The burden of HIV/AIDS care continues to increase in the South. The South accounted for the largest proportion (39%) of the more than 362,000 persons living with AIDS as of December 2001 (Fig. 2). AIDS prevalence has increased steadily because effective treatments prolong survival after an AIDS diagnosis.35 Because the South currently contributes the highest number of prevalent AIDS cases, it is likely that resources needed for patient care and treatment will escalate in this region.
Annual rates of reported cases of AIDS in 200123 and of gonorrhea in 200225 by state highlight the impact of HIV and STDs in the southern region. Areas with the highest rates of gonorrhea per 100,000 population in 2002 include many of the same southern states with the highest rates of AIDS per 100,000 population (e.g., Delaware: 201.1 gonorrhea, 31.1 AIDS; Maryland: 176.6, 34.6; South Carolina: 228.1, 17.9; Georgia: 224.6, 20.8; Florida: 133.6, 31.3; Mississippi: 241.7, 14.6; Louisiana: 254.8, 19.3). Similarly, rates of syphilis tend to be higher in the southern states than in other geographic regions.13 Reflecting high-risk sexual behaviors, high rates of STDs call attention to risks for HIV spread or for resurgence of HIV in communities as new cohorts of young men, and women, come of age.36,37 Although studies of HIV incidence have been focused on high-risk populations in some large cities where STDs have experienced a resurgence and current rates of HIV incidence are presumed to be highest,38,39 there have been periodic reports of clusters of new HIV infections associated with high STD rates that have highlighted risks for rapid heterosexual HIV spread within rural communities both in the South and elsewhere.40,41
AIDS rates per 100,000 non-Hispanic black population in rural areas in the South (45) are lower than in blacks in rural areas in the Northeast (222) Midwest, (77) or West (60).33 However, the South is the only region in which more than half of reported AIDS cases are in black persons. Blacks constituted 54%, 51%, and 56% of AIDS cases in urban, less urban, and rural areas of the South, respectively. Given the increasing prevalence of HIV/AIDS in the South, the high number of black men and women with AIDS in this region supports a focus on HIV/STD prevention among minority populations in the South.
Thus, several characteristics differentiate the HIV epidemic in men and women in the South as compared with other regions of the United States: a disproportionate concentration in less urban and rural regions and among blacks, the highest proportion of prevalent HIV/AIDS cases, and high rates of AIDS and STDs.
Demographic and Behavioral Risk Characteristics of Women With HIV/AIDS in the United States and in the South
The population of U.S. women with HIV/AIDS is less heterogeneous than that of men in terms of race/ethnicity and risk exposure category. In 2001, a higher proportion of women reported with AIDS were black (63%) or Hispanic (17%) compared with men with AIDS (44% and 20%, respectively).20 The proportionate distribution of AIDS cases by risk exposure categories differs for nonurban areas compared with urban areas. Because screening of the blood supply has virtually eliminated transmission by blood or blood products, and barring rare or unusual transmission circumstances, women acquire HIV either through sharing drug-injecting paraphernalia or through sexual contact with an HIV-infected male. Among women diagnosed with AIDS through 2001 from urban and less urban areas, the largest proportion acquired HIV as a result of injecting drug use. Smaller proportions were exposed to HIV through heterosexual contact with a male injecting drug user or with other males in a recognized HIV risk category or known to be HIV-positive. However, in rural areas, the risk profile is remarkably different, because heterosexual transmission from male partners not known to be injecting drug users predominates (Fig. 3). In contrast, among men, the proportionate distribution of AIDS cases by risk categories (MSM, IDU, MSM-IDU, and heterosexual contact) are nearly identical regardless of size of metropolitan area of residence (data not shown).23 Many women in rural areas reportedly are unaware of any primary risk behaviors of their male sexual contacts (i.e., injecting drug use, sex with other men) and may only know that a heterosexual partner was diagnosed with HIV.29,42 Secondary heterosexual spread of HIV, i.e., heterosexual transmission from a person who was infected through heterosexual contact, as well as primary heterosexual spread from men who do not acknowledge bisexuality or injecting drug use, combine to challenge understanding of precisely which risk behaviors account for the predominance of heterosexual exposure among women in rural areas.11,29,42 Further research is needed to identify other behavioral characteristics that may be instructive in designing appropriate and effective prevention interventions.43
Because AIDS represents the end stage of HIV disease, examining new diagnoses of HIV infection sheds light on more recent transmission patterns, especially among young adults who are necessarily more recently infected as a result of their recent entry into the age group in which high-risk sexual and drug-using behaviors are initiated. Among the cohort of young women ages 15 to 19 years in 1994 who acquired HIV through heterosexual contact, annual rates of new HIV diagnoses were highest in the South where they increased gradually as the cohort aged (Fig. 4).44 In contrast, among such women infected through injection drug use, rates were highest in the Northeast (data not shown).44 Recent reports suggest that blacks account for 74% of all heterosexually acquired infections reported from 29 HIV-reporting states and that females account for 89% of heterosexually acquired infections in 13 to 19 year olds.45 Given the relative homogeneity of case reports of women with HIV/AIDS, the characteristics of urban versus nonurban HIV-infected women do not differ markedly, except for the predominance of heterosexual transmission among women in the rural South.
