The care of HIV-infected adults in rural areas of the United States

Acceptability, Feasibility, and Preliminary Impact of 4 Remotely-Delivered Interventions for Rural Older Adults Living with HIV

People living with HIV (PLH) who live in rural areas of the United States (US) face more challenges to obtaining medical care and suffer higher mortality rates compared to non-rural PLH. Compared with younger PLH, older PLH (age 50+) also face additional challenges to maintaining their health and wellbeing. Despite the heightened barriers to receiving care and remaining adherent to treatment among older rural PLH, few interventions to increase viral suppression and improve quality of life exist for this population. We pilot-tested four remotely-delivered interventions-group-based social support, group-based stigma-reduction, individual strengths-based case management, and individual technology detailing-aimed to improve care engagement and quality of life in rural older PLH in the southern US. Participants (N = 61, Mage = 58, 75% male) completed surveys and self-collected blood specimens at baseline and 3 months; in between, they were randomized to 0-4 interventions. We assessed feasibility, acceptability, and preliminary impact on medication adherence, viral suppression, quality of life, depressive symptoms, and hypothesized mediating mechanisms. More than 80% participated in assigned intervention(s), and 84% completed the study. Interventions were highly acceptable to participants, with more than 80% reporting they would recommend interventions to peers. More than 80% found the social support and case management interventions to be relevant and enjoyable. We found promising preliminary impact of interventions on quality of life, medication adherence, depressive symptoms, internalized stigma, and loneliness. Remotely-delivered interventions targeting rural older PLH are feasible to conduct and acceptable to participants. Larger scale study of these interventions is warranted.

Predictors of Viral Suppression Among People Living with HIV in Rural Oregon

With recent outbreaks of HIV in rural areas of the United States, it has become increasingly important to understand the factors affecting health outcomes of people with HIV living in rural areas. We assessed predictors of durable HIV viral suppression among rural participants using a pooled 7-year dataset from the Medical Monitoring Project (MMP), a cross-sectional, representative sample of individuals receiving HIV medical care in Oregon. Only 77.3% of rural participants achieved durable HIV viral suppression, while 22.7% had at least one detectable HIV viral load measurement within the past 12 months. The primary predictors of viral suppression were ARV adherence, poverty, and reported heavy drinking in the past 30 days. These results highlight the influence of social factors on health outcomes for persons with HIV living in rural areas and inform areas for policy and program change.

Factors associated with lack of care engagement among older, rural-dwelling adults living with HIV in the United States

PURPOSE

Most people living with HIV (PLH) in the United States are over age 50 and this sector of PLH continues to grow. Aging with HIV can be challenging due to comorbid medical conditions, mental health disorders, substance use, and lack of social and practical support. Additional challenges are faced by older PLH living in the rural United States, such as longer distances to health care, concerns over privacy and stigma, and social isolation. PLH in rural areas have higher mortality rates than urban PLH. We aimed to understand factors associated with HIV care engagement and quality of life in rural US adults over age 50.

METHODS

We conducted a cross-sectional study to evaluate the association between patient-level factors and a combined outcome variable encompassing multiple aspects of care engagement.

FINDINGS

Either online or on paper, 446 participants completed our survey. One-third of the participants (33%) were from the southern United States; one-third were women; one-third were non-White; and 24% completed the survey on paper. In multiple regression analysis, lower income, residing in the southern United States, lacking internet access at home, not having an HIV specialist provider, higher levels of stress, living alone, and longer distance to an HIV provider were all associated with lower engagement in HIV care.

CONCLUSIONS

Our findings demonstrated multiple potential options for interventions that could improve care engagement, such as providing and enhancing access to technology for health care engagement and remotely delivering social support and mental health services. Research on such potential interventions is needed for older, rural PLH.

Factors associated with quality of life, depressive symptoms, and perceived stress among rural older adults living with HIV in the United States

PURPOSE

Rural older people living with HIV (PLH) in the United States are a population of growing size and significance. A better understanding of factors associated with quality of life (QOL), depressive symptoms, and stress in this population-especially modifiable factors-could inform future interventions.

METHODS

Online or on paper, we surveyed 446 PLH aged 50+ residing in rural counties across the United States (Mage = 56, 67% male, 67% White, and 23% Black). Associations between social support, HIV stigma, satisfaction with medical care, discrimination in health care settings, and structural barriers and health-related QOL, depressive symptoms, and perceived stress were assessed using multiple linear regressions.

FINDINGS

Controlling for demographics, greater social support was associated with better QOL, fewer depressive symptoms, and less stress. Greater HIV stigma was associated with more depressive symptoms and stress. Satisfaction with care was associated with better QOL and less stress. Discrimination in medical settings was associated with lower QOL and more depressive symptoms and stress. Finally, experiencing more structural barriers was associated with lower QOL and more depressive symptoms and stress.

CONCLUSIONS

In addition to engagement in care and viral suppression, QOL and mental health are also critical considerations for rural older PLH. Increasing social support, reducing or providing skills to cope with HIV stigma, improving quality of care, reducing discrimination and stigma in medical settings, and reducing or mitigating the impact of structural barriers present potential targets for interventions aiming to improve the well-being of older rural PLH.

HIV Treatment Outcomes in Rural Georgia Using Telemedicine

Background

The increasing shortage of specialized health care services contributes to the ongoing HIV epidemic. Telemedicine (TM) is a potential tool to improve HIV care, but little is known about its effectiveness when compared with traditional (face-to-face [F2F]) care in rural populations. The objective of this study was to compare the effectiveness of HIV care delivered through TM with the F2F model.

Methods

We conducted a retrospective chart review of a subset of patients with HIV who attended a TM clinic in Dublin, Georgia, and an F2F clinic in Augusta, Georgia, between May 2017 and April 2018. All TM patients were matched to F2F patients based on gender, age, and race. HIV viral load (VL) and CD4 count gain were compared using t test and Mann-Whitney U statistics.

