Opportunities to Improve Prevention and Services for HIV-Infected Women in Nonurban Alabama and Mississippi

Objective: The intent of this study was to identify opportunities for improving the effectiveness of HIV prevention before nonurban (rural and small-city resident) Southern women are infected and the medical and social services offered to them after they are infected.

Cited Here...: At several HIV clinics in nonurban Alabama and Mississippi, women with HIV infection (who reside in small cities and towns outside of Birmingham) were identified and interviewed about the period during which they probably acquired HIV and about their needs and the services provided after they were found to be infected with HIV.

Cited Here...: Before they were infected, these 211 young (mean age, 33 years), mainly African-American (67%) women often reported being seen at HIV testing sites (37%) and, among drug users, at drug treatment facilities (30%), where they presumably received counseling to prevent becoming infected. Once infected, many (21%) said they were not directed to HIV treatment sites, half (50%) were sexually active in the month before they were interviewed, many (13%) sought treatment of sexually transmitted diseases in the 12 months before the interview, and many (36%) reported unmet needs for HIV treatment related to having no insurance or Medicaid.

Conclusions: Prevention and treatment of HIV for nonurban Southern women are not fully effective. Given the continued sexual activity of these women, more focus on preventing transmission from persons who are already infected is warranted.

In the United States, an epidemiologic shift is occurring in reported AIDS and HIV cases. An increasing number of cases are occurring in persons of minority background, in heterosexual women and men, in nonurban residents, and in the South ⁽¹⁾. Several studies in the rural South ^(2-8) have further suggested that there may be key missed opportunities in the prevention of HIV as well as gaps in the medical and social services offered to persons with HIV/AIDS in this resource-limited area of the country.

METHODS

This analysis was nested within a larger study that involved interviews and sexually transmitted disease (STD) testing of HIV-infected residents of nonurban Alabama ⁽⁸⁾ and Mississippi. Briefly, after signing informed consent forms approved by the Centers for Disease Control and local institutional review boards, patients seen at 16 HIV clinics in these two states who resided outside the single metropolitan statistical area with a population of more than 500,000 persons (Birmingham) were interviewed about the period during which they probably acquired HIV and their needs and the services provided to them after they were found to be infected with HIV.

We first wanted to examine HIV-related behaviors and activities before the interviewed patients contracted HIV infection. This putative period of infection was defined ⁽⁸⁾ as either (1) the period from June 1981 to the time when the first AIDS cases were reported in the two states or to the time of a patient's first positive HIV test (often, AIDS diagnosis); or (2) the time from the last negative HIV test to the first positive test for patients who had this information. For these latter patients, a mean putative infection age was calculated by taking the midpoint between their last negative HIV test result and their first positive HIV test result and subtracting it from their age at the time of the interview.

This analysis focused on gaps in the primary prevention of HIV infection (i.e., places where these women may have received counseling about prevention of HIV infection) and in secondary prevention (i.e., needs for medical and social services after they were discovered to be infected). Frequencies were calculated by Statistical Analysis Software version 8.0 (SAS Institute, Cary, NC, U.S.A.).

RESULTS

Sociodemographics

Two hundred eleven HIV-infected women receiving HIV-related services and residing in nonurban Alabama and Mississippi completed this interview from January 1995 through September 1998. Of these 211 women, 142 (67%) were African-American and 63 (30%) were white. The mean age at interview was 33 years (range: 16-69 years). For the 78 (37%) patients who had a last negative test followed by a positive one, the estimated mean age at infection was 28.5 years. Of the 189 women who answered, 94 (50%) were single (never married), 27 (14%) were married, and 68 (36%) were separated or divorced. One hundred fifty-five (73%) reported a high school education or less. One hundred sixty-eight (80%) were unemployed at the time of the interview, and 179 (85%) reported a personal income of less than $12,000 annually (all dollar amounts in US dollars).

Potential Prevention Opportunities During the Putative Infection Period

During the putative period of infection, high-risk drug-using behaviors and high-risk sexual behaviors associated with drug use were common. Seventy-three (35%) women reported ever using crack or cocaine during this period, and 22 (10.5%) reported injection drug use. Of these women, 82% reported sharing needles. Fifty women (24%) reported trading sex for money or drugs. Thirty-one (30%) women who reported using drugs during their putative period of infection also reported being enrolled in some form of drug or alcohol treatment program during this same period (Table 1).

