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Tearing Down Fences Hiv/STD prevention in rural america

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"STDs are hidden epidemics of tremendous health and economic consequences in the United States. They are hidden because Americans are reluctant to address sexual health issues in an open way and because of the biologic and social characteristics of these diseases. All Americans have an interest in STD prevention because all communities are impacted by STDs, and all individuals directly or indirectly pay for the costs of these diseases."

Institute of Medicine, The Hidden Epidemic: Confronting Sexually Transmitted Diseases


Chapter 2: Epidemiology of HIV/STDs in Rural America
The Spread of HIV/STD to Rural Areas
Risk Factors for HIV/STD in Rural Areas
Protecting Rural America against AIDS
Epidemiology Summary

The Spread of HIV/STD to Rural Areas

The spread of HIV to rural areas of the United States is clearly a significant threat to public health.[1-3] Moreover, rates of chlamydia and gonorrhea remain high in rural America. In 2008, the rate of chlamydia in rural micropolitan counties (population less than 50,000) was 312.20 cases per 100,000 population compared to 412.40 per 100,000 for the most urban counties with populations of 50,000 or more [4]. The relatively high rural rate shows that rural America is not far behind the urban areas of the nation when it comes to the acquisition and transmission of chlamydia. Gonorrhea provides a similar example. In 2008, the rate in rural counties was 77.8 versus 116.8 cases per 100,000 for urban counties [4]. Although the rural rate is two-thirds of the urban rate, it nonetheless indicates that gonorrhea is not uncommon in rural areas. In 2006, new cases of primary and secondary (P&S) syphilis continued to cluster in the South more than in other geographic areas of the country. A 13% increase in new P&S syphilis cases occurred also in the West between 2005 and 2006.[5] Although the 2008 incidence rate of primary and secondary syphilis in rural micropolitan counties remains low and is one-third the rate in urban areas [4], it is of concern that there are increases in P&S syphilis in geographic areas with large rural areas. High rates of STDs indicate not only high rates of unprotected sex but also that there are a large number of people in rural areas who are more susceptible to HIV due to their having another STD.

Fortunately, the rates of HIV and AIDS cases in most of rural America have remained relatively low compared to rates in metropolitan areas. Since the early 1990s, 5% to 8% of the annual new AIDS cases have been diagnosed among those who live in rural areas. In 2008, 9.8% of the newly diagnosed HIV cases were in non-metropolitan areas. [6] Although the proportion of rural people living with HIV and AIDS is relatively small, 45,728 people from rural areas were living with HIV and 28,537 were living with AIDS at the end of 2008. [6]. This number is an underestimate since it does not include those who are currently unaware of their HIV+ status, migrate to rural areas after diagnosis or those who are diagnosed in urban areas and do not provide their home address to avoid hometown stigma. Having more rural people living with HIV/AIDS means there are also more people requiring services and more people capable of transmitting the virus.

Hidden within the seemingly level national incidence of new rural HIV and AIDS cases, is a soaring incidence of new cases and deaths from AIDS in the rural and non-rural South[7] (defined by the CDC as Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia). In 2006, 67% of all new rural AIDS cases were located in the rural South and there were more deaths from AIDS there than in any other area of the country.[7, 8] Two decades of the highest rates of STDs in the South, recent increases in syphilis, and the ongoing disproportionate infection of Blacks and Latinos adds additional weight to the need to reduce STDs including HIV in the rural South.[7]

pie chart racial ethnic disparities in rurla aids cases 2007

Rural Blacks and Latinos, especially those living in the rural South and Northeast, bear a disproportionate burden of HIV/AIDS. Blacks account for 51% of rural HIV cases, Whites 37%, Latinos 10%, and American Indian/Alaska Native (AI/AN) 2% (Figure 3).[6] Men continue to comprise the majority of reported rural AIDS cases (9.1 per 100,000) at nearly three times the rate for women (3.1 per 100,000) (Figure 4).[8]


pie chart AIDS cases by sexAlthough little research has focused specifically on rural men of color who have sex with men, attention to this group may be warranted based on the findings from a study in five urban centers showing that 46% of Black MSM and 17% of Latino MSM who were tested were HIV positive. Of those tested, 67% of the Black MSM and 48% of the Latino MSM were unaware of their status.[9] Although Black and Latino MSM are more likely than White MSM to have sex with women also,[10] studies show that Black MSM are no more likely to engage in HIV high-risk behaviors than other MSM.[11,12] Unprotected bisexual activity among Black men is associated with secrecy and appears related to habituation to same-sex relations during incarceration and the need to maintain a heterosexual identity in homophobic communities.[13] Additional research is needed to better understand how structural factors contribute to the disproportionate burden of HIV on rural men of color.

In 2008, the rural distribution of new AIDS cases among teens, young adults, middle age adults, and older adults was similar to non-rural areas with the largest proportion of new rural cases diagnosed among adults ages 35-44. Evidence indicates that nearly half of rural HIV infections are diagnosed “late,” that is, within 12 months of advancing to AIDS.[14,16] This suggests that the acquisition of HIV probably occurs most often among rural residents in their late twenties and early thirties.

bar chart AIDS cases by trransmission

As shown in Figure 5, exposure through male-to male sexual contact accounts for over half of all male AIDS cases. About 20% are attributed to injection drug use exposure.[6] These are nearly the same proportions as in urban areas.

