Friday, December 2, 2011

Does rurality have an impact on HIV/AIDS transmission and treatment?

In advance of World AIDS Day, the Reno Gazette Journal published a story reporting that people with HIV/AIDS were living in every Nevada county. In fact, in 2010, 448 people with HIV/AIDS were living in Nevada's rural counties.

This got me to thinking about how living with HIV/AIDS might be different for someone in a rural place rather than an urban one. The Nevada State Health Division's 2008 profile of HIV/AIDS in Nevada recognized the disparate impact that the disease has in rural counties when it stated that although Nevada's rural counties "are small in population, and the number of new cases [reported each year], the impact of new cases in these areas is significant as access to resources and care are difficult in these areas of Nevada." As pointed out in previous posts on this blog, rural people often have a difficult time obtaining access to the kinds of specialized healthcare needed to treat a wide variety of diseases. This problem is likely exacerbated when attempting to obtain treatment for something as complex as HIV/AIDS.

Aside from the difficulty of obtaining a diagnosis or treatment for HIV/AIDS, I wondered how some of the characteristics of rural areas might bear on the disease. For instance, do traditional rural values lead to the generally lower HIV/AIDS rates in Nevada's rural places? Nevada's most populous county, Clark County, led the state in 2008 with an HIV/AIDS infected rate of 334.1 people per 100,000 population. Two places classified as rural followed: Carson City had an infected rate of 310.08 and Storey County had 228.2 per 100,000. Washoe County, Nevada's other metropolitan county, was fourth with a rate of 189.9 people infected with HIV/AIDS. All of Nevada's 13 other rural counties had lower rates.

Could it be that the traditional family values we have discussed in rural places is responsible for these lower rates? After all, it is well known that unprotected sex and intravenous drug use are two of the primary risk factors for acquiring HIV/AIDS. Both factors conflict with the traditional values that most people associate with rural areas.

The data from the 2008 survey of Nevada provides mixed results. Of all people living in Nevada with HIV/AIDS, those living in rural areas had a lower rate of infection as a result of men having sexual intercourse with men (referred to as MSM in the study). Clark County residents with HIV/AIDS had a risk rate of 65%, Washoe County a risk rate of 53%, and rural residents a risk rate of 39% for MSM. This means that the rate of HIV/AIDS transmission as a result of MSM is roughly 15-25% lower in Nevada's rural counties.

This is offset by an increased transmission rate through intravenous drug use however. In Nevada's rural counties, 20% of all people living with HIV/AIDS likely acquired the disease through intravenous drug use. This is much higher than the 11% risk factor for infected people in Washoe and Clark Counties. The transmission rate as a result of heterosexual activity was also higher in Nevada's rural counties. 14% of HIV/AIDS infected persons in rural counties likely acquired the disease through heterosexual conduct compared to 12% in Clark County and 9% in Washoe County.

It is impossible to formulate any general conclusion based on this data in regards to rural places and their traditional values. Perhaps the transmission rate is lower among homosexual men because those populations are smaller in rural places. Or maybe there are similar rates of transmission but not as many rural people with the disease get tested or diagnosed each year. When they are diagnosed, perhaps rural people are more willing to admit to intravenous drug use but not homosexual activity. Any number of explanations might explain the apparent discrepancies in transmission methods between rural and urban Nevadans.

I also wondered how the lack of anonymity in rural places might affect people living with HIV/AIDS. Do more people know about rural Nevadans infected with the disease because of the lack of anonymity? Are they singled or subject to discrimination as a result? This might explain why the numbers of people living with HIV/AIDS in rural Nevada has decreased from a high of 896 people in 2008 to 448 people in 2010. There is also the possibility that infected people left rural places in order to obtain more specialized care in urban areas or for some other reason altogether. Without having information about each person's motivation for leaving rural Nevada, it is impossible to know how rural characteristics such as lack of anonymity and attachment to place might have factored into the migration decisions of infected people.

Before reading the article, I had never really contemplated the issues facing HIV/AIDS infected people in rural places. However, after thinking about it and looking at the data, it is apparent that the challenges they face might be even greater than those faced by their urban counterparts. As noted earlier and discussed several times in class, access to specialized healthcare is severely lacking in many rural areas. Also, if lack of anonymity is prevalent in rural places, it is quite likely that more of their neighbors and friends will be aware of their disease than infected people in urban places. Attachment to place might make it difficult for rural people to make the decision to move to an urban setting where they can obtain more specialized treatment and care. Rural people are hardly ever mentioned when discussing HIV/AIDS, but it is important that they not be forgotten when discussing the topic.


KB said...

I agree that with the data given for Nevada it is difficult to determine why the rural rate of HIV/AIDS is lower. As KevinN stated, a lack of anonymity might contribute to the lower rates of HIV/AIDS in rural Nevada. Those who receive treatment through medications may want to leave rural areas to avoid interactions such as those at the local pharmacy. While medical information is confidential, some may feel uncomfortable receiving their HIV/AIDS medication from the local pharmacists and technicians who work at what is likely the only pharmacy in the area. The pharmacy employees may know the infected person, his or her family, and his or her significant other. I have a feeling that at least some infected rural residents decide to move out of the area to avoid members of the community knowing they have HIV/AIDS.

As KevinN explained, though, it is difficult to tell how many people might feel this way. Rural communities can also be supportive of established community members who are in need. For some, staying in a rural community close to friends and family despite the lack of anonymity may be more desirable than living in a city where personal support could be less available. It would be fascinating to have a more in-depth study of rural people with HIV/AIDS across numerous states to increase the empirical data on the issue.

JLS said...

What an interesting piece. I also had never really contemplated the realities of living with HIV/AIDS in a rural area. I think the opportunity for/frequency of testing in each rural and urban communities might be an area deserving of more research. Like other medical services, testing for sexually-transmitted diseases and HIV/AIDs might be more difficult in rural areas. It would also be interesting to see how rural America compares to the rest of the world. Many Americans have to opportunity to receive excellent treatment for their HIV/AIDS, but that isn't the case the world over. Is that the case in rural America?

Patricija said...

Another thought that came to mind is HIV/AIDS education in schools. Due to religious reasons, sex education is insufficient if not present at all in rural schools and HIV/AIDS education is often linked to sex education.

Further, I wonder if rural communities have utilized the clean needle method used in many urban cities. The program provides areas where people can exchange dirty needles with clean ones, thereby minimizing the risk of spreading disease. While the method is often criticized by many as promoting drug use, most public policy and health experts agree that the benefit of preventing disease like HIV/AIDS outweighs the risk of promoting drug use.