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“The Title I program changed the way AIDS services were provided in the community,” says Seattle’s Fiaño. She worked for the EMA’s Planning Council and later became manager for the EMA’s Title I program. Because of the new program, “we did a lot of things that we’d never done before,” she said. These included such things as conducting needs assessments; client surveys; focus groups; and community forums. Activities like these underline the program’s consumer orientation and HRSA’s continued emphasis on responding comprehensively to clients’ needs.

“People were in and out of hospitals,” Fiaño reminds us. “We provided a lot of case management and home health care.” It is impossible for people who came to know the epidemic in America after the advent of HAART to fathom the breadth of suffering, pain, and death. During the first six years of the Ryan White HIV/AIDS Program (1990-1995), it is estimated that nearly 325,000 gay men died of AIDS in America.14 HIV care providers talk of those years of being a period of soaring infections and constant death – of going to a Planning Council meeting and seeing the empty chair of a recently deceased community member.

As the Ryan White HIV/AIDS Program grew in the early years, it helped build systems of care that did not previously exist. For example, in Atlanta, Grady Hospital was (and still is) the largest provider of care to the poor in the region. When the Ryan White HIV/AIDS Program was enacted, the hospital had a five- or six-month wait for appointments. With new financial resources from HRSA, the EMA’s Planning Council developed a triage system to unburden Grady Hospital by funding local health departments and agencies like AID Atlanta and St. Joseph’s Health System who would see clients, ultimately reducing their wait time to a couple of weeks.15

Across the country, new service providers emerged, and more established groups were able to add new services. In the first five years of the Ryan White Program, HIV/AIDS spending through HRSA increased from $220.6 million in 1991 to $633 million in 1995. Through collaboration and planning, stronger care infrastructures developed and as time passed they became increasingly competent at serving people living with HIV/AIDS. “I think we are successful because we are accountable to the populations that we are supposed to be serving,” says Seattle’s Fiaño.

Beyond the Epicenters: Reaching Gay Men in Smaller Towns and Rural Areas

While HIV/AIDS emerged in urban America it did not stay there, and gay men living outside these cities faced unique barriers to care. Among the most obvious was that of distance. Those with access to transportation and living in close proximity to a large city could access care with the frequent added benefit of receiving care with the anonymity that large urban areas provide. But not everyone could travel and even for many who could, urban areas were simply too far away.

Photo of a woman health-care provider consulting an African-American man


Other factors confronted gay men living in smaller cities, towns, and rural areas. Bigotry and homophobia had driven tens of thousands of gay men to cities for decades. Gay men living with HIV/AIDS in rural areas were silenced and isolated by the stigma attached to both their gayness and their HIV infections. Depth of education in clinical treatment of HIV disease and the comparatively lower incidence rates limited both the quality of care and the breadth of services. HRSA’s Title II (Part B) grants to States and U.S. Territories and the Title III (Part C) Early Intervention Services (EIS) program began to address these problems. The Part B State grants and the Part C EIS grant did not exclusively target urban centers, helping to ensure the services were available to gay men living in less heavily populated areas. Low Prevalence Planning Grants, however, specifically directed funds for HIV care and services outside traditional epicenters.

The importance of HRSA’s AETCs in increasing culturally competent clinical care capacity in not only rural areas, but across the entire country cannot be overstated. Over the Ryan White HIV/AIDS Program’s history, more specific initiatives have been undertaken to expand access to and improve the quality of HIV care in rural parts of the country.

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