Despite the advent of these lifesaving drugs, many barriers to care remained for rural PLWHA. Living far from the research hospitals that populate urban areas, many rural PLWHA depended on community and migrant health centers, federally qualified health centers (FQHCs), and other clinics that received government funds to operate in low-income areas. While these establishments were an important part of health care delivery in their communities, many lacked the expertise to properly care for PLWHA. Funding from the Ryan White HIV/AIDS Program and training from area AETCs helped address this obstacle; and today, many community and migrant health centers continue to play a crucial role in delivering care to PLWHA.
This trend continues today with HRSA’s Bureau of Primary Health supporting nearly 9,000 community health sites across the country, improving access to preventive and primary care to millions of patients including those in geographically isolated and economically distressed communities.18,19 To assist patients in finding a community health center—many of which provide HIV/AIDS care as well as other primary care for low-income populations—HRSA has launched a locator search engine: http://ask.hrsa.gov/pc/.
Changing Demographics, Shifting Tactics
Since the onset of the disease, the demographic profile of PLWHA has changed substantially. As discussed previously, in the early 1980s reported cases occurred primarily in White gay men living in cities.20 Over the years, the burden has shifted to minorities in both rural and urban areas. This change has resulted in serious challenges in terms of resources, communication, and outreach.
In rural areas, the burden is particularly acute. Minorities comprise just 15 percent of the total rural population but 30 percent of the rural poor21 and 62 percent of rural HIV diagnoses among adults and adolescents.22 Minorities also face many barriers to care—such as chronic poverty among people in the Southeast, a lack of stable medical care for migrant workers, and language barriers faced by newcomers to this country.”23
To help address these kinds of obstacles, HRSA’s HIV/AIDS Bureau has funded multiple rural grant recipients in its Women of Color and American Indian/Alaska Native SPNS Initiatives. HAB has also published newsletters specific to rural health care delivery and to mobile populations, and has provided additional resources on its technical assistance site. Moreover, HRSA’s Office of Rural Health has launched the HIV/AIDS Rural Project (HARP) to target the spread of HIV in rural communities, particularly among minorities and those in the rural South.
Men who have sex with men (MSM) continue to face high HIV prevalence, particularly young black MSM in both urban and rural areas.24 In addition to dealing with medical and logistical barriers to care and the stigma of having HIV/AIDS, MSM are often further stigmatized for their sexual orientation. Although recent research shows that Americans are more accepting of homosexuality than ever before,25 bias against MSM and other sexual minorities is still widespread.26 That reality only increases the pressure on these individuals not to disclose their HIV status and seek medical care, particularly in small towns where anonymity and confidentiality can seem elusive.
The Burden of Stigma in Rural Areas
Stigma as it relates to HIV/AIDS exists in all communities, both urban and nonurban. In rural communities, however, it can be more difficult for PLWHA to cope with stigma, and it can compromise their willingness to get tested or engage in care.
Sometimes, PLWHA feel compelled to travel long distances for HIV care, not because there are no qualified doctors or clinics nearby, but because leaving the area affords them the anonymity they desperately desire. “If you have ever lived in a rural area, you know that everybody at the health department knows your momma or your cousin,” says Hiers of AIDS Alabama. “People loathe getting tested [or treated] in that environment.”