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HIV/AIDS in Rural America

February 16, 2017

photo closeup of a female patient's eyes looking at the camera
Confronted by multiple medical and behavioral health disparities, rural Americans living with HIV/AIDS also face widespread stigma that makes it harder to get testing and care and are more likely to drop out of care, experts say.

Faced with time and distance barriers along with enduring social bias, HIV-positive rural dwellers are less likely to find a clinic near their homes, more apt to drop out of care and more vulnerable to pervasive stigma where they live and work, experts said at a recent webcast.

Reports of disparities in HIV care come on the heels of recent studies by the Centers for Disease Control and Prevention that found lower adherence to "healthy behaviors" among rural residents – particularly smoking cessation – and gaps in the availability of care across a range of health conditions.

Among potentially preventable deaths in 2014 singled out by the CDC were 25,000 fatalities from heart disease, and 46,000 more from cancers, accidental injuries, chronic lower respiratory diseases and stroke.

HIV-positive people face a special burden, said patients and providers in a recent webcast hosted by the HRSA-funded National Center for Innovation in HIV Care.

"If you don't know what's going on and you're just sick, it's really dangerous to be in the rural areas because too many physicians … don't know anything about" HIV, said one patient who was diagnosed with AIDS nearly 10 years ago, in a videotaped testimonial.

"I've met people out here … with real fear of anybody knowing that they were HIV positive."

Rural residents are less inclined to seek HIV screening. And when they do, they often try to avoid friends and neighbors by traveling to distant "metropolitan" clinics, said experts who spoke at the presentation, entitled, "Living with HIV in Rural America: Stigma and Other Barriers to Care."

Infected people in rural areas are more likely to be referred to HIV care within three months of receiving a diagnosis, but they are less likely to remain in care – essential to keeping the virus under control and reducing its spread.

These patients also "are significantly more likely to be diagnosed at a later stage of HIV disease," explained John Nelson of the AIDS Education and Training Center, "so they may be presenting sick, and going right for care, but then dropping out …"

Webinar presenters: Donna E. Sweet, MD, AAHIVS, MACP - Professor of Medicine at the University of Kansas School of Medicine Wichita; John Nelson, PhD, CNS, CPNP - Program Director of the AIDS Education and Training Center National Coordinating Resource Center (FXB Center); Anna Kinder, M.S.OTR/L - Project Director of WyAETC Mountain West AIDS Education and Training Center.

Added Dr. Donna Sweet of the University of Kansas School of Medicine: "Rural residents are more likely to be diagnosed with AIDS at the time of initial diagnosis," suggesting that they have been infectious far longer before they find out they are sick.

And the stigma of testing positive often extends "into the waiting room and into the clinic," said Anna Kinder of the Mountain West AIDS Education and Training Center, as local providers are often reluctant to take such patients into their practices.

Nationally, less than one of three affected people is "out" to their providers, and as many as 20 percent of transgender people have been completely denied medical care based on their identity, a 2011 report​ found. And an estimated 28 percent have been verbally accosted in a medical setting.

The result, said Sweet, is that the number of new  HIV/AIDS infections reported annually nationwide – an estimated 40,000 cases – may be more difficult to reduce until clinical bias is addressed in rural health.

Rural HIV/AIDS: The Challenge

Rural residents are:

  • Less likely to get HIV tested
  • More likely to internalize HIV-related stigma (S. Kalichman, H. Katner, E. Banas, & M. Kalichman; 2016)
  • More likely to be tested in non-rural places (S. Kalichman, H. Katner, E. Banas, & M. Kalichman; 2016)
  • More likely to be diagnosed with AIDS at the time of initial HIV diagnosis
  • Less likely to be retained in care (CDC, Rural Health Committee; 2016)
  • Less likely to be virally suppressed (CDC, Rural Health Committee; 2016) 

Watch the webcast.

The HRSA-funded Rural Health Information Hub - a rural health information clearinghouse - has created a Rural HIV/AIDS Prevention and Treatment Toolkit.

Last Reviewed: February 2017

Date Last Reviewed:  July 2017