Social, Demographic, and Behavioral Characteristics of Men and Women With HIV/AIDS in Southern Rural Areas
The data presented thus far suggest that HIV-infected women in the South are disproportionately of black race, living in less urban or nonurban areas, and exposed to HIV by an HIV-infected male sex partner without recognized primary risk factors. We were interested in exploring data on possible explanatory factors for the predominance of heterosexual transmission among HIV-infected southern women. Various scenarios could account for this: a self-sustaining heterosexual HIV epidemic fueled by high-risk sexual behaviors in a population with high background rates of STDs known to potentiate HIV spread; immigration of men infected through injecting drug use or male-male sexual contact in larger urban areas who transmit HIV to women in rural areas through sexual contact; and immigration of women who were infected elsewhere, e.g., in larger urban areas, through heterosexual contact with male injecting drug users or bisexual men. The predominance of heterosexually acquired HIV among women in this setting highlights the importance of examining factors associated with HIV transmission for both women and men. In the areas where Rural SHAS was conducted, sexual transmission accounts for the majority of cases in women (66%) and in men (27% heterosexual contact and 40% homosexual contact). Women with HIV/AIDS were less likely than men to have completed high school (50% and 64%, respectively); less likely to be employed (13% and 25%, respectively); and more likely to have an annual income <$10,000 (80% and 58%, respectively) (Fig. 5). A high proportion of women and men reported a history of an STD (55% and 51%, respectively). Noninjecting drug use, especially the use of crack cocaine, has reportedly been associated with increased risk of heterosexual HIV transmission.27,46 In the Rural SHAS project, crack use was reported by 42% of women and 37% of men. Consistent use of latex condoms can protect against HIV transmission; however, the results of the Rural SHAS study highlighted the formidable challenge in promoting condom use given that 98% of women and 69% of men reported unprotected heterosexual contact and that 24% of women and 36% of men practiced risky sex after they knew they were HIV-infected.
Migration after a diagnosis of HIV/AIDS may contribute to further geographic HIV spread.47 In Rural SHAS, 36% of those interviewed migrated to their rural area of residence after they knew they were HIV-infected, 34% migrated to their rural area of residence before testing HIV-positive, with the remaining 30% reporting they had not lived outside of their current rural area of residence. Immigration of persons infected elsewhere (e.g., in urban areas) may account for a substantial proportion of infections among rural residents.30 However, other reports have shown that, once HIV is introduced, rapid spread of HIV within rural sex networks can occur against a background of high STD rates.40
HIV Care and Treatment Issues in Rural Areas
Residents of rural areas, by definition, face challenges in accessing medical care and treatment as a result of greater geographic distances to medical facilities, the relative lack of accessible tertiary care facilities, or fewer highly specialized physicians, who tend to be located in more urbanized settings. Several prior reports have highlighted these challenges. In a study of a cluster of HIV-infected adolescents and young adults in rural Mississippi, a survey of local internists and family practitioners indicated that they treated few HIV-infected patients and lacked knowledge of specialty HIV care practices.40 Setting up a network of social, mental health, and case management services by linking the local health department and local physicians to a remote medical consultant enabled improvements in the quality and accessibility of care in this rural area. A nationally representative sample of HIV-infected persons in the United States found disparities in access to HIV care and treatment for residents of rural areas compared with urban areas.48 Specifically, rural patients were less likely to have received recommended antiretroviral treatment regimens or to have received standard prophylaxis for opportunistic infections. In addition, rural residents were cared for by providers seeing few HIV-infected patients.48 Previous studies have shown that patients whose physicians have greater experience with HIV care have fewer hospitalizations and better survival, including in rural areas.49–51 Lack of insurance among HIV-infected persons in the nonurban South may contribute to poor-quality HIV care and treatment. In the Rural SHAS project, 35% of those interviewed had no insurance and, of these, one third had never received antiretroviral therapy (CDC, unpublished data).
