Rural Prevention Report
(Fall 1997, Vol. 4, No. 2)

HIV/AIDS Patterns Differ Between Rural Sample and National Data

A recent report of HIV infected persons and persons with AIDS in rural Virginia(1) indicates different infection patterns benveen rural areas and the entire nation. When the Virginia results are contrasted to AIDS case data from the U.S. Centers for Disease Control and Prevention (CDC)(2),three important patterns emerged. In rural areas, a higher percentage of the cases were female and heterosexually acquired, and a lower percentage resulted from injecting drug use (see Figure 1 on page 3).

Editor's Note: RCAP is collaborating with the Center for AIDS Prevention Studies at the University of California, San Fancisco, to analyze HIV/STD risk behavior of rural residents who participated in the National Sexual Health Survey. Highlights of the complete report will be presented in a future Rural Prevention Report.

In the Virginia study, the medical records of 590 predominantly rural HIV infected persons from 1982 to 1993 were examined to determine risk factors for infection. From this group, 127 were given a questionnaire requesting additional information. The 1993 CDC HIV/AIDS surveillance report was selected as basis for comparison. Major patterns include:

• Of the 590 sample, one female (25% of total sample) was HIV infected for every three males. Nationally, one female (12.5% of total sample) for about every seven males was diagnosed with AIDS. Among HIV positive whites in the 530 sample, the ratio of infected females to males was 1 to 3.5. Nationally, one white female (6% of total white sample) for every 15.3 white males was diagnosed with AIDS. Among HIV positive blacks in the 590 sample, the ratio of infected females to males was nearly equal (1.0 td 1.1). Nacionally, one black female (21% of total black sample) for every 3.7 black males was diagnosed with AIDS.
• Of the 590 sample, 29% reported engaging only in heterosexual activity; nationaly, 7% reported the same. Of the 127 sub-sample, 97% of the HIV/AIDS female patients and 25% ofthe HIV/AIDS male patients reported engaging only in heterosexual activity. Nationally, 35% and 2% ofthe females and males, respectiveiy were classified as being heterosexually infected.
• Of the 590 sample, 5% reported injecting drug use as the exclusive risk behavior; nationally, 25% of all AIDS cases were classified as resuiting from injecting drug use.
• Of the 590 sample, 60% and 37% were white and black, respectively; nationally, 50% and 31% of all AIDS cases were white and black, respectively.
• Sixty-seven percent of the 127 sub-sample continued to engage in sexual activity after their diagnosis. Of these, 15% reported inconsistent condom use and 6% reported never using condoms during subsequent sexual encounters.
• Of the cases which were contracted in Virginia, 95% were acquired while living in areas of less than 100,000 persons.

In general, the findings of the Virginia study appear to be representative of other rural areas in the United States.(3) For example, a recent CDC-sponsored surveillance project of women in rural areas of the South determined that 66% of HIV/AIDS cases were attributable to heterosexual contact.(4) The patterns reported here indicate that the required emphasis of HIV prevention education for rural areas may be unique. Seemingly, in rural communities increased attention should be direcred toward heterosexuals and females.

a heterosexual; b homosexual; c injecting drug use * the national percentages also include a negligible portion of AIDS cases from 1981.

1 Roberts, N.E., Collmer, J.E., Wispelwey, B. & Farr, B.M (1997). Urbs in rure redux: Changing risk factors for rural HIC infection. The American Journal of Medical Sciences, 314, 3-10.
2 Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 1994; 5(no.4).

REFERENCES

1. Roberts, N.E., Collmer, J.E., Wispelwey, B. & Farr, B.M (1997). Urbs in rure redux: Changing risk factors for rural HIC infection. The American Journal of Medical Sciences, 314, 3-10.
2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 1994; 5 (no.4).
3. Rural Center for AIDS/STD Prevention. (1996). HIV/AIDS in Rural America. (Fact Sheet #8). Bloomington, IN: RCAP.
4. Centers for Disease Control and Prevention (1997). HIV/AIDS Prevention. July, 1-2.

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RCAP Publishes Second Monograph

RCAP has spnsored the publication of the monograph, "Prevention of AIDS/STD in Rural Communities II" as a special edition ot the Health Education Monograph Series. The first edition of this monograph was published in 1996 and contained eight articles. The monograph, edited by RCAP co-director Mohammad R. Torabi, is published by Eta Sigma Gamma, the National Professional Health Education Honorary. The 1997 monograph includes seven articles and will be published this fall. The articles address several important issues related to HIV/AIDS in rural communities. Persons on the RCAP mailing list will receive a free copy of the monograph.