Table 1

Reported drug or alcohol treatment programs were as follows: 6 women had received methadone maintenance/detoxification; 7 had lived at a residential therapeutic community; 8 had received outpatient drug rehabilitation; 17 had received inpatient drug rehabilitation; and 21 had attended 12-step programs such as Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous.

Seventy-eight (37%) persons in this study had received a median of three negative HIV tests before testing HIV-positive. Of the main reasons why 171 women said they had been tested, 54 (32%) reported concern about contact with a known or suspected HIV-infected sex partner, 41 (24%) had been seen for an illness, 25 (15%) had been seen because of pregnancy, 21 (12%) had been seen because their physician recommended it, 15 (9%) had been seen because it was offered at a clinic they attended, 11 (6%) had been seen because they believed they were in a known risk group, and 4 (2%) had been seen because it was a requirement of or offered as part of a drug treatment program.

Gaps in Prevention and Medical/Social Services After HIV Infection

After receiving the results from their first positive HIV test, 44 (21%) women reported that they were not told where they could go to get HIV treatment (see Table 1). Also, after finding out that they were infected, many women remained sexually active: 106 (50%) had been sexually active in the previous month, and 28 (13%) of all women reported having been to a doctor or clinic in the 12 months before the interview for the purpose of evaluating or treating an STD (see Table 1).

Seventy-six (36%) women reported having no insurance (including public assistance such as Medicaid), and 24 (11%) reported having lost insurance in the preceding 12 months. The reasons cited most often for losing insurance were because I lost my job (8 women [33%]) and I could no longer pay the premium (3 women [13%]). Of the 24 women who had lost insurance in the 12 months before interview, 9 (38%) subsequently did not seek treatment of their HIV because they did not believe they could pay for it. An additional 9 (4%) women reported that they had been denied treatment of their HIV in the prior 12 months because they could not pay for it. When questioned regarding which medical or social services they needed but were unable to get, the most frequent responses were dental services (39 women [19%]), transportation (14 women [7%]), mental health counseling (11 women [5%]), shelter or housing (10 women [5%]), and child care (9 women [4%]) (see Table 1).

DISCUSSION

A substantial proportion of these mainly young and African-American HIV-infected women in rural and small-city Alabama and Mississippi had been seen at venues where they may not have received effective prevention counseling before they acquired HIV infection. Whether these missed opportunities in primary prevention were the result of no counseling or less than effective counseling at sites where they received previously negative HIV test results cannot be determined. Review and improvement of current HIV counseling at such locations are clearly indicated, however.

Many women (21%) also reported that they were not told where they might receive HIV treatment and social services. Although some respondents may have forgotten the referrals they received, the women in this study were already in care when interviewed; thus, there was a strong selection bias to include women who did receive successful referrals to care in the study. Because only about half of HIV-infected persons are currently in care nationwide ⁽⁹⁾, it is clear that more must be done to link persons successfully to care at the time they first learn they are infected. For example, a recent investigation of a small cluster of HIV-infected adolescent girls in Mississippi found that they did not know of HIV specialist care available in their town or where or how to apply for Medicaid benefits ⁽¹⁰⁾. Model programs are being developed that rely on more intensive case management of newly diagnosed HIV-infected persons to improve their chances of receiving HIV care earlier and more frequently (L. Gardner, Ph.D., written communication, June 2001).

There continue to be additional prevention opportunities even once women are receiving care. Half of these HIV-infected women had been sexually active in the previous month, and fully 13% of all women had needed to be seen for STD evaluation in the 12 months before the study interview. More focus on preventing transmission from HIV-infected persons is warranted, and this should include repeated counseling during routine HIV care.

As the HIV epidemic in the South is rapidly growing compared with other parts of the country ⁽¹⁾, more must be done to address these fundamental inefficiencies in primary and secondary prevention of HIV. We believe that the initial health care contact, often with HIV public health staff, should be used fully to provide counseling and referral.

Acknowledgments:

The authors thank Hala Fawal (School of Public Health, University of Alabama at Birmingham) and John Beltrami (Georgia Department of Human Services) for their contributions to the study design and execution, Richard Holmes (Alabama State Health Department) for facilitating this study, and Sharyn Janes (University of Southern Mississippi) for supervising and coordinating the Mississippi interviews. They also thank the staff and study volunteers from the 19 Alabama interview sites coordinated by seven clinics in Hobson City, Birmingham, Eutaw, Tuscaloosa, Huntsville, Montgomery, and Mobile and the nine Mississippi clinics located in Biloxi, Hattiesburg, Jackson, Vicksburg, Marks, and Tupelo.