Our review of the available data and literature suggests that research focused on the unique needs of minority, less urban, and nonurban men and women in the southern United States will enhance effectiveness of HIV prevention and care in this region. We have illustrated key features of the HIV epidemic among women compared with men in the nonurban South: the predominance of heterosexual transmission; the disproportionate impact on black women; the complex dynamics of predisposing risk behaviors in men as well as in women; and multiple challenges in access to quality diagnosis, care, and treatment. The southern region has the highest proportion of prevalent AIDS cases, high AIDS and STD rates, and the highest rates of new HIV diagnoses in women. It has the highest proportion, and highest rates, of AIDS in nonmetropolitan areas, although the majority of cases are still reported from urban areas. HIV-infected women in the rural South are characterized by low socioeconomic status. The high proportion of sexually acquired HIV infection reflects numerous factors that facilitate sexual transmission directly (multiple sex partners, lack of condom use, practicing risky sex even after knowledge of HIV infection) and indirectly (drug and alcohol use, STDs). After knowledge of infection, it may be particularly difficult to ensure equity in access to quality HIV care for patients who face logistic or economic barriers.
The population-based surveillance data reported in this article have limitations. Both STD and HIV/AIDS surveillance case reports collect only limited behavioral and clinical data and are most useful to describe the epidemiology in the affected population of men and women in a given area. They are less useful in exploring the underlying social and behavioral factors that determine why some persons or populations are disproportionately at risk for sexually transmitted infections. The SHAS interview data remedy some of the deficiencies of surveillance data but are themselves limited in being less representative of the general population of persons with HIV/AIDS and are subject to other methodological limitations such as recall bias. We only had detailed behavioral data from 4 southern states, which may not be representative of the entire region. Our presentation of supporting data from the relevant literature is necessarily selective and the complex dynamics involved in HIV and STD transmission among rural residents requires more in-depth analysis than we can achieve in this article. Despite the limitations of each of the data sources and supporting evidence presented here, the consistency of findings across multiple sources emphasizes why concerns about the spread of HIV into nonurban areas have been raised persistently for more than 10 years.52,53
Female, minority, nonurban women face a multitude of HIV prevention and care issues. Although we have presented epidemiologic data from multiple sources that document these challenges, structuring an integrated plan to address them remains an elusive goal. The compilation of papers in this special issue provides a framework for prioritizing the effort to fill gaps in research and knowledge. Public health efforts must be mobilized in a more concerted way to prevent the establishment of an endemic HIV presence among these vulnerable women. Migration of high-risk and infected persons from rural to urban and back to rural areas is unlikely to abate. Therefore, the importation into rural populations of HIV knowledge and strategies for prevention, care, and treatment that have proven effective in urban areas would be desirable. Yet, adapting interventions effective in urban settings to rural settings requires further research. We argue that HIV prevention strategies for rural women must also focus on men or they risk having little impact. Research is needed on determinants of partner selection, barriers to condom use, and strategies to reduce social drug and alcohol use. Underlying social factors such as low education and income may prove tougher obstacles to prevention and care in rural regions. Nevertheless, we feel that research that examines the complex interplay of social and behavioral risk factors prevalent in the nonurban South can lead to more effective intervention programs and reduce the HIV burden among women. It is critical to help HIV-infected persons prevent transmission of their infection by reducing barriers to early detection and providing HIV-infected persons with state-of-the-art medical and preventive services.54 Ultimately, preventing heterosexual transmission of HIV and STDs in women may require research that recognizes the interdependence of men and women in practicing safer sex. Ensuring equity in access to HIV education, prevention programs, and treatment in nonurban areas remains a compelling challenge.
1.Centers for Disease Control and Prevention. Current trends: first 100,000 cases of acquired immunodeficiency syndrome—United States. MMWR Morb Mortal Wkly Rep 1989; 38:561–563.
2.Centers for Disease Control and Prevention. The second 100,000 cases of acquired immunodeficiency syndrome—United States, June 1981–December 1991. MMWR Morb Mortal Wkly Rep 1992; 41:28–29.
3.Centers for Disease Control and Prevention. First 500,000 AIDS cases—United States, 1995. MMWR Morb Mortal Wkly Rep 1995; 44:849–853.