Results

Three hundred eighty-five patients were included in the analyses (F2F = 200; TM = 185). The mean CD4 in the TM group was higher (643.9 cells/mm³) than that of the F2F group (596.3 cells/mm³; P < .001). There was no statistically significant difference in VL reduction, control, or mean VL (F2F = 416.8 cp/mL; TM = 713.4 cp/mL; P = .30). Thirty-eight of eighty-five patients with detectable VL achieved viral suppression during the study period (F2F = 24/54; TM = 14/31), with a mean change of 3.34 × 10⁴ and –1 to 0.24 × 10⁴, respectively (P = 1.00).

Conclusions

TM was associated with outcome measures comparable to F2F. Increased access to specialty HIV care through TM can facilitate HIV control in communities with limited health care access in the rural United States. Rigorous prospective evaluation of TM for HIV care effectiveness is warranted.

Assessing clinical quality performance and staffing capacity differences between urban and rural Health Resources and Services Administration-funded health centers in the United States: A cross sectional study

BACKGROUND

In the United States, there are nearly 1,400 Health Resources and Services Administration-funded health centers (HCs) serving low-income and underserved populations and more than 600 of these HCs are located in rural areas. Disparities in quality of medical care in urban vs. rural areas exist but data on such differences between urban and rural HCs is limited in the literature. We examined whether urban and rural HCs differed in their performance on clinical quality measures before and after controlling for patient, organizational, and contextual characteristics.

METHODS AND FINDINGS

We used the 2017 Uniform Data System to examine performance on clinical quality measures between urban and rural HCs (n = 1,373). We used generalized linear regression models with the logit link function and binomial distribution, controlling for confounding factors. After adjusting for potential confounders, we found on par performance between urban and rural HCs in all but one clinical quality measure. Rural HCs had lower rates of linking patients newly diagnosed with HIV to care (74% [95% CI: 69%, 80%] vs. 83% [95% CI: 80%, 86%]). We identified control variables that systematically accounted for eliminating urban vs. rural differences in performance on clinical quality measures. We also found that both urban and rural HCs had some clinical quality performance measures that were lower than available national benchmarks. Main limitations included potential discrepancy of urban or rural designation across all HC sites within a HC organization.

CONCLUSIONS

Findings highlight HCs' contributions in addressing rural disparities in quality of care and identify opportunities for improvement. Performance in both rural and urban HCs may be improved by supporting programs that increase the availability of providers, training, and provision of technical resources.

The Health Resources and Services Administration's Ryan White HIV/AIDS Program in rural areas of the United States: Geographic distribution, provider characteristics, and clinical outcomes

Background

People living with HIV (PLWH) residing in rural areas experience substantial barriers to HIV care, which may contribute to poor HIV health outcomes, including retention in HIV care and viral suppression. The Health Resources and Services Administration’s Ryan White HIV/AIDS Program (HRSA RWHAP) is an important source of HIV medical care and support services in rural areas. The purpose of this analysis was to (1) assess the reach of the RWHAP in rural areas of the United States, (2) compare the characteristics and funded services of RWHAP provider organizations in rural and non-rural areas, and (3) compare the characteristics and clinical outcomes of RWHAP clients accessing medical care and support services in rural and non-rural areas.

Methods and findings

Data for this analysis were abstracted from the 2017 RWHAP Services Report (RSR), the primary source of annual, client-level RWHAP data. Organizations funded to deliver RWHAP any service (“RWHAP providers”) were categorized as rural or non-rural according to the HRSA FORHP’s definition of modified Rural-Urban Commuting Area (RUCA) codes. RWHAP clients were categorized based on their patterns of RWHAP service use as “visited only rural providers,” “visited only non-rural providers,” or “visited rural and non-rural providers.” In 2017, among the 2,113 providers funded by the RWHAP, 6.2% (n = 132) were located in HRSA-designated rural areas. Rural providers were funded to deliver a greater number of service categories per site than non-rural providers (44.7% funded for ≥5 services vs. 34.1% funded for ≥5 services, respectively). Providers in rural areas served fewer clients than providers in non-rural areas; 47.3% of RWHAP providers in rural areas served 1–99 clients, while 29.6% of non-rural providers served 1–99 clients. Retention in care and viral suppression outcomes did not differ on the basis of whether a client accessed services from rural or non-rural providers.

Conclusions

RWHAP providers are a crucial component of HIV care delivery in the rural United States despite evidence of significant barriers to engagement in care for rural PLWH, RWHAP clients who visited rural providers were just as likely to be retained in care and reach viral suppression as their counterparts who visited non-rural providers. The RWHAP, especially in partnership with Rural Health Clinics and federally funded Health Centers, has the infrastructure and expertise necessary to address the HIV epidemic in rural America.

Cause-specific mortality among HIV-infected people in Ontario, 1995-2014: a population-based retrospective cohort study

BACKGROUND

Risk factors for cause-specific mortality have not been widely studied among people with HIV infection. Our objectives were to estimate rates of and risk factors for all-cause and cause-specific mortality from 1995 to 2014 among HIV-infected people in Ontario.

METHODS

We conducted a population-based retrospective cohort study using provincial health databases of people with HIV infection who were aged 16 years or more, were residents of Ontario between 1995 and 2014, and had HIV infection according to a previously validated algorithm. We used International Classification of Diseases codes to classify the underlying cause of death and estimated age-adjusted mortality rates per 100 person-years for 1995 to 2014. We used descriptive statistics to characterize the cohort at baseline and calculated adjusted mortality rate ratios (RRs) using generalized estimating equations.

RESULTS

Among 23 043 people, the all-cause mortality rate declined from 6.69 to 1.53 per 100 person-years over the study period, and the rate of death from HIV/AIDS declined from 4.75 to 0.46 per 100 person-years. Concomitantly, the proportions of deaths due to cancer, cardiovascular disease and other noncommunicable diseases rose; however, rates remained constant or declined. Compared to males, females had higher mortality due to cardiovascular disease (adjusted RR 1.36, 95% confidence interval [CI] 1.04-1.77), noncommunicable causes (adjusted RR 1.75, 95% CI 1.39-2.20) and, by 2010-2014, any cause (adjusted RR 1.19, 95% CI 1.02-1.38). Residing in a low-income neighbourhood was associated with increased risk for most causes, including HIV/AIDS (adjusted RR in 2010-2014 1.86, 95% CI 1.49-2.31). Rural residence was associated with increased mortality due to malignant disease (adjusted RR 1.60, 95% CI 1.10-2.34) and noncommunicable disease (adjusted RR 1.86, 95% CI 1.25-2.77). Being an immigrant was associated with lower risk of death from all causes.

