an opportunity to play an integral role in supporting community-based and school-based HIV/STD prevention efforts. However, historically some faith-based groups have served as a passive barrier by avoiding the issue. Other faith-based organizations have created an active barrier by labeling HIV/STD risk behaviors as sins to be shunned and consequently hidden from public view. Advocacy for HIV/STD prevention may require a role change for some of the faith community.

Although faith-based organizations are important in this respect throughout the country, the role of the Black faith community in HIV/STD prevention is critical given the disproportionate impact of HIV, AIDS, and other STDs on rural Black Americans. In October 2007, the National Conclave on HIV/AIDS Policy for Black Clergy in conjunction with the National Black Leadership Commission on AIDS announced their intention to take a leadership role in eliminating HIV among Blacks in the U.S. They plan to aggressively promote HIV testing among their congregations and insure that all Black clergy are equipped to address HIV-related issues in a scientifically sound manner. In addition, Black clergy will promote the ABC/D prevention model that advises people to abstain, be faithful, use condoms, and avoid engaging in risky behavior.[11] It will be essential for rural HIV/STD prevention specialists to offer their expertise to support this effort and expand it to include STD prevention.

Faith-based organizations have played key roles in HIV/STD prevention in developing countries for years and we can learn from their experience.

For example, throughout Africa, the Salvation Army has provided HIV education, testing, and counseling, relief supplies, and spiritual support for those infected by HIV/AIDS. In Asia, World Vision is promoting and distributing condoms, treating STDs, and trying to reduce risk behaviors among sex workers, truck drivers, migrant workers, fishermen, and injecting drug users. International AIDS workers note that involving faith communities requires patience, thoughtful partnerships, and respectful conversation between potentially contentious positions.[12] The potential influence of faith-based organizations on community norms, their ability to reach broadly into the community, and their potential participation in prevention programs all make the effort a good investment.

Rural American faith-based organizations may also play a supportive role for those at increased risk of HIV/STD infection. The faith community has the potential to provide sanctuary for teens through youth development programs and nonjudgmental counseling. They can promote empowerment and develop employment programs for low-income women. Many faith-based organizations provide spiritual support, transportation, food, and shelter to those infected with or affected by HIV/AIDS. They can advocate for open discussions about risky sexual behaviors and ways to combat poverty and racism, both of which may contribute to HIV infection in rural communities as much as individual behaviors.[13] Rural HIV/STD prevention specialists can contribute to this process by providing clergy with essential HIV/STD prevention information and by motivating local clergy using approaches sensitive to individual religious beliefs and values.

Although faith-based organizations have a unique potential for participating in HIV/STD prevention, the degree to which an organization or congregation chooses to participate and the pace at which they become involved will vary greatly. At the very least, rural faith-based organizations should identify the HIV/STD prevention needs of their faith community, open a conversation about HIV/STD prevention among their members, and be actively involved in reducing HIV/STD stigma and denial. Some faith-based organizations may be comfortable representing the faith-based community on community HIV/STD prevention tasks forces. Others may be comfortable providing spiritual and/or concrete support to those who are most vulnerable to infection or those already affected by HIV/STD infection. Additional guidance about how to work with the faith community to promote and support HIV/STD prevention is available through Faith-Based HIV Prevention Interventions: A Technical Assistance Guide for Working with Communities of Faith.

Healthcare Providers

Rural health-care providers can play a leadership role in HIV/STD prevention education by committing to ask patients about their risk behaviors and counseling patients how to reduce HIV/STD risk with consideration for individual needs and circumstances.

Healthcare providers have unique and powerful influence over people’s health behavior. In rural settings, medical professionals may be in a position to reach “hidden” populations at heightened risk for infection. This would include anyone with multiple sex partners, teens, pregnant women, clients using drugs or having sex with a drug user, women trading sex for economic survival, and men engaging in sex with other men whether or not they identify as gay. Healthcare providers are also in a position to normalize risk behavior screening, HIV and STD testing, and prevention counseling. It is critical for rural providers to appreciate the role they can play in early identification and treatment of common STDs such as chlamydia and gonorrhea by annually testing sexually active female patients 25 or younger for these infections using a simple urine test. Early treatment of these infections can prevent infertility, reduce the risk of HIV infection, and provide an opportunity to educate patients about the risks of STDs including HIV.

Despite these opportunities for incorporating HIV/STD prevention into rural medical protocols, rural providers may be uncomfortable having these discussions with patients who may also be neighbors and friends. They may be inadequately trained to conduct sexual and risk histories and to provide HIV/STD testing and counseling. In addition, many rural providers are already overburdened due to inadequate numbers of rural healthcare professionals. Consequently, they may be hesitant to add a prevention intervention that will require additional time, even minimal time. In contrast to urban medical facilities, there usually is no specially trained person to take on the responsibility for HIV/STD prevention in rural clinics. An additional barrier is that rural providers and healthcare facilities may lack knowledge about federal and state resources available to assist those diagnosed with HIV/AIDS.

Rural communities should first and foremost utilize those who are already trained, funded, and comfortable addressing HIV/STD prevention education. Most states have Disease Intervention Specialists (DIS) who are trained to conduct field investigations of communicable diseases by locating and counseling persons exposed to, infected with, or having a positive test for a communicable disease such as an STD, HIV, or tuberculosis (TB). DIS often visit HIV-infected clients at their home, help identify those who may also have been exposed, and can offer on the spot confidential rapid tests and counseling to partners. DIS also provide information to physicians, local health departments, and medical laboratories about the diagnosis and treatment of patients and the prevention, detection, and reporting of communicable diseases. First responders might also be trained to provide HIV/STD education and offer HIV/STD testing and counseling. In Indian Country, paraprofessional community health representatives (CHR) are in an ideal situation to provide HIV/STD education and could be trained to conduct HIV and STD testing and counseling if that is acceptable within the tribe.