4.Verghese A, Berk SL, Sarubbi F. Urbs in rure: Human immunodeficiency virus infection in rural Tennessee. J Infect Dis 1989; 160:1051–1055.
5.Rumley RL, Shappley JC, Waivers LE, et al. AIDS in rural eastern North Carolina—Patient migration: a rural AIDS burden. AIDS 1991; 5:1373–1378.
6.Cohn SE, Klein JD, Mohr JE, et al. The geography of AIDS: Patterns of urban and rural migration. South Med J 1994; 87:599–606.
7.Berry DE, McKinney MM, McClain M. Rural HIV service networks: Patterns of care and policy issues. AIDS Public Policy J 1996; 11:36–46.
8.Graham RP, Forrester ML, Wysong JA, et al. HIV/AIDS in the rural United States: Epidemiology and health services delivery. Med Care Res Rev 1995; 54:435–452.
9.Davis K, Stapleton J. Migration to rural areas by HIV patients: Impact on HIV-related health care use. Infect Control Hosp Epidemiol 1991; 12:540–543.
10.Centers for Disease Control and Prevention. Heterosexually acquired AIDS—United States, 1993. MMWR Morb Mortal Wkly Rep 1994; 43:155–160.
11.Neal JJ, Fleming PL, Green TA, et al. Trends in heterosexually acquired AIDS in the United States, 1988 through 1995. J Acquir Immun Defic Syndr 1997; 14:465–474.
12.Wortley PM, Fleming PL. AIDS in women in the United States, recent trends. JAMA 1997; 278:911–916.
13.Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2002. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2003.
14.Centers for Disease Control and Prevention. Tracking the hidden epidemics: Trends in STDs in the United States 2000:1–31.
15.Thomas JC, Schoenbach VJ, Weiner DH, et al. Rural gonorrhea in the southeastern United States: A neglected epidemic? Am J Epidemiol 1996; 143:269–277.
16.Lansky A, Nakashima AK, Jones J, et al. Risk behaviors related to heterosexual transmission from HIV-infected persons. Sex Transm Dis 2000; 27:483–489.
17.Centers for Disease Control and Prevention. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR Morb Mortal Wkly Rep 1987; 36(suppl 1):1–15.
18.Centers for Disease Control and Prevention. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep 1992; 41(RR-17):1–19.
19.Centers for Disease Control and Prevention. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus and acquired immunodeficiency syndrome. MMWR Recomm Rep 1999; 48(RR-13):1–31.
20.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 2001; 13(No. 2):1–44.
21.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 2002; 14:1–40.
22.Nakashima AK, Fleming PL. HIV/AIDS surveillance in the United States, 1981–2001. J Acquir Immun Defic Syndr 2003; 32:S68–S85.
24.Centers for Disease Control and Prevention. Case definitions for infectious conditions under public health surveillance 1997. MMWR Recomm Rep 1997;46(RR-10):1–55.
26.Buehler JW, Diaz T, Hersh BS, et al. The supplement to HIV/AIDS surveillance project: An approach for monitoring HIV risk behaviors. Public Health Rep 1996; 111(suppl 1):133–137.
27.Campsmith ML, Nakashima AK, Jones JL. Association between crack cocaine use and high-risk sexual behaviors after HIV diagnosis. J Acquir Immun Defic Syndr Hum Retrovirol 2000; 25:192–198.
28.Centers for Disease Control and Prevention. Supplement to HIV/AIDS Surveillance (SHAS): Demographics and behavioral data from a supplemental HIV/AIDS behavioral surveillance project, 1997–2000. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2004; Special Surveillance Report No. 2:5–6, 24.
29.Centers for Disease Control and Prevention. Risks for HIV infection among persons residing in rural areas and small cities—Selected sites, southern United States, 1995–1996. MMWR Morb Mortal Wkly Rep 1998; 47:974–978.
30.Lansky A, Nakashima AK, Diaz T, et al. Human immunodeficiency virus infection in rural areas and small cities of the southeast: Contributions of migration and behavior. J Rural Health 2000; 16:20–30.
31.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Supplemental Report, HIV/AIDS in urban and nonurban areas of the United States 2000; 6:1–16.
32.Steinberg S, Fleming P. The geographic distribution of AIDS in the United States: Is there a rural epidemic? J Rural Health 2000; 16:11–19.