INTERPRETATION

Over the study period, death was increasingly due to common chronic conditions rather than to HIV infection itself. Care should incorporate the prevention and management of these conditions, especially among females and those residing in rural and low-income areas.

Washington state satellite HIV clinic program: a model for delivering highly effective decentralized care in under-resourced communities

To improve access to high-quality HIV care in underserved regions of Western Washington (WA) State, we collaborated with the WA State Department of Health (DOH) and community partners to launch four satellite HIV clinics. Here, we describe this innovative clinical care model, present an estimate of costs, and evaluate patient care outcomes, including virologic suppression rates. To accomplish this, we assessed virologic suppression rates 12 months before and 12 months after the satellite clinics opened, comparing people living with HIV (PLWH) who enrolled in the satellite clinics versus all PLWH in the same regions who did not. We also determined virologic suppression rates in 2015 comparing satellite clinic versus non-satellite clinic patients and compared care quality indicators between the satellite clinics and the parent academic clinic. Results demonstrate that the change in virologic suppression rate 12 months before to 12 months after the satellite clinics opened was higher for patients who enrolled in the satellite clinics compared to all those in the same region who did not (18% versus 6%, p < 0.001). Virologic suppression in 2015 was significantly higher for satellite clinic than non-satellite clinic patients at three of four sites. Care quality indicators were met at a high level at the satellite clinics, comparable to the parent academic clinic. Overall, through community partnerships and WA DOH support, the satellite clinic program increased access to best practice HIV care and improved virologic suppression rates in difficult-to-reach areas. This model could be expanded to other regions with inadequate access to HIV practitioners, though financial support is necessary.

Is there a rural/urban gap in the quality of HIV care for treatment-naïve HIV-positive individuals initiating antiretroviral therapy in British Columbia?

Rurally located people living with HIV (PLWH) face unique challenges associated with remoteness that may negatively affect their HIV care outcomes. The Programmatic Compliance Score (PCS) has been used previously as a quality of care metric, and is predictive of mortality for treatment-naïve individuals initiating combination antiretroviral therapy (cART). This study looked at whether the rurality of PLWH impacted their PCS. PCS was calculated for PLWH (≥19 years old) initiating cART in British Columbia between 2000 and 2013. Rurality was determined at the time of cART initiation using two methodologies: (1) a categorical postal code method; and (2) the General Practice Rurality Index (GPRI), a score representing an individual's degree of rurality. Ordinal logistic regression modeling was used to assess the relationship between rurality and PCS. Among 4616 PLWH with an evaluable PCS, 176 were classified as rural and 3512 as urban (928 had an unknown postal code). After adjusting for age, sex, hepatitis C status, Indigenous ancestry, and year of cART initiation, categorical rurality was not associated with a worse PCS (adjusted odds ratio (AOR) 1.04; 95% CI: 0.77-1.39). However, an increasing degree of rurality was associated with a worse PCS (AOR (per 10 increase in GPRI) 1.13; 95% CI: 1.06-1.20). Given that a poor PCS has been shown to be predictive of all-cause mortality for individuals initiating cART, strategies to improve access to HIV care for rural individuals should be evaluated.

The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions

The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the epidemic into locations where populations are dispersed and health care resources are limited. Rural-urban differences along the care continuum demonstrate the implications of this sociogeographic shift. Greater attention is needed to build a more comprehensive understanding of the rural HIV epidemic in the United States and Canada, including research efforts, innovative approaches to care delivery, and greater community engagement in prevention and care.

Qualifications, Demographics, Satisfaction, and Future Capacity of the HIV Care Provider Workforce in the United States, 2013-2014

BACKGROUND

The human immunodeficiency virus (HIV)-infected population in the United States is increasing by about 30 000 annually (new infections minus deaths). With improvements in diagnosis and engagement in care, additional qualified HIV care providers may be needed.

METHODS

We surveyed a probability sample of 2023 US HIV care providers in 2013-2014, including those at Ryan White HIV/AIDS Program (RWHAP)-funded facilities and in private practices. We estimated future patient care capacity by comparing counts of providers entering and planning to leave practice within 5 years, and the number of patients under their care.

RESULTS

Of surveyed providers, 1234 responded (adjusted response rate, 64%): 63% were white, 11% black, 11% Hispanic, and 16% other race/ethnicity; 37% were satisfied/very satisfied with salary/reimbursement, and 33% were satisfied/very satisfied with administrative time. Compared with providers in private practice, more providers at RWHAP-funded facilities were HIV specialists (71% vs 43%; P < .0001) and planned to leave HIV practice within 5 years (11% vs 4%; P = .0004). An estimated 190 more full-time equivalent providers (defined as 40 HIV clinical care hours per week) entered practice in the past 5 years than are expected to leave in the next 5 years. If these rates continue, by 2019 patient care capacity will increase by 65 000, compared with an increased requirement of at least 100 000.

CONCLUSIONS

Projected workforce growth by 2019 will not accommodate the increased number of HIV-infected persons requiring care. RWHAP-funded facilities may face attrition of highly qualified providers. Dissatisfaction with salary/reimbursement and administrative burden is substantial, and black and Hispanic providers are underrepresented relative to HIV patients.

