The Struggle to Provide HIV/AIDS Prevention and Treatment in Rural Areas

by Candi Helseth

Proponents of rural life laud open spaces and close-knit communities as advantages of rural living. But those attributes become deterrents in the prevention and treatment of HIV/AIDS in rural areas, according to Dr. William L. Yarber, senior director at the Rural Center for AIDS/STD Prevention (RCAP) and a senior research fellow at The Kinsey Institute for Research in Sex, Gender, and Reproduction at Indiana University.

“There’s a lot of denial in rural communities that AIDS (Acquired Immune Deficiency Syndrome) is even a problem because everyone there thinks they know everything about everyone,” Dr. Yarber said. “But rural America is not immune to AIDS as many rural residents presume. And because studies show that rural individuals are less likely to use condoms and women are less likely to require that a partner wear a condom, the spread of AIDS remains an ongoing threat to public health.”

According to National Center for Health Statistics (NCHS) data, AIDS is the fifth leading cause of death in the United States among people ages 25-44. Nationwide, about two-thirds of new HIV diagnoses are attributed to men who have sex with men (MSM). Overall, 9.8 percent of persons diagnosed with HIV live in nonmetropolitan areas, according to the Centers for Disease Control (CDC). And, CDC reports, while HIV has slowly decreased in metropolitan areas since 1985, it is showing a moderate increase in nonmetropolitan areas, reflecting the spread of the epidemic from urban into smaller suburban and non-urban areas.

Jeffrey Basinger

Jeffrey Basinger, Executive Director of NCAP, says that rural AIDS patients face isolation and lack of social support.

In Colorado, four regional organizations under the umbrella of the Colorado AIDS Project (CAP) offer HIV/AIDS education, testing, treatment and supportive services, covering the state’s entire geographical terrain. One of these, the Northern Colorado AIDS Project (NCAP) serves a mostly rural, eight-county region where, NCAP Executive Director Jeffrey Basinger says, their clients and families face loneliness, isolation and a lack of social support.

“There is no evidence that AIDS stigma has decreased in rural areas as it has in urban areas,” Dr. Yarber concurred. “As a result, rural residents are less likely to use prevention or seek help. When there is still considerable fear of friends and neighbors finding out if you buy a condom or have an AIDS test, it makes it more likely you won’t take that step.”

NCAP provides about 700 free HIV tests every year. NCAP does testing in both urban and rural areas and residents can choose where to access services. Sixty percent of clients are at or below the federal poverty level and in some areas, clients would have to drive 150 miles each way to the nearest urban service, Basinger said, so access would be greatly compromised if services weren’t provided in the rural areas. NCAP strives to protect privacy by using out-of-the-way testing locations at public facilities and stressing its non-judgmental, client-centered, confidential approach.

NCAP markets its services through area organizations and specific Internet sites. Individuals who receive an HIV/AIDS diagnosis are referred for medical treatment and connected to other services such as mental health counseling, housing and transportation assistance. The Colorado AIDS Project organizations also collaborate to provide testing and services through other venues, such as Colorado ManREACH, an organization intended to educate and build community among rural MSM. Funded by the Colorado Department of Public Health and Environment, ManREACH sponsors events throughout the year in various areas of the state.

“We’re primarily trying to create a community for the time these men spend together whereas they probably don’t have a community of acceptance where they live or the resources, including meeting places, that urban men do,” ManREACH Co-director Richard Rivers said. “For the most part, we’re engaging in activities and workshops that allow us to get to know ourselves and others better that, if and when the time comes, we will negotiate safe sex because we are concerned about that person’s health and know him. We’re providing a holistic support network that guys in rural areas don’t get. HIV prevention is certainly a goal and we believe we do that through community building.”

About 70 percent of NCAP’s 204 clients diagnosed with HIV/AIDS in 2010 are male. Most NCAP females who contracted AIDS reported they were involved in a heterosexual relationship, Basinger said. As a person living with AIDS, Basinger demonstrates that people with AIDS can live productive, healthy lifestyles. And while he is grateful that treatment has improved longevity, he says the responding change in public attitude that AIDS is no longer a major public health concern is dangerous.

“HIV/AIDS has slipped off the public radar,” he asserted. “This virus doesn’t discriminate. It can be linked directly to every other social justice issue we deal with – drug addiction, poverty homelessness, mental health, sexism – taboo subjects that polarize political environments and negatively impact funding necessary to provide testing and assistance.”

RCAP strives to keep AIDS, and particularly its impact on America’s rural population, on the public radar. A joint project of Indiana University, the University of Colorado, and the University of Kentucky, RCAP was founded in 1994 and has its headquarters at Indiana University. RCAP provides prevention resources to professionals and the public, develops and evaluates educational materials and approaches to rural HIV/STD prevention, and shares strategies that might work to overcome behavioral and social barriers related to rural HIV/STD prevention. RCAP regularly has ongoing contact with HIV/AIDS organizations in more than 30 states.

“We really encourage rural partners to share ideas that aren’t costly because all of us are understaffed and underfunded,” Dr. Yarber said. “RCAP currently faces funding issues too. It would be a shame if we have to close, because other organizations are only looking at urban area problems. Rural problems are very different.”

No one-size-fits-all solution exists for rural areas, Dr. Yarber concluded, but RCAP offers providers an opportunity to learn what other rural communities are doing and then to adapt and build a program based on their region’s needs. RCAP has released Tearing Down Fences: HIV/STD Prevention in Rural America, an electronic publication that highlights research and programs throughout rural America. RCAP is also developing a web-based, cost-effective tool called CREATE (Create Rural Education AIDS Tailoring Effort).

To learn more, email RCAP’s Dr. William Yarber at: yarber@indiana.edu.

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