Tearing Down Fences HIV/STD Prevention in Rural America Susan Dreisbach, Ph.D.

Tearing Down Fences addresses: What is unique about rural HIV/STD prevention? What prevention strategies might work?

Rural America

STDs in Rural America 2008 in “micropolitan” and “nano” counties Chlamydia rates 312 and 246 (vs. 412 per 100,000 in metro counties) Chlamydia rates 428 and 322 (vs. 448) in South Gonorrhea rates 78 and 56 per 100,000 (vs. 117) 2007 IHS epidemiology shows chlamydia and syphilis rates that exceed the US average Young women ages 15-29 bear the greatest burden of disease and adverse consequences Source: CDC, National STD Morbidity Surveillance System , 2008

HIV/AIDS in Rural America (2007) >51,000 people living with AIDS in non-metro US 13% new AIDS diagnoses in “micropolitan” areas 5% new AIDS diagnoses in “nano” counties Highest prevalence rate and # cases HIV and AIDS in rural South Racial and ethnic minorities disproportionate burden Male-to-male sexual transmission most frequent Growing number of women infected through heterosexual contact in rural South Source: CDC, HIV/AIDS Surveillance in Urban and Nonurban Areas (through 2007) slide set

HIV/STD Behavioral Risk Factors Rural Americans less likely to use a condom (Anderson, et al. Family Planning Perspectives, 1999) Among low-income Black women, rural residents more likely to report: Not having a preferred means of protection because she did not worry about HIV/STD A belief that her current partner is HIV negative, even though not tested for HIV Not receiving prenatal HIV counseling (Crosby, et al, AJPH, 2002)

Rural HIV/STD Prevention Challenges Limited resources Poverty Geographic & social isolation

Rural HIV/STD Prevention Challenges Traditional values Reluctance to talk about HIV/STDs Stigma toward HIV/STDs Stigma toward those engaging in risky behaviors Small town atmosphere Confidentiality Access to services

Strategies that May Work “One size fits all” not realistic Education Testing Surveillance System Linkage to Care Behavioral Interventions

Educational strategies to increase awareness and can decrease stigma Community Schools Faith-Based Organizations Clinics CREATE Project http://comm.uky.edu/rcap

HIV and STD Testing Outreach – examples Local health care providers DIS Corrections Immigrant Populations MSM Circuit rider

Surveillance of Disease and Behaviors Who is responsible? Determining if locally acquired or “imported” Partner notification Keeping local providers up to date Plan for dealing with a new case Catalyst for Action vs.  Stigma

Linkage to Care Comprehensive Care Clinics Phone, mail, transportation Disease Intervention Specialists (DIS) Connecting to Care for PLWHA 13

Behavioral Interventions How to decide when a behavioral intervention should be used in a rural setting:  Risk behavior  Incident cases Resources available Competing demands

Do DEBIs work for rural settings? Few Effective Behavioral Interventions designed specifically for rural areas Selection and Adaptation processes critical Match behavioral and disease patterns Match resources Feasible with rural target population Feasible within rural community context

DEBIs Adapted for Rural Settings MPowerment adapted for rural MSM Community PROMISE for MSM VOICES/VOCES for MSM and Youth Safety Counts for injecting drug users (IDU) SISTA for African-American Women + adaptations Reducing the Risk for Youth Focus on Kids and Impact for African-American youth and their families RESPECT – testing and counseling

Other Evidence-Based Approaches Internet Risk-Reduction Counseling for MSM Taking it to the Population for IDU STAND (Students Together Against Negative Decisions) for Youth and NATIVE STAND Strong African American Families Project Red Talon – multi-component with media, testing, education for community, families, individuals

Tearing Down Fences Explains the unique challenges of rural HIV/STD prevention Provides examples of education, surveillance, links to care, and behavioral interventions that have been used in other rural communities and may work in yours

Tearing Down Fences Is NOT a silver bullet It DOES give you some ammunition It IS an opportunity to begin conversations and initiate change

Thank you. Please contact RCAP for additional copies of Fences www Thank you! Please contact RCAP for additional copies of Fences www.indiana.edu/~aids