Impact of a Telehealth Program That Delivers Remote Consultation and Longitudinal Mentorship to Community HIV Providers

Background.  To increase human immunodeficiency virus (HIV) care capacity in our region, we designed a distance mentorship and consultation program based on the Project ECHO (Extension for Community Healthcare Outcomes) model, which uses real-time interactive video to regularly connect community providers with a multidisciplinary team of academic specialists. This analysis will (1) describe key components of our program, (2) report types of clinical problems for which providers requested remote consultation over the first 3.5 years of the program, and (3) evaluate changes in participants' self-assessed HIV care confidence and knowledge over the study period. Methods.  We prospectively tracked types of clinical problems for which providers sought consultation. At baseline and regular intervals, providers completed self-efficacy assessments. We compared means using paired-samples t test and examined the statistical relationship between each survey item and level of participation using analysis of variance. Results.  Providers most frequently sought consultation for changing antiretroviral therapy, evaluating acute symptomatology, and managing mental health issues. Forty-five clinicians completed a baseline and at least 1 repeat assessment. Results demonstrated significant increase (P < .05) in participants' self-reported confidence to provide a number of essential elements of HIV care. Significant increases were also reported in feeling part of an HIV community of practice and feeling professionally connected to academic faculty, which correlated with level of program engagement. Conclusions.  Community HIV practitioners frequently sought support on clinical issues for which no strict guidelines exist. Telehealth innovation increased providers' self-efficacy and knowledge while decreasing professional isolation. The ECHO model creates a virtual network for peer-to-peer support and longitudinal mentorship, thus strengthening capacity of the HIV workforce.

HIV Diagnoses, Prevalence and Outcomes in Nine Southern States

A group of nine states in the Southern United States, hereafter referred to as the targeted states, has experienced particularly high HIV diagnosis and case fatality rates. To provide additional information about the HIV burden in this region, we used CDC HIV surveillance data to examine characteristics of individuals diagnosed with HIV in the targeted states (2011), 5-year HIV and AIDS survival, and deaths among persons living with HIV (2010). We used multivariable analyses to explore the influence of residing in the targeted states at diagnosis on deaths among persons living with HIV after adjustment for demographics and transmission risk. In 2011, the targeted states had a higher HIV diagnosis rate (24.5/100,000 population) than the US overall (18.0/100,000) and higher proportions than other regions of individuals diagnosed with HIV who were black, female, younger, and living in suburban and rural areas. Furthermore, the targeted states had lower HIV and AIDS survival proportions (0.85, 0.73, respectively) than the US overall (0.86, 0.77, respectively) and the highest death rate among persons living with HIV of any US region. Regional differences in demographics and transmission risk did not explain the higher death rate among persons living with HIV in the targeted states indicating that other factors contribute to this disparity. Differences in characteristics and outcomes of individuals with HIV in the targeted states are critical to consider when creating strategies to address HIV in the region, as are other factors identified in previous research to be prominent in the region including poverty and stigma.

Demographic and Health Services Characteristics Associated With Testing for Sexually Transmitted Infections Among a Commercially Insured Population of HIV-Positive Patients

BACKGROUND

Presence of a sexually transmitted infection (STI) can increase the likelihood of HIV transmission, and current treatment guidelines indicate that HIV-positive persons should be screened yearly for STIs. Therefore, we examined recent insurance claims data to determine whether private insurance beneficiaries who are HIV-positive were receiving recommended STI testing.

METHODS

We used data from the 2011 and 2012 MarketScan data sets, a longitudinal population-based database that collects claims from commercially insured persons in private insurance and is conducted by Truven Health Analytics. Over a 13-month period, we calculated rates of testing for chlamydia, gonorrhea, and syphilis among an HIV-positive population and determined the factors that contributed to differences in testing rates.

RESULTS

Overall testing rates were 22.2% for chlamydia, 21.9% for gonorrhea, and 51.1% for syphilis. Significant predictors of STI testing were sex, age, type of health plan, engagement with the health care system, and geographic location. Most notably, persons receiving viral load testing were more likely to receive testing for chlamydia [odds ratio (OR): 1.72; 95% confidence interval (CI): 1.63 to 1.81], gonorrhea (OR: 1.72; 95% CI: 1.64 to 1.81), and syphilis (OR: 3.38; 95% CI: 3.25 to 3.53) compared with persons not receiving viral load testing.

DISCUSSION

Not all commercially insured HIV-positive patients are receiving recommended testing for STIs. Presence of STIs could affect the transmission of HIV and has deleterious effects on health outcomes of the patients. Targeted efforts based on demographics, health plan type, and other quality-of-care measures could help identify populations for whom testing rates for STIs among HIV-positive persons could be improved.

Distance from care predicts in-hospital mortality in HIV-infected patients with severe sepsis from rural and semi-rural Virginia, USA

There are few data regarding outcomes from severe sepsis for HIV-infected patients living in rural or semi-rural settings. We aim to describe the characteristics and predictors of mortality in HIV-infected patients admitted with severe sepsis to the University of Virginia located in semi-rural Charlottesville, Virginia, USA. We queried the University of Virginia Clinical Data Repository for cases with ICD-9 codes that included: (1) infection, (2) acute organ dysfunction, and (3) HIV infection. We reviewed each case to confirm the presence of HIV infection and severe sepsis. We recorded socio-demographic, clinical, and laboratory data. We used a generalised linear mixed-effects model to assess pre-specified predictors of mortality. We identified 74 cases of severe sepsis in HIV-infected patients admitted to University of Virginia since 2001. The median (IQR) age was 44 (36-49), 32 (43%) were women, and 56 (76%) were from ethnic minorities. The median (IQR) CD4+ T-cell count was 81 (7-281) cells/µL. In-hospital mortality was 20%. When adjusted for severity of illness and respiratory failure, patients who lived >40 miles away from care or had a CD4+ T cell count <50 cells/µL had > four-fold increased risk of death compared to the rest of the study population (AOR = 4.18, 95% CI: 1.09-16.07, p = 0.037; AOR = 4.33, 95% CI: 1.15-16.29, p = 0.03). In HIV-infected patients from rural and semi-rural Virginia with severe sepsis, mortality was increased in those that lived far from University of Virginia or had a low CD4+ T cell counts. Our data suggest that rural HIV-infected patients may have limited access to care, which predisposes them to critical illness and a high associated mortality.