Although men account for the majority of rural AIDS cases, the rural epidemic may be shifting to women, particularly Black women in the rural South.[5,17-20] In the rural South and Northeast, the majority of HIV-infected Black women report being exposed through heterosexual sex with an HIV infected partner.[6] Often, they are not aware of the behaviors that put their partner (Figure 6) at risk.[18]


The shift of infection to Black women is partly an extension of the legacy bar chart of high rates of STDs in the southern U.S.[4,15-18] However, a complex web of factors contributes to this shift. These factors include racism and discrimination, persistent poverty, limited educational and employment opportunities, substance abuse, high rates of HIV/STD among Black men, high rates of incarceration, and a lack of accessible and affordable prevention and health care services.[19]

In addition to the increasing rate of infection among women of color in the South and North, there is an increasing rate of infection among women who are involved in methamphetamine use in the Midwest and West, especially if they inject the drug or have sex with an infected partner.[20]


Risk Factors for HIV/STD in Rural Areas

Despite, the compelling epidemiological evidence relative to HIV and STD in rural America, little is known about the prevalence of sexual risk-taking behaviors among rural Americans in comparison to individuals from metropolitan areas. Fortunately, a handful of studies exist that provide a starting point for investigations of HIV/STD risk behaviors, and their antecedents, among rural Americans. For example, one study found that rural women were more likely than their metropolitan counterparts to report never using condoms for HIV prevention.[20] A related study among low-income Black women found that rural women were more likely than their metropolitan counterparts to report:

  • not having HIV prevention counseling during pregnancy
  • not using condoms
  • not having a preferred method of protection because they did not worry about HIV/STD
  • having a sex partner who had not been tested for HIV, and
  • believing that their current partner was HIV negative, even without an HIV test. [21]

Data from the 1995 National Health and Social Life Survey indicated that rural Americans were less likely than their non-rural counterparts to report any change in sexual behavior in response to the AIDS epidemic, including condom use.[22] Also, a recent analysis of data collected from a national probability sample found that individuals living in rural areas were less likely to use condoms than those living in large metropolitan areas.[23]

In a recent analysis of data from the National Survey of Family Growth24 investigators found remarkable similarities between metropolitan and rural Americans relative to their reported behavioral risks for HIV/STD acquisition. There were no significant differences between rural and urban men and women in terms of lifetime number of sexual partners, rates of unprotected sex (in previous four weeks), condom use at last sexual encounter, ever having had an HIV test, and discussing correct condom use with a health professional during the last HIV test. Also, non-metropolitan men were significantly less likely to report discussing STDs other than HIV with a health professional after their last HIV test.

Protecting Rural America against AIDS

Fortunately, the prevalence of HIV/AIDS in rural America is relatively low at this time, offering a window of opportunity for intervening to prevent a potential increase in rural HIV/AIDS. This “window” is somewhat delicate because public perceptions may dictate that action should follow rather than precede a public health problem.

An important epidemiological principle is that new cases of a sexually transmitted disease (incident cases) are a function of the number of untreated cases in the population (prevalence). In essence, the “risk” in sexual behaviors and injection drug use behaviors rises and falls in correspondence with the respective presence or absence of the disease within the sexual or injecting network of a given person. Because sexual networks are often based on geographic location, it is apparent that “rural risk” and “urban risk” for any single behavior (e.g., unprotected anal sex) may vary due to differences in the size of the pool of infection. That means that one is more likely to be exposed to HIV or an STD in an urban area with a high prevalence of those diseases. Conceivably, detecting and treating all bacterial STDs with antibiotics in rural areas could eliminate the pool of those diseases, reducing the risk for chlamydia and gonorrhea unless the infections were “imported” from urbanized areas. However, the scenario for HIV is much different since HIV cannot be cured and prevalence only declines as a function of death.

The composition of the sexual network and number of concurrent partners also impacts HIV/STD risk. Having more than one partner in a given time increases passing STDs between those partners and within their sexual networks. Since options for sexual partners may be limited in smaller communities, a few people with multiple concurrent partners may spread disease to a large network in rural areas.[25] One study found that more than half of rural Blacks with heterosexually transmitted HIV had multiple partners, 40% had concurrent partners, and 87% believed their partners had sex with others during their relationship.[26]


Although rates of HIV infection and AIDS are relatively low in many rural areas, rural rates of more common STDs approach rates in urban areas indicating that risky behaviors exist in rural as well as urban communities. While male-to-male sexual activity is responsible for the greatest number of HIV infections, increasingly, heterosexual exposure is spreading the infection to rural women, especially women of color. The sexual and drug injection behaviors that put individuals at risk for transmission of STDs are quite similar for urban and rural residents and have increased in the past decade in rural areas due to methamphetamine use. Concurrent sexual relationships are not uncommon in rural social networks. This means that as pools of HIV or other STD infections increase in rural areas, the chance for new infections increases.

Rural stigmatization of drug use, male to male sex, and having multiple partners hinders discussion of HIV/STD risks and early detection through risk assessment and testing. Stigmatization discourages the use of rural venues by men to find male sexual partners and encourages travel to urban centers where the pool of infection is larger. Similarly, traditional values and denial that HIV and STDs even exist in rural communities further block prevention efforts especially with teens as they explore their sexuality and question their sexual identity.

Dedicated HIV/STD professionals have at least a twofold task in light of this. First, they must understand that acting early in an epidemic while prevalence is low is the best assurance that incidence will not dramatically escalate. Second, they must consider that people in rural areas may be hesitant to attend to something like HIV and other STDs that remain “hidden” in their community. This second point is addressed in the subsequent chapter pertaining to HIV/STD prevention education in rural America.

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