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Barriers to HIV/AIDS Care in Rural Communities

Many social, environmental, and economic factors converge to cause barriers and challenges that complicate HIV/AIDS treatment and prevention in rural areas. Some overarching factors include poverty in many rural areas, limited resources, and structural barriers that pose challenges to accessing services.

This section describes barriers to treating and preventing HIV/AIDS in rural communities. Often, many of these factors intersect, amplifying the barriers to treatment and prevention.

Unique Social Aspects of Rural Communities

  • Stigma – Stigma in rural communities can have a widespread impact on both HIV/AIDS treatment and prevention, including making individuals less willing to be tested and/or treated for HIV. Stigma can present barriers to care for populations that have a high prevalence of HIV, including sexual orientation and gender identity minorities, as well as intravenous drug users.
  • Privacy and lack of anonymity – Because rural communities are small and tend to have close-knit social networks, it can be difficult for individuals to privately seek HIV/AIDS services. Community members may see individuals accessing these services, or may work at an organization where HIV testing or treatment services are provided. Combined with social stigma, the inability to privately access services may deter people from getting tested for HIV or seeking care for HIV/AIDS.
  • Lack of awareness – There is a lack of awareness of the prevalence of HIV in rural communities. Because the HIV epidemic has historically been most intense in urban areas, there may be a lack of awareness that HIV/AIDS is a problem in rural communities. In addition, prevalence of HIV/AIDS in rural areas may be underestimated, as individuals who are tested in urban areas may move back to rural areas for family support after a diagnosis, or individuals from rural areas may provide testing facilities a false address out of fear that others will learn about their HIV status.

Physical Isolation, Low Population Density, and Persistent Poverty

  • Lack of services: Rural communities may not be able to sustain important services, such as public transportation and homeless shelters, due to sparse populations. Lack of basic transportation services can make it difficult for individuals in rural areas to access HIV/AIDS services. In addition, a lack of services can make it challenging for HIV-positive individuals with low resources, such as people who are homeless, to engage in regular HIV care or adhere to an HIV treatment regimen.
  • Lack of specialized service providers: Rural communities may lack healthcare providers who specialize in providing care to people with HIV/AIDS. Rural residents may need to travel long distances to find a provider, which impacts retention in HIV treatment.
  • Lack of Ryan White providers: Because of the high rates of persistent poverty in rural areas, people in rural communities often require financial assistance to subsidize their treatment, especially if they are uninsured and unable to qualify for Medicaid. Though the Health Resources and Services Administration (HRSA) Ryan White Program provides subsidized or free treatment to HIV-positive individuals, as of 2019, only about 8% of Ryan White providers were practicing in HRSA-designated rural areas, making the high cost of treatment a significant barrier in rural communities that lack this key resource.
  • Low population density and HIV prevalence: Because of the low population density in rural areas, and consequently the low density of HIV-positive individuals, rural HIV programs have a high per person operating cost compared to programs that serve people in urban areas.
  • Cost of treatment: Cost of HIV treatment can be unaffordable for people who live on low incomes, especially if they are uninsured and unable to qualify for Medicaid.
  • Insufficient internet access: Although there is demonstrated progress in advanced telecommunications capabilities, rural and tribal areas still continue to lag behind in broadband deployment, severely impacting access to critical health information and telehealth services.

The interaction between community stigma, consequences of isolation, lack of financial resources, and other barriers demonstrate that these factors must all be addressed together, in order to reduce their collective impact and improve HIV/AIDS prevention and treatment in rural areas.

For rural stakeholders who are interested in implementing an HIV/AIDS prevention or treatment program, various cross-cutting program implementation considerations are discussed in Module 4: Implementation Considerations.

Resources to Learn More

Suboptimal Geographic Accessibility to Comprehensive HIV Care in the US: Regional and Urban–Rural Differences
Document
Discusses access to HIV care facilities in urban and rural areas based on travel distance to care sites. Analyzes national data to determine average driving time to care sites and percentage of people living with HIV who have a drive time of greater than 30 minutes.
Author(s): Masiano, S., Martin, E., Bono, R., et al.
Citation: Journal of the International AIDS Society, 22(5)
Date: 5/2019

The Health Resources and Services Administration's Ryan White HIV/AIDS Program in Rural Areas of the United States: Geographic Distribution, Provider Characteristics, and Clinical Outcomes
Document
Analyzes 2017 data from the HRSA Ryan White HIV/AIDS Program (RWHAP) Services Report to determine the program's reach in rural areas. Compares rural and urban characteristics for providers, services, clinical outcomes, and clients supported by RWHAP. Discusses barriers to rural HIV care delivery and RWHAP's mediation of those barriers.
Author(s): Klein, P., Geiger, T., Chavis, N., et al.
Citation: PLoS One, 15(3)
Date: 03/2020

HIV Prevention and Treatment Challenges in Rural America: Policy Brief and Recommendations to the Secretary
Document
Provides an overview on the prevalence of HIV and access to HIV prevention and treatment services in rural communities. Discusses challenges to providing and accessing HIV prevention and treatment efforts in rural areas, including the lack of local healthcare services, the cost of care, and HIV-related stigma. Describes federal programs that support HIV prevention and treatment services in rural areas. Offers policy recommendations to address these barriers and to reduce rural HIV disparities.
Organization(s): National Advisory Committee on Rural Health and Human Services (NACRHHS)
Date: 5/2020

Living with HIV in Rural America: Stigma and Other Barriers to Care
Video/Multimedia
Video highlighting the barriers to accessing HIV care in rural areas and strategies to overcome these challenges. Discusses the types of stigma encountered and methods to lesson stigma for people living with HIV including the use of community health workers (CHWs), mobile vans, and remote provider education and training.
Author(s): Sweet, D.E., Nelson, J., & Kinder, A.
Organizations(s): National Center for Innovation in HIV Care, U.S. Health Resources & Services Administration
Date: 2017