Experiences of HIV-positive gay, bisexual and other men who have sex with men residing in relatively rural areas

Most previous studies of the sexual behaviour of gay, bisexual and other men who have sex with men living with HIV are based on samples of men recruited within relatively urban and suburban areas of the USA. The aim of the present study was to explore the potential challenges associated with HIV-related stigma and residing in a relatively rural area. We conducted a qualitative study based in south-central Indiana, a relatively rural area of the USA. Twenty-three HIV-positive gay, bisexual and other men who have sex with men, aged 21-48 years, were interviewed on topics regarding community engagement, perceived HIV-related stigma, relationship formation, sexual behaviour and HIV status disclosure. Findings indicate HIV-related stigma is commonly reported at the interpersonal and community levels. Because of this, men face complex situations on how and when to disclose their HIV status to members of their social and sexual networks. Although many participants reported many challenges associated with relationship formation, all expressed a desire for romantic and/or sexual connections with other men and/or women. Results suggest that new programmatic approaches are necessary to inform the work of social service and medical providers on mechanisms to intervene and combat stigma and discrimination inherent in communities, programmes and policies.

Rural AIDS diagnoses in Florida: changing demographics and factors associated with survival

PURPOSE

To compare demographic characteristics and predictors of survival of rural residents diagnosed with acquired immunodeficiency syndrome (AIDS) with those of urban residents.

METHODS

Florida surveillance data for people diagnosed with AIDS during 1993-2007 were merged with 2000 Census data using ZIP code tabulation areas (ZCTAs). Rural status was classified based on the ZCTA's rural-urban commuting area classification. Survival rates were compared between rural and urban areas using survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level socioeconomic and health care access factors.

FINDINGS

Of the 73,590 people diagnosed with AIDS, 1,991 (2.7%) resided in rural areas. People in the most recent rural cohorts were more likely than those in earlier cohorts to be female, non-Hispanic black, older, and have a reported transmission mode of heterosexual sex. There were no statistically significant differences in the 3-, 5-, or 10-year survival rates between rural and urban residents. Older age at the time of diagnosis, diagnosis during the 1993-1995 period, other/unknown transmission mode, and lower CD4 count/percent categories were associated with lower survival in both rural and urban areas. In urban areas only, being non-Hispanic black or Hispanic, being US born, more poverty, less community social support, and lower physician density were also associated with lower survival.

CONCLUSIONS

In rural Florida, the demographic characteristics of people diagnosed with AIDS have been changing, which may necessitate modifications in the delivery of AIDS-related services. Rural residents diagnosed with AIDS did not have a significant survival disadvantage relative to urban residents.

Barriers to care for rural people living with HIV: a review of domestic research and health care models

Historically, the availability of heath care in rural areas has been sparse, and specialized care for people living with HIV (PLWH) has been especially problematic. Rural patients are faced with substantially greater barriers to care than their urban counterparts. A systematic review of empirical studies was conducted concerning barriers to care among patients infected with HIV in rural areas of the United States. This systematic review yielded 15 viable articles for analysis. Among the 27 barriers identified, the most commonly discussed were transportation needs, provider discrimination and stigma, confidentiality concerns, and affordability and lack of financial resources. Barriers to care must be addressed in conjunction with one another in order to alleviate their impacts. Key health care models addressing these concerns are highlighted and used to address the state of the field and provide suggestions for future research.

Rural residence and adoption of a novel HIV therapy in a national, equal-access healthcare system

Rural persons with HIV face barriers to care that may influence adoption of advances in therapy. We performed a retrospective cohort study to determine rural-urban variation in adoption of raltegravir-the first HIV integrase inhibitor-in national Veterans Affairs (VA) healthcare. There were 1,222 veterans with clinical indication for raltegravir therapy at time of its FDA approval in October 2007, of whom 223 (19.1%) resided in rural areas. Urban persons were more likely than rural to initiate raltegravir within 180 days (17.3% vs. 11.2%, P = 0.02) and 360 days (27.5% vs. 19.7%, P = 0.02), but this gap narrowed slightly at 720 days (36.3% vs. 31.8%, P = 0.19). In multivariable analysis adjusting for patient characteristics, urban residence predicted raltegravir adoption within 180 days (odds ratio 1.72, 95% CI 1.09-2.70) and 360 days (OR 1.63, 95% CI 1.13-2.34), but not 720 days (OR 1.26, 95% CI 0.84-1.87). Efforts are needed to reduce geographic variation in adoption of advances in HIV therapy.

Sexual behavior as a function of stigma and coping with stigma among people with HIV/AIDS in rural New England

The relationship between coping with HIV/AIDS stigma and engaging in risky sexual behavior (i.e., inconsistent condom use) was examined in HIV-positive adults living in rural areas. Participants answered questions about their experiences with HIV/AIDS prejudice and discrimination (enacted stigma) and their perceptions of felt HIV/AIDS stigma (disclosure concerns, negative self-image, and concern with public attitudes). They were also asked about how they coped with HIV/AIDS stigma, and about their sexual activity during the past 90 days. We hypothesized that using disengagement coping to manage the stress of HIV/AIDS stigma would be related to risky sexual behavior. Multinomial logistic regression results showed that using disengagement coping (avoidance, denial, and wishful thinking) coupled with high levels of enacted stigma was associated with less risky rather than more risky sexual behavior. That is, disengagement coping coupled with high stigma increased the odds of not having vaginal or anal sex versus inconsistently using condoms. Implications for people with HIV/AIDS who use disengagement coping to manage stress to deal with HIV/AIDS stigma are discussed.

Rural HIV-infected women's access to medical care: ongoing needs in California

HIV-infected women living in rural areas often have considerably less access to care than their urban and suburban counterparts. In much of the USA, little is known about HIV care among rural populations. This study elucidated barriers to care for rural women in California. Methods included retrospective structured interviews conducted with 64 women living in rural areas and receiving HIV care at 11 California healthcare facilities. Facilities were randomly sampled and all HIV-infected female patients seeking care at those facilities during a specified time period were eligible. The most commonly cited barriers to accessing care included physical health problems that prevented travel to care (32.8%), lack of transportation (31.2%), and lack of ability to navigate the healthcare system (25.0%). Being divorced/separated/widowed (compared to being either married or single) was associated with reporting physical health as a barrier to care (p=0.03); being unemployed (p=0.003) or having to travel 31-90 minutes (p=0.007, compared to less than 31 or greater than 90) were both associated with transportation as a barrier; and speaking English rather than Spanish was associated with reporting "difficulty navigating the system" (p=0.04). Twenty-nine women (45.3%) reported difficulty in traveling to appointments. Overall, 24 (37.5%) women missed an HIV medical appointment in the previous 12-month period, primarily due to their physical health and transportation limitations. Physical health and transportation problems were both the major barriers to accessing health services and the primary reasons for missing HIV care appointments among this population of HIV-infected women living in rural areas. Providing transportation programs and/or mobile clinics, as well as providing support for patients with physical limitations, may be essential to improving access to HIV care in rural areas.

