Rural Health FYI, 5/98

"President's Message," Rural Health FYI, May/June, 1998

Tim Size, President, National Rural Health Association

This is my last FYI column as president of NRHA. These opportunities to talk directly to you, the members, have been a real and unexpected pleasure, There has been no particular rhyme or reason to the choice of subjects other than they have been on topics I think are important and need more attention within the rural health community. This last column is no exception. My purpose here is to emphasize some of what we know about rural HIV/AIDS, what NRHA has done and will be doing along with examples of what each of us can do locally.

Are rural people at risk for HIV/AIDS?

"Data from the Centers for Disease Control and Prevention (CDC) show that among the more than one-half million AIDS cases reported through 1995, 84 percent were from major metropolitan areas. However the greatest rate of increase in AIDS cases between 1992 and 1995 occurred in nonmetropolitan areas." (NRHA Rural Clinician Quarterly, Winter 1998)

"Newly reported AIDS cases in rural areas of the US are increasing in the South, among young people, among African-Americans and Hispanics, and among people infected through heterosexual contact. In many rural areas, heterosexual contact accounts for the most HIV transmission. In addition, having a sexually transmitted disease such as syphilis and gonorrhea may increase the likelihood of HIV transmission. Injection drug use and non-injection drug use, especially crack cocaine use, puts many rural residents at risk for HIV. Drug use is closely linked to prostitution, especially among women and teens." (From the fact sheet: What are Rural HIV Prevention Needs?, Center for AIDS Prevention Studies, University of California available at <www.epibiostat.ucsf.edu/capsweb> or through the National AIDS Clearinghouse at 800-458-5231.)

"The HIV virus does not recognize nor does it discriminate based on geographic boundaries, and therefore it is critically important that greater public and private resources are committed to preventing the spread of AIDS in rural communities." (Darin Johnson, NRHA Director of Government Affairs) A quick glance at the map below shows the geographic diffusion of the AIDS well into states considered rural and not just the major urban centers of the east and west coasts.

The Difficult Interplay of Virus and Deeply Held Beliefs

"Moderation and tolerance--an appreciation of the modest virtues--are the bedrock moral principles of the American middle class: on most controversial issues, Americans instinctively try to find the centrist position between two extremes and attempt to carve out private spaces in which people can do what they want as long as others do what they want. But these two principles can contradict each other. If one believes in tolerance for everyone under all conditions, one is hardly moderate. No other issue taps into such a potential conflict more than the issue of homosexuality." (One Nation After All By Alan Wolfe.)

HIV/AIDS is our most politicized disease; differences in deeply held values held by good people across the country become totally entwined with the development of local and national agreements on how to best prevent the virus's spread. And while HIV/AIDS clearly is not limited to individuals who are homosexual, they are still the community most identified with this disease; our attitudes about homosexuality strongly effect our capacity to talk openly about needed prevention behaviors. In a similar manner, repeated recommendations by national health care leaders to institute needle exchanges have been just as often blocked by the concern of being or being seen as soft on drugs.

"Rural communities can provide their members both strong support and strong condemnation at times. In rural areas, traditional moral values, conformity to community norms and intolerance of diversity can be strong. In some cases, homophobia, racism, sexism, and stigmatization of people with AIDS, homosexuals, minorities and drug users makes effective HIV prevention nearly impossible. Confidentiality can be hard to maintain in rural areas, yet is crucial for many residents due to fear of stigmatization. Testing for HIV, discussing sexual practices with clinicians, obtaining drug treatment, or buying condoms in local stores-all important preventive activities-can be difficult to do confidentially in rural areas." (What are Rural HIV Prevention Needs?, cited above.)

NRHA Public Policy Recommendations

I would highly recommend your reading "HIV/AIDS in Rural America" adopted last November by the Health Policy Board, part of the growing collection of excellent NRHA Issue Paper's, . They can be found at our web site <www.NRHA.rural.org>. A summary of NRHA's current public policy recommendations are as follows:

1. NRHA will bring together a wide variety of public and private organizations to discuss, develop and implement three comprehensive strategies--intervention in the public schools, public education strategies and continuing education efforts targeting rural providers.

2. NRHA supports the CDC collecting HIV/AIDS data by county or non-MSA and the appropriate dissemination of such data.

3. NRHA urges the federal Health Resources and Services Administration to provide data on the rural share of HIV/AIDS specific funds.