33.U.S. Census Bureau. Census 2000 PHC-T-2. Ranking tables for states: 1990 and 2000. Table 1. States ranked by population: 2000. Internet release date: April 2, 2001. Available at: http://factfinder.census.gov
. Accessed May 25, 2004.
34.HIV/AIDS surveillance slide set #L206, updated 2001 (archived). Atlanta: Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention.
35.Lee LM, Karon JM, Selik R, et al. Survival after AIDS diagnosis in adolescents and adults during the treatment era, United States, 1984–1997. JAMA 2001; 285:1308–1315.
36.Centers for Disease Control and Prevention. Resurgent bacterial sexually transmitted disease among men who have sex with men—King County, Washington, 1997–1999. MMWR Morb Mortal Wkly Rep 1999; 48:773–777.
37.Centers for Disease Control and Prevention. Increases in unsafe sex and rectal gonorrhea among men who have sex with men—San Francisco, California, 1994–1997. MMWR Morb Mortal Wkly Rep 1999; 48:45–48.
38.McFarland W, Busch MP, Kellogg TA, et al. Detection of early HIV infection and estimation of incidence using a sensitive/less sensitive enzyme immunoassay testing strategy at anonymous counseling and testing sites in San Francisco. J Acquir Immun Defic Syndr 1999; 22:484–489.
39.Centers for Disease Control and Prevention. HIV incidence among young men who have sex with men—seven U.S. cities, 1994, 2000. MMWR Morb Mortal Wkly Rep 2001; 50:440–444.
40.Centers for Disease Control and Prevention. Cluster of HIV-infected adolescents and young adults—Mississippi, 1999. MMWR Morb Mortal Wkly Rep 2000; 49:861–864.
41.Centers for Disease Control and Prevention. Cluster of HIV-positive young women—New York, 1997–1998. MMWR Morb Mortal Wkly Rep 1999; 48:413–416.
42.Klevens RM, Fleming PL, Neal JJ, et al. Is there really a heterosexual AIDS epidemic in the United States? Findings from a multisite validation study, 1992–1995. Am J Epidemiol 1999; 149:75–84.
43.Centers for Disease Control and Prevention. A method for classification of HIV exposure category for women without HIV risk information. MMWR Recomm Rep 2001; 50(RR-6):31–40.
44.Lee LM, Fleming PL. Trends in human immunodeficiency virus diagnoses among women in the United States, 1994–1998. JAMWA 2001; 56:94–99.
45.Centers for Disease Control and Prevention. Heterosexual transmission of HIV—29 states, 1999–2002. MMWR Morb Mortal Wkly Rep 2004; 53:125–129.
46.Chiasson MA, Stoneburner RL, Hildebrandt DS, et al. Heterosexual transmission of HIV-1 associated with the use of smokeable freebase cocaine (crack). AIDS 1991; 5:1121–1126.
47.Buehler JW, Frey RL, Chu SY. The migration of persons with AIDS: Data from 12 states, 1985–1992. Am J Public Health 1995; 85:1552–1555.
48.Cohn SE, Berk ML, Berry SH, et al. The care of HIV-infected adults in rural areas of the United States. J Acquir Immun Defic Syndr Hum Retrovirol 2001; 28:385–392.
49.Turner BJ, Ball JK. Variations in inpatient mortality for AIDS in a national sample of hospitals. J Acquir Immun Defic Syndr 1992; 5:978–987.
50.Kitahata MM, Koepsell TD, Deyo RA, et al. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patient's survival. N Engl J Med 1996; 334:701–706.
51.Kitahata MM, Van Rompaey SE, Shields AW. Physician experience in the care of HIV-infected persons is associated with earlier adoption of new antiretroviral therapy. J Acquir Immun Defic Syndr 2000; 24:106–114.
52.Gardner LI, Brundage JF, Burke DS, et al. Evidence for spread of the human immunodeficiency virus epidemic into low prevalence areas of the United States. J Acquir Immun Defic Syndr 1989; 2:521–532.
53.Lam NS, Liu K-B. Spread of AIDS in rural America, 1982–1990. J Acquir Immun Defic Syndr Hum Retrovirol 1994; 7:485–490.
54.Centers for Disease Control and Prevention. Advancing HIV prevention: New strategies for a changing epidemic. MMWR Morb Mortal Wkly Rep 2003; 52:329–332.
*Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont; Midwest (also referred to as “Central”): Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming. Cited Here...
© Copyright 2006 American Sexually Transmitted Diseases Association