Frequency of human immunodeficiency virus (HIV) testing in urban vs. rural areas of the United States: results from a nationally-representative sample

BACKGROUND

Studies in the United States show that rural persons with HIV are more likely than their urban counterparts to be diagnosed at a late stage of infection, suggesting missed opportunities for HIV testing in rural areas. To inform discussion of HIV testing policies in rural areas, we generated nationally representative, population-based estimates of HIV testing frequencies in urban vs. rural areas of the United States.

METHODS

Secondary analysis of 2005 and 2009 Behavioral Risk Factor Surveillance System (BRFSS) data. Dependent variables were self-reported lifetime and past-year HIV testing. Urban vs. rural residence was determined using the metropolitan area framework and Urban Influence Codes and was categorized as 1) metropolitan, center city (the most urban); 2) metropolitan, other; 3) non-metropolitan, adjacent to metropolitan; 4) non-metropolitan, micropolitan; and 4) remote, non-metropolitan (the most rural).

RESULTS

The 2005 sample included 257,895 respondents. Lifetime HIV testing frequencies ranged from 43.6% among persons residing in the most urban areas to 32.2% among persons in the most rural areas (P < 0.001). Past-year testing frequencies ranged from 13.5% to 7.3% in these groups (P < 0.001). After adjusting for demographics (age, sex, race/ethnicity, and region of residence) and self-reported HIV risk factors, persons in the most remote rural areas were substantially less likely than persons in the most urban areas to report HIV testing in the past year (odds ratio 0.65, 95% CI 0.57-0.75). Testing rates in urban and rural areas did not change substantively following the 2006 Centers for Disease Control and Prevention recommendation for routine, population-based HIV testing in healthcare settings. In metropolitan (urban) areas, 11.5% (95% CI 11.2-11.8) reported past-year HIV testing in 2005 vs. 11.4% (95% CI 11.1%-11.7%) in 2009 (P = 0.93). In non-metropolitan areas, 8.7% (95% CI 8.2%-9.2%) were tested in 2005 vs. 7.7% (95% CI 7.2%-8.2%) in 2009 (P = 0.03).

CONCLUSIONS

Rural persons are less likely than urban to report prior HIV testing, which may contribute to later HIV diagnosis in rural areas. There is need to consider strategies to increase HIV testing in rural areas.

HIV-related medical service use by rural/urban residents: a multistate perspective

OBJECTIVE

Geographic location may be related to the receipt of quality HIV health care services. Clinical outcomes and health care utilization were evaluated in rural, urban, and peri-urban patients seen at high-volume US urban-based HIV care sites.

METHODS

Zip codes for 8773 HIV patients followed in 2005 at seven HIV Research Network sites were categorized as rural (population <10,000), peri-urban (10,000-100,000), and urban (>100,000). Clinical and demographic characteristics, inpatient and outpatient (OP) utilization, AIDS-defining illness rates, receipt of highly active antiretroviral therapy (HAART), opportunistic infection (OI) prophylaxis usage, and virologic suppression were compared among patients, using χ(2) tests for categorical variables, t-tests for means, and logistic regression for HAART utilization.

RESULTS

HIV-infected rural (n=170) and peri-urban (n=215) patients were less likely to be Black or Hispanic than urban HIV patients. Peri-urban subjects were more likely to report MSM as their HIV risk factor than rural or urban subjects. Age, gender, CD4 or HIV-RNA distribution, virologic suppression, HAART usage, or OI prophylaxis did not differ by geographic location. In multivariate analysis, rural and peri-urban patients were less likely to have four or more annual outpatient visits than urban patients. Rural patients were less likely to receive HAART if they were Black. Overall, geographic location (as defined by home zip code) did not affect receipt of HAART or OI prophylaxis.

CONCLUSION

Although demographic and health care utilization differences were seen among rural, peri-urban, and urban HIV patients, most HIV outcomes and medication use were comparable across geographic areas. As with HIV care for urban-dwelling patients, areas for improvement for non-urban HIV patients include access to HAART among minorities and injection drug users.

HIV-infected patients and treatment outcomes: an equivalence study of community-located, primary care-based HIV treatment vs. hospital-based specialty care in the Bronx, New York

The HIV-infected population in the USA is expanding as patients survive longer and new infections are identified. In many areas, particularly rural/medically underserved regions, there is a growing shortage of providers with sufficient HIV expertise. HIV services incorporated into community-based (CB), primary care settings may therefore improve the distribution and delivery of HIV treatment. Our objective was to describe/compare patients and treatment outcomes in two settings: a community-located, primary care-based HIV program, and a hospital-based (HB) specialty center. CB providers had on-site access to generalist HIV experts. The hospital center was staffed primarily by infectious disease physicians. This was a retrospective cohort study of 854 HIV-positive adults initiating care between 1/2005 and 12/2007 within an academic medical center network in the Bronx, NY. Treatment outcomes were virologic and immunologic response at 16-32 and 48 weeks, respectively, after combination antiretroviral therapy (cART) initiation. We found that HB subjects presented with a higher prevalence of AIDS (59% vs. 46%, p<0.01) and lower initial CD4 (385 vs. 437, p<0.05) than CB subjects. Among 178 community vs. 237 hospital subjects starting cART, 66% vs. 62% achieved virologic suppression (95% confidence interval (CI) difference -0.14-0.06) and 49% vs. 59% achieved immunologic success, defined as a 100 cell/mm³ increase in CD4 (95% CI difference 0.00-0.19). The multivariate-adjusted likelihoods of achieving viral suppression [OR=1.24 (95% CI 0.69-2.33)] and immunologic success [OR=0.76 (95% CI 0.47-1.21)] were not statistically significant for community vs. hospital subjects. Because this was an observational study, propensity scores were used to address potential selection bias when subjects presented to a particular setting. In conclusion, HIV-infected patients initiate care at CB clinics earlier and with less advanced HIV disease. Treatment outcomes are comparable to those at a HB specialty center, suggesting that HIV care can be delivered effectively in community settings.