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Study Examines the Impact of HIV/AIDS Disease on Rural Women

Study Examines the Impact of HIV/AIDS Disease on Rural Women A recent study of rural women infected with HIV found that the psychological and psychosexual issues faced by the women have not been adequately addressed within their communities. Comprehensive interviews of 12 HIV-infected rural women were conducted over a one and one-half year period. Six major themes emerged from the interviews. Important findings include:

• Spiritual. A search for meaning, significance and purpose was underway, personal priorities shifted, and a sense of mission developed, with the rural environment enhancing the spiritual dimension.
• Physical. Finding adequate, integrated, and accessible heath care was a problem, especially for poor women.
• Emotional. Feelings of loss and limitation, and multiple fears were prevalent, especially at diagnosis and at the death of a friend or loved one. Some women reported positive self esteem changes and growing sense of empowerment as time progressed.
• Social. Social support was uneven. Actua and perceived discrimination was reported.
• Sexual. Decrease in sexual activity was noted by most women, often resulting from partner withdrawl.
• Maternal. Some mothers had began emotionally disengaging from their children to prepare them for future independence, should the mothers die.

Major study recommendations for improving the life of rural HIV infected women included (a) conduct spiritual retreats, (b) provide instrumental assistance, such as transportation and child care, (c) provide non-AIDS-related social activities, (d) create HIV support groups, (e) provide improved support services for children of infected mothers, (f) provide improved buddy training programs, (g) increase AIDS specific training for rural heath care providers, (h) better coordinate existing health and social services, and (i) improve HIV education and treatment programs.

SOURCE
Hendrixson, L. L. (1997. June). The psychological and psychosexual impact of HIV/AIDS disease on rural women: A qualitative study. (Doctoral dissertation, New York University. 1996). Dissertation Abstracts International, 57(12), 5312A.

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Life Differences of Rural and Urban Persons with HIV Disease Reported

Rural persons living with HIV reported significantly lower satisfaction with life than their urban counterparts, according to a recent study that investigated the psychosocial differences benveen rural and urban persons with HIV/AIDS. The study, conducted by the Center for AIDS Intervention Research of the Medical College of Wisconsin, surveyed 276 persons living with HIV/AIDS in a Midwestern state. The questionnaire measured respondents' quaity of life, perceptions of loneliness, social support, experiences with AIDS-related discrimination, access to services, and illness-related coping strategies. Besides lower satisfaction with iife, the rural persons living with HIV/AIDS, in contrast to similar urban residents, had (a) lower perceptions of social support from family members and friends, (b) reduced access to medical and mental heath care, (c) elevated levels of loneliness, (d) more community stigma, (e) heightened personal fear that their HIV serostatus would be learned by others, and (f) more maladaptive coping strategies. The study concluded that "programs designed to improve the life circumstances of persons living with HIV disease in rural areas, particularly those that facilitate access to adequate heath care, increase perceptions of social support, and improve illness-related coping are urgently needed." SOURCE: Heckman, T. G., Kalichman, S. C., Franzoi, S. L., & Kelly, J. A. (In press). Psychological differences between urban and rural persons living with HIV/AIDS. Journal of Rural Health.

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History of STDs Leading Predictor of Subsequent HIV Infection

Results of a 10-year study of heterosexual couples living in Northern California indicate that a history of a sexually transmitted disease infection was the leading predictor for subsequent HIV infection. Eighty-two HIV infected women and their non-injection drug using male partners and 360 HIV infected men and their non-injection drug using female partners were studied to determine the rates and risk factors for heterosexual transmission of HIV.

After 10 years, 68 (19%) and 2 (2.4%) ofthe HIV negative women and men, respectively, had become infected with HIV. Women were approximately eight times more likely to become infected than men. The male-to-female average infectivity rate per sexual contact was far less than one percent. History of STD infection was the strongest predictor of subsequent HIV infection, with the practice of anal sex and lack of condom use aso being strong predictors. The researchers concluded that infectivity for HIV through heterosexual transmission is low and that the study results confirm the significant contribution of both STD infection and injection drug use to acquiring HIV.

