Although the HIV/AIDS epidemic initially emerged in urban areas, it has now spread to rural America. In 2003, the number of people who became infected in rural areas increased to 7.6% of total cases compared with 5% of total cases in 1995.1 The shift of the disease to rural communities brings with it numerous challenges.
Planning and implementation of preventive services are particularly challenging in rural communities for a variety of reasons, including long travel distances to HIV/AIDS services, inadequate supply of HIV/AIDS specialists, medical services, and social/support services in rural areas, concerns over greater confidentiality issues that arise due to stigma of the disease which prohibits persons who may be infected from getting tested, pronounced overall health disparities between rural and urban populations (including chronic diseases and sexually transmitted diseases), poorer economic conditions (including increasing numbers of under-and-uninsured), and limited substance abuse treatment services, which make untreated addiction a barrier in adequate treatment for those persons also infected with HIV.2–3 Additionally, rural areas have their own set of cultural needs which can affect prevention strategies.
Added to providing adequate services in rural areas are the other alarming trends that could affect the disease burden even more:
• While other regions of the United States are experiencing either a decline or leveling off of HIV/AIDS, the South has alarmingly increasing rates.4 In fact, the South has over one half of all cases of rural AIDS cases, but rural Southerners make up 35% of the total rural population.5
• By region, Blacks account for the majority of HIV/AIDS diagnoses in the South (54%) and Northeast (53%). Black males account for more HIV/AIDS diagnoses than males of any other racial/ethnic population in the South (48%) and Northeast (47%). Black females account for the majority of HIV/AIDS diagnoses among females in the South (72%).6 [End Page 10]
• The majority of Black female cases of HIV/AIDS are a result of heterosexual transmission, which indicates a shift from earlier patterns of intravenous drug use (IVDU) transmission. Among Black males, over half of rural cases are men who have sex with men (MSM). Twenty percent are due to IVDU and 20% are due to heterosexual contact.5
• HIV/AIDS among migrant workers and immigrants is on the rise, and because of the mobility of this group, traditional prevention and surveillance strategies are difficult.5
Prevention strategies addressing these traits of rural communities must be part of any plan to confront the epidemic over the next few decades. Here, two rural physicians from different parts of the country, one a Preventive Medicine/Public Health physician and researcher, the other a Family Practitioner, address future implications and directions they think will be needed to combat this epidemic. Each author presents the view from where they practice, but both see stigma and fear continuing to permeate their communities, creating barriers to effective prevention and care. Policies and programs that focus on stigma and fear are needed to eliminate HIV/AIDS in rural areas of the U.S.
Breaking the Epidemic of Silence (by Pamela Foster, MD, MPH)
I moved to Alabama from metropolitan New York City about four years ago. Although I now live in a moderate sized city (population 200,000), I carry out much of my preventive activities in small rural towns in Alabama. Throughout my career, I have been concerned about HIV/AIDS, especially in the Black community. I witnessed early on in the epidemic the fear and stigma associated with HIV/AIDS in many of the cities in and around which I lived. Unfortunately, stigma and fear have been slow to disappear.
Nowhere is HIV/AIDS as silent as it is in the Deep South. No one wants to discuss the AIDS, let alone prevent it. Traditional prevention strategies have been minimally effective in the community, as is demonstrated by increasing rates of infection in the region. Until we begin to break the silence associated with HIV/AIDS, any prevention strategies (including especially primary prevention strategies) will be in vain. But to break the silence associated with this disease is...