4. NRHA supports access to essential health care resources for all Americans.

5. NRHA, in coordination with various federal agencies, should convene a task force of experts to determine whether rural Americans have the same access to treatment for HIV/AIDS as Americans living in urban areas and to make policy recommendations as needed.

6. NRHA supports HRSA recommending a new Title II formula (federal formula grants to states) that would proportionately distribute funds to rural areas.

The National Rural HIV/AIDS Initiative

The NRHA in conjunction with the federal Office of National AIDS Policy is developing the National Rural HIV/AIDS Initiative, a direct outcome of our Southeastern Conference on Rural HIV/AIDS: Issues in Prevention and Treatment held last August in Atlanta. The mission of the project is to address the growing impact of the HIV/AIDS epidemic in rural and frontier America, and to foster increased national, state, and local awareness and resources to education, prevention and treatment efforts in rural communities. The National Rural HIV/AIDS Initiative will be composed of four specific projects:

A National Task Force composed of providers, care givers, persons living with HIV/AIDS, government officials, and community and religious leaders will convene to develop a set of recommendations on rural HIV/AIDS. The charge to the task force will be to provide specific direction for both government and the private sector in preventing AIDS and HIV transmission in rural America, as well as improving access to health care for those already living in rural communities with HIV and AIDS.

Track at the Orlando Conference--There is a Rural HIV/AIDS Track at the Orlando NRHA Annual Conference focusing on the issues of rural HIV/AIDS beginning with a presentation by Dr. Scott Hitt, Chairman of the Presidential Advisory Committee on HIV/AIDS.)

A Western Conference will address the very unique issues and delivery systems present in the western United States. The conference will focus specifically on issues affecting Native Americans, migrant workers, and aliens. Additionally, many topics discussed at the 1997 Southeastern Conference on HIV/AIDS will be on the agenda: including effective education and prevention programs, outreach to gay and bisexual populations, and the impact of managed care and physician networks in providing health care services to persons living with HIV and AIDS.

Public Service Announcement Campaign--the NRHA and the Office of National AIDS Policy will join forces with the country music industry to develop a series of public service announcements (PSAs) to educate and prevent the transmission of HIV and AIDS in rural America. The PSA campaign will be a catalyst for educating rural Americans, especially children and young adults, that AIDS is not just an urban problem, but that its affects are taking a toll of people living in rural communities.

For more information or to learn how you or your organization can play a role in the National Rural HIV/AIDS Initiative, please contact the National Rural Health Association at (202) 232-6200 or the Office of National AIDS Policy at (202) 632-1090.

Get Involved In Your Community

About one in every 300 to 400 people are infected with HIV. All of us can make an individual difference in the fight against this epidemic. A partial list of suggestions from the Winter 1998 issue of the NRHA Rural Clinician Quarterly include the following:

In the Community--"participate in or organize an HIV/AIDS fund-raising event; coordinate with a local medical school to initiate the STATS project in your area--Students Teaching AIDS to Students--prepares medical students to visit schools and other youth community centers to teach young people about HIV infection and AIDS."

In Your Faith Community--"Focus on the impact of HIV/AIDS during religious educational programs, and invite people living with HIV/AIDS to share their stories; start a service program where members of your congregation can work with an area AIDS group to provide meals, transportation, shelter, companionship or other services to people living with HIV/AIDS."

In the Health Care Setting--"Organize a workshop to educate health professionals about the ethical issues surrounding HIV/AIDS; ask AIDS service organizations serving various ethnic and racial groups to make a presentation to your staff regarding cultural sensitivity and HIV."

In Conclusion

I'd again like to quote Darin Johnson, as NRHA's lead staffer on our work with HIV/AIDS : "Even as new drug therapies become available, those living with HIV and AIDS in rural and frontier areas still face serious access and treatment issues. One of the goals of the NRHA's initiative is to work with rural providers to ensure they have the most current information about protocols for treating HIV and AIDS patients. The NRHA, through its national initiative, hopes to bring a greater awareness and commitment to the prevention and treatment of HIV and AIDS in rural America. As AIDS touches the lives of more and more families in rural communities, it is important issues of stereotypes, access to proper and affordable care and systems of support be addressed."