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

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

3. Rural America

4. 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 bear the greatest burden of disease and adverse consequences
Source: CDC, National STD Morbidity Surveillance System , 2008

5. 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

6. 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)

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

8. 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

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

10. Educational strategies to increase awareness and can decrease stigma
Community
Schools
Faith-Based Organizations
Clinics
CREATE Project

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

12. 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

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

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

15. 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

16. 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

17. 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

18. 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

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

20. Thank you. Please contact RCAP for additional copies of Fences www
Thank you! Please contact RCAP for additional copies of Fences