Community Health Centers can be key players in rural HIV/STD prevention. Located in every state and territory, community health centers provide high-quality, affordable care regardless of insurance status or ability to pay. Health centers offer HIV testing, health care, and counseling services. They bring expertise in accessing resources for low-income, uninsured, or underinsured people who are living with HIV/AIDS through the federal Ryan White CARE Act (RWCA). They are also well positioned to lead rural collaborations among clinics, hospitals, and individual providers.

Most rural areas can take advantage of Title X reproductive health clinics where there are clinicians well-versed in HIV/STD prevention and management protocols. In rural Colorado, local public health nurses often conduct a risk assessment and then refer clients at heightened risk for HIV/STD to Title X family planning facilities in their county or a neighboring county. Title X clinics conduct risk assessments, HIV/STD testing, STD treatment, or referral for treatment. Title X clinics also receive regular updates on HIV/STD prevention skills such as how to conduct a sexual history and state-of-the-art diagnosis and treatment of HIV and other STDs. These training updates are often held in rural locations and are usually open to all local clinicians. Additional information about Title X family planning services and training opportunities can be found through the Office of Population Affairs.

There are 11 regional AIDS Education and Training Centers (AETCs) and a National Minority AETC whose mission is to train health care and dental professionals to diagnose, treat, and manage HIV infection. AETCs bring training to rural health professionals in their communities to teach them how to take sexual and risk histories, conduct HIV tests, manage HIV+ patients, and counsel them about reducing HIV/STD risk behaviors. AETC training can increase providers’ knowledge of federal resources available to them for HIV detection and management such as Ryan White CARE Act funds and those provided to community-based primary care providers in underserved areas through section 330 of the Public Health Service Act. They may also be able to link local physicians with university-based infectious disease doctors to provide ongoing support for local HIV treatment. Regional AETCs provide pocket guides to help health care providers assess HIV/STD risk, educational pamphlets for waiting rooms, and examination room posters that encourage patients to talk with their care providers about HIV and preventing infection.

Another federally funded resource is the National Network of STD/HIV Prevention Training Centers (PTCs) which provides prevention training throughout the country (). The PTCs try to offer travel support to those traveling long distances for HIV/STD training. They also bring training to rural communities if there is a need and interest. The PTCs provide three categories of training. First they provide clinicians with the latest knowledge and clinical skills for the prevention, diagnosis and management of STD infections. Second, the PTCs offer training in evidence-based individual, group, and community level interventions shown to change behaviors to prevent the transmission of HIV and other STDs. Third, the PTCs offer extensive training on partner management services. Currently, they are offering interventions to train clinicians to use brief tailored messages to effectively counsel and motivate HIV+ clients to reduce their risk of transmitting HIV and/or getting a new STD (see the Partnership for Health intervention in Chapter 6).

The Capacity Building Branch of the CDC provides training and technical assistance to organizations funded by the CDC and state health departments to help them build the infrastructure needed to improve the delivery and effectiveness of HIV/STD prevention. Capacity building may be particularly valuable for rural organizations that lack other resources for developing infrastructure. Capacity building assistance supports the implementation and/or adaption of effective HIV/STD prevention interventions and strategies. These strategies include implementation of rapid HIV testing, comprehensive risk counseling and services, and prevention counseling. To learn more about training events or request capacity building services, go to the Capacity Building website.

One innovative technology available to rural providers is an Internet-based system of notifying partners of exposure to an STD. Commercial programs such as inSPOT enable people to anonymously notify partners by email that they may have been exposed to HIV or another STD. There are humorous and serious message options, both of which are nonjudgmental and to the point. Some state health departments provide this program. A Kentucky non-profit has developed its own comparable notification service that can be accessed free of charge at Stop the Spread On-line.

Summary

This chapter has presented a broad spectrum of what HIV/STD prevention education might look like in rural settings. Knowing the community, honoring local values, thinking creatively, and leveraging existing resources are keys to success. Although science-based accurate, developmentally and culturally appropriate HIV/STD prevention programs might ideally be offered in rural schools, some communities may prefer after-school programs, youth development programs, or a youth information hot line. Increasing public awareness of HIV/STD risk and decreasing stigma may start as thoughtful responses to local occurrences such as an increase in teen births or chlamydia rates. Advocacy groups can bring people together to open the conversation. Bringing community leaders, the faith community, and health care providers together in such a way creates the potential for powerful prevention opportunities. And perhaps most important, rural communities can take advantage of existing resources while capitalizing on volunteers and local resources available to them to maximize prevention efforts and minimize cost.

In addition to the concepts outlined in this chapter, three overarching principles deserve elaboration. First, education designed to actively engage recipients tends to be far more effective in motivating behavior change. Numerous studies have shown that people are more likely to adopt safer sex behaviors in response to education programs that are interactive rather than those coming across as a directive. Second, education programs designed to promote safer sex and other HIV/STD prevention behaviors should always be tailored based on the cultural values of the target audience as well as their level of literacy. Clearly, programs that work are based on the values, needs, beliefs, and practices of the specific target audience and these audiences differ from one rural area to the next. Literacy is equally important and the prospect of finding low literacy in rural communities should always be anticipated. Finally, education designed to promote HIV/STD protective behaviors is far different from “academic education.” That means it is vital to remain nonjudgmental and to avoid being directive. Sex is an extremely personal behavior that people tend to value as a freedom in their lives. When education creates even an appearance of trespassing on this freedom, the effort may fail. The goal is to create conditions that allow people to adopt protective behaviors as a result of their decisions.

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