Julie Scofield
Executive Director,
National Alliance of State and Territorial AIDS Directors

Rural communities face many unique challenges that often go unrecognized. Geographic and cultural barriers greatly influence the availability, accessibility and provision of services. Providers may cover vast distances, little public transportation exists, inclement weather can strand clients for days, and stigma may make clients uncomfortable receiving services in their community or taking part in the planning process.

These barriers increase the difficulties in responding to the rural HIV/AIDS, STD and viral hepatitis epidemics. Clients in rural areas face competing needs and HIV prevention is seldom the top priority for someone facing broader challenges such as isolation and poverty. In some instances, the lack of infrastructure presents a further challenge to delivering HIV prevention messages to clients. And many experts argue that prevention in rural areas requires more resources because of the long distances clients and outreach workers must travel to obtain and deliver services. Furthermore, rural communities are often faced with adapting interventions that work in urban areas to rural and frontier contexts.

While communities of color are disproportionately affected by HIV and STDs in rural areas, particularly the rural South, it is more difficult to relay prevention messages because these populations are relatively small and diffuse. It is important to work with these communities and acknowledge the cultural variability of rural communities of color. Furthermore, stigma and homophobia can be very strong in rural America, leading rural gay men to feel more isolated and less accessible through traditional HIV and STD outreach.

While these challenges can be daunting, they are not insurmountable. With Tearing Down Fences, we now have a comprehensive compilation of interventions and strategies for and by those in rural communities. Tearing Down Fences also concisely frames the unique needs and challenges faced by rural communities and can be an important tool for educating policymakers, planners and programmers about the issues impacting HIV/AIDS prevention in rural America.

In particular, Chapters 1 and 2 lay out a foundation for the contexts that challenge HIV/STD prevention in rural America, most poignantly the social isolation as well as the geographic isolation many face. Building upon these chapters, Chapter 3 lays out how HIV /STD prevention education currently works and can work, and Chapter 4 outlines HIV testing in rural areas. Each of these chapters includes profiles from the field. Chapter 6 further explores the contexts of HIV and STDs in rural America by profiling what it is like to be living with HIV/STDs in rural areas, again including vignettes from several local programs. Chapter 7 provides perhaps the meatiest section of the document, outlining behavioral interventions that may work in rural America, including considerations for selecting and adapting interventions. Several rural programs are fully described in this chapter. Tearing Down Fences concludes with a look toward opportunities for the next decade, aptly summarizing the challenges we all face that are felt more acutely in rural areas.

NASTAD is pleased to have been involved in the development of this important document. It well compliments NASTAD’s National HIV Prevention Blueprint, which calls for a national commitment to provide full coverage of tools to prevent infection to all populations, ever expand the prevention arsenal, encourage all people living with HIV/AIDS to know their status and be linked into care, and to address the complexity of individuals’ lives.

Tearing Down Fences concludes by noting that while there are no magic bullets to ending rural HIV/STDs, there are many opportunities. We must collectively seize these opportunities to ensure that no one is left behind as we refocus our attention on HIV prevention in the U.S.

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