SOURCE
Padian, N. S., Shiboski, S, C., Glass, S. O., & Vittinghoff, E. (1997). Heterosexual transmission of human immunodeficiency virus (HIV) in Northern California: Results from a 10 year study. American Journal of Epidemiology, 146; 350-357.

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Swiss AIDS Prevention Efforts Evaluated

A nation-wide evaluation of the Switzerland AIDS prevention program from 1987 through 1994 was conducted to monitor sexual and HIV prevention behavior changes. Data were collected via an annual telephone survey of samples representative of the general population aged 17 through 45 years.

No major changes in level of sexual activity (lifetime number of partners, frequency of sexual encounters in the past week) or potential exposure to risk of HIV transmission (acquisition ofa new steady partner during the year or of casual partners in the last 6 months) were observed. Systematic condom use with a new steady partner and with casual partners increased.

The researchers concluded that a general-population approach to AIDS prevention was able to achieve largescale improvements in condom-based protection against HIV infection without inducing other major changes in sexual behavior.

SOURCE
Dubois-Arber, F., Jeannin, A., Konings, E., & Paccaud, F. (1997). Increased condom use without other major changes in sexual behavior among the general population of Switzerland. American Journal of Public Health, 87, 558-565.

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Video Profiles AIDS Patient in Rural Indiana

A recently aired television video "Facing AIDS in Rural America," profiles a Southern Indiana AIDS patient who is a husband and a father of four. The program was produced by WTIU, the pubic broadcasting television station at Indiana University. The patient taks about how he gave up proximity to support and medical care in Phoenix and moved back home to French Lick, Indiana to be close to his extended family and to "find peace." He describes the problems he and his family face living in a rural area. A copy of the video is available free from RCAP (see page 4).

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Rural Illinois Youth Have Low Personal Concern about AIDS/STDs

This study examined the heath concerns of adolescents and their perceptions of their peers' heath concerns. Data were collected from a convenience sample of 419 high school students in rural southern Illinois in May 1990.

AIDS and STDs were not among the top 25 health areas rated as "a personal concern for myself" or "a concern among my best friends." However, AIDS and STDs were the third and eighth most highly rated ateas for "a concern among other teenagers." About 80% of the sample considered AIDS and STDs as concerns of teenagers other than their best friends.

The top ten "personal concerns for myself" were being successful, choosing an occupation or career, making good grades, what they would be like in 10 years, having friends, dating, going to college, having a boyfriend or girlfriend, having one's own family, and getting along with parents.

The data show that adolescents' self-report heath concerns differ from their perceptions of their peers' health concerns. The presence of this difference suggests that adolescents may perceive themselves as being invulnerable to harm.

SOURCE
Weiler, R. M. (1997). Adolescents' perceptions of health concerns: An exploratory study among rural Midwestern youth. Health Education & Behavior, 24 287-299.

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In the literature...

Men's Behavior Change Following Infection with a Sexually Transmitted Disease. B. Payn, K. Tranfer, J. Billy, & W. Grady. Family Planning Perspectives 29 (July/August 1997): 152-157.

• An analysis of data on 20-39-year-old men participating in the 1991 National Survey of Men finds that of 466 respondents who had ever had a STD, 25% had sex while infected. However, 85% ofthese men informed their partner of the STD before having coitus. Black men were significantly less likely than whites to have had sex while infected. Overall, 29% of men with an STD did not modify their sexual behavior or condom use.

Secondary Sexual Characteristics and Menses in Young Girls Seen in Office Practice: A Study from the Pediatric Research in Office Settings Network. M. Herman-Giddens, et al. Pediatrics 99 (April 1997): 505-512.

• This study determined the current prevalence and mean ages of onset of pubertal characteristics in young girls seen in pediatric practices in the United States. The mean ages of onset of breast development for African American and white girls were 8.87 and 9.96, respectively; and for pubic hair development, 8.87 years and 10.51 years, respectively. Menses occurred at 12.16 in Afro-Americans and 12.88 years of age in whites.

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National Hotlines

National AIDS Hotline

• English Service (7 days/week, 24 hours/day): (800) 342-2437
• Spanish Service (7 days/week, 8 a.m.-2 a.m. EST): (800) 344-7432
• TDD Service for the Deaf (Monday-Friday, 10 a.m.-10 p.m. EST): (800) 243-7889

National STD Hotline

• (Monday-Friday, 8 a.m.-11 p.m. EST): 800/227-8922

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