Silent endurance and profound loneliness: socioemotional suffering in African Americans living with HIV in the rural south

We explored how community responses to HIV contribute to distress in African Americans living with HIV in the rural South of the United States. We listened to the voices of community members through focus groups and African Americans with HIV through interviews. Community avoidance of HIV, negative views of HIV, and discriminatory behavior powerfully affected the distress of people living with HIV (PLWH). Ongoing distress, coupled with limited support, led to a life in which many PLWH endured their pain in silence and experienced profound loneliness. We conceptualized their experiences as socioemotional suffering--the hidden emotional burden and inner distress of not only living with HIV, a complex serious illness, but also with the societal attitudes and behaviors that are imposed on the illness and on PLWH. To improve the quality of life and health of PLWH, we cannot focus solely on the individual, but must also focus on the local community and society as a whole.

Rural residence is associated with delayed care entry and increased mortality among veterans with human immunodeficiency virus infection

CONTEXT

Rural persons with human immunodeficiency virus (HIV) face many barriers to care, but little is known about rural-urban variation in HIV outcomes.

OBJECTIVE

To determine the association between rural residence and HIV outcomes.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study of mortality among persons initiating HIV care in Veterans Administration (VA) during 1998-2006, with mortality follow-up through 2008. Rural residence was determined using Rural Urban Commuting Area codes. We identified 8489 persons initiating HIV care in VA with no evidence of combination antiretroviral therapy (cART) use at care entry, of whom 705 (8.3%) were rural.

OUTCOME MEASURE

All-cause mortality.

RESULTS

At care entry, rural persons were less likely than urban persons to have drug use problems (10.6% vs. 19.5%, P < 0.001) or hepatitis C (34.3% vs. 41.2%, P = 0.001), but had more advanced HIV infection (median CD4: 186 vs. 246, P < 0.001). By 2 years after care entry, 5874 persons had initiated cART (528 rural [74.9%] and 5346 urban [68.7%], P = 0.001), and there were 1022 deaths (108 rural [15.3%] and 914 urban [11.7%], P = 0.004). The mortality hazard ratio for rural persons compared with urban was 1.34 (95% confidence interval: 1.05-1.69). The hazard ratio decreased to 1.18 (95% confidence interval: 0.93-1.50) after adjustment for HIV severity (CD4 and AIDS-defining illnesses) at care entry, and was 1.17 (95% confidence interval: 0.92-1.50) in a model adjusting for age, HIV severity at care entry, substance use, hepatitis B or C diagnoses, and cART initiation.

CONCLUSIONS

Later entry into care drives increased mortality for rural compared with urban veterans with HIV. Future studies should explore the person, care system, and community-level determinants of late care entry for rural persons with HIV.

Standard of care: promoting antiretroviral adherence in clinical care

Although there has long been demand for programs and procedures that support or enhance adherence to antiretroviral therapy (ART) among HIV+ patients, there is scant evidence about the extent to which medical clinics have been able to incorporate adherence interventions into their standard care. A survey of clinical care settings in New York and Connecticut indicated that the current standard of care is to provide only minimal levels of adherence services, with ad hoc adherence support being offered on an as-needed basis, often by overburdened primary care staff. These results suggest a strong need for the development of ART adherence interventions that are not only easily translatable to real-life clinical settings, but also offer an organized compendium of resources for HIV+ patients, from initiation to maintenance.

Experiences of stigma and discrimination among adults living with HIV in a low HIV-prevalence context: a qualitative analysis

Little is known about how people living with HIV in low prevalence contexts face the challenges of stigma and discrimination. Low prevalence and rural communities are unique environments in which HIV-related stigma and discrimination may be intensified due to lower tolerance of differences among people and greater fear of HIV. This study examined the experiences of 16 individuals living with HIV who reside in a predominantly rural area with low HIV prevalence. We used in-depth interviews to explore participants' experience with stigma and discrimination in social and health care settings and their behavioral and emotional responses. In their day-to-day lives, participants described feeling social rejection, being forced to follow different rules of social contact, and being treated differently. In health care settings, participants described specific instances when they felt providers were afraid of them and when they were refused or discouraged treatment or treated differently based on their HIV status. Participants experienced stigma and acts of discrimination in different settings (e.g., physician and dentist offices and hospitals) and from a range of types of providers (e.g., physicians, nurses, and dentists). Behavioral and emotional responses to perceived acts of stigma and discrimination included anger, shame, social isolation, and self-advocacy. Findings point to a need to develop tailored interventions to address stigma and discrimination for individuals, health care personnel and the community-at-large.

Living in rural New England amplifies the risk of depression in patients with HIV

BACKGROUND

The importance of depression as a complication of HIV infection is increasingly understood, and people living in rural areas are at increased risk for depression. However, it is not known whether living in rural areas amplifies the risk of depression in patients with HIV.

METHODS

We compared the prevalence of depression between rural and metropolitan HIV patients seen at the Dartmouth-Hitchcock HIV Program in a retrospective cohort study. Using the validated Rural-Urban Commuting Area Score, we categorized patients as living in small town/rural areas, micropolitan or metropolitan towns. Then, using a multivariate logistic regression model to adjust for demographic factors that differed between rural and metropolitan patients, we estimated the impact of living in rural areas on the odds of depression.

RESULTS

Among 646 patients with HIV (185 small town/rural, 145 micropolitan, 316 metropolitan), rural patients were older, white, male, and men who have sex with men (ANOVA, F-statistic < 0.05). The prevalence of depression was highest in rural patients (59.5 vs. 51.7 vs. 41.2%, F statistic < 0.001), particularly rural patients on antiretroviral therapy (72.4 vs. 53.5 vs. 38.2%, F-statistic < 0.001. A multivariate logistic regression model showed that the odds of depression in rural patients with HIV were 1.34 (P < 0.001).

CONCLUSION

HIV-infected patients living in rural areas, particularly those on antiretroviral therapy, are highly vulnerable to depression.

Estimation of the prevalence of AIDS, opportunistic infections, and standard of care among patients with HIV/AIDS receiving care along the U.S.-Mexico border through the Special Projects of National Significance: a cross-sectional study

There is high demand for care among the Hispanic population in states along the U.S.-Mexico border. The objective is to describe the standard of care received by people living with HIV/AIDS (PLWH/A) at enrollment into one of five Special Projects of National Significance (SPNS) Sites located along the U.S.-Mexico border. This cross-sectional study describes the presence of opportunistic infections (OIs), AIDS status and two types of standard of care received by 707 PLWH/A participating in SPNS. Patients receiving care through SPNS in one of the five sites between June 1, 2002 and December 31, 2003 were invited to participate to the medical chart review component of the study. The association between sociodemographic variables and the prevalence of OIs and AIDS at enrollment was estimated using multivariate hierarchical logistic models. More than one quarter of the 707 participants had at least one OI recorded and 58% of new and 60% of existing patients had AIDS at enrollment in SPNS. The association between being Hispanic and having higher prevalence of OI and AIDS at entry varied by SPNS site. Standard of care was well followed overall. This is the first study describing HIV stage and OI prevalences and standard of care in PLWH/A in all U.S.-Mexico bordering states. Being of Hispanic ethnicity may not fully explain discrepancy in access to care along the border.

Adherence to antiretroviral therapy in patients enrolled in a comprehensive care program in Cambodia: A 24-month follow-up assessment

Background

The long-term maintenance of antiretroviral therapy (ART) remains an important issue, especially in limited-resource settings where additional barriers exist. A cross-sectional study was performed 24 months after ART initiation for patients treated in Cambodia in order to estimate the prevalence and identify determinants of non-adherence.

Methods

Adults receiving ART for 24 ±2 months were considered eligible for the study. Self-reported non-adherence was defined according to an algorithm based on six items. The questionnaire also assessed ART-related side effects and HIV disclosure. HIV-1 RNA plasma viral load was measured using real-time PCR. Multivariate rare events logistic regression analysis was used to identify independent factors associated with non-adherence.

Results

A total of 346 patients participated in the study. At 24 months, 95% of patients were adherent, 80% had HIV RNA <40 copies/ml and 75% had CD4+ T-cell counts >200 cells/mm3. Virological success was significantly higher in adherent patients than in non-adherent patients (81% versus 56%, P=0.021). Living in a rural area, limited HIV disclosure and perceived lipodystrophy were independently associated with non-adherence.

Conclusions

At 24 months, adherence to ART was high and explained positive virological outcomes. In order to maintain adherence and long-term virological benefits, special attention should be given to patients living in rural areas, those with lipodystrophy-related symptoms and others who express difficulties disclosing their condition to close family members.

Increased mortality in rural patients with HIV in New England

Although patients with human immunodeficiency virus (HIV) infection who live in the rural United States receive less expert care and less antiretroviral treatment, the impact of living in rural areas on mortality from HIV infection is unstudied. We compared mortality rates in 327 rural and 317 urban patients with HIV infection in a retrospective cohort study using a multivariate logistic regression model. Rural patients with HIV infection were older at the end of follow-up (43.4 vs. 41.4 years, p = 0.002), and more likely white (93.0% vs. 77.9%, p < 0.001), and a greater proportion were men who have sex with men (55.5% vs. 36.1%, p < 0.001). While the mean year of diagnosis was 1994 in rural patients and 1995 in urban patients (p < 0.001), the mean CD4(+) T cell count at presentation was similar in the two groups: 376 vs. 351 cells/mul (p = 0.298). Rural patients in our cohort were more likely to receive antiretroviral medications at any CD4 count (73.7 vs. 62.1%, p =0.0016), and received PCP prophylaxis at comparable rates (23.5% vs. 25.6%,p =0.555). Mortality was higher in rural patients (10.4% vs. 6.0%, p = 0.028). The risk of mortality remained higher in rural patients when adjusting for age, sex, race, HIV risk factors, year of diagnosis, travel time, lack of insurance, and receipt of antiretroviral treatment or PCP prophylaxis in a logistic regression model (OR 2.11, 1.064 to 4.218, p = 0.047). Patients with HIV who live in rural areas have higher mortality rates than urban patients with HIV.

Factors associated with fewer visits for HIV primary care at a tertiary care center in the Southeastern U.S

In this study we sought to evaluate sociodemographic and clinical characteristics associated with decreased access to HIV outpatient care in a University-based clinic in the Southeastern U.S. The number of HIV outpatient clinic visits per person-year was estimated among 1,404 HIV-infected individuals participating in a large observational clinical cohort study. On average, participants attended 3.38 visits per person-year (95% CI = 3.32, 3.44), with 71% attending fewer than 4 visits per year. Younger persons, of Black race/ethnicity, with less advanced HIV disease, and a shorter time from entry to HIV care, had poorer access to care, as did participants without health insurance and residing a greater distance from care. Vulnerable subgroups of HIV-infected patients in the South have decreased access to ongoing HIV health care. Interventions including more intensive counseling and active outreach for newly HIV diagnosed individuals and support with obtaining health insurance and transportation may lead to improved outcomes.

Characteristics of HIV-infected adults in the Deep South and their utilization of mental health services: A rural vs. urban comparison

Insufficient utilization of mental health services has been described among HIV-infected individuals in urban areas; however, little is known about utilization of mental health services among rural-living HIV-infected individuals. This article examines use of mental health services by HIV-infected adults in the Southern U.S., where approximately two-thirds of rural HIV cases reside, and compares mental health services use between those in rural and urban areas. Data were obtained from surveys of HIV-infected individuals receiving care at tertiary Infectious Diseases clinics in the Southern U.S. (n = 474). Study findings indicated that participants living in areas with a higher proportion of rural-living individuals were less likely to report seeing a mental health provider (p < .001) in the last year even though there were no differences in level of psychological distress by degree of rurality. Participants living in more rural areas also reported significantly fewer mental health visits in the previous month (p = .025). Furthermore, rural living was significantly associated with being African-American, heterosexual, less educated, and having minor children in the home. Due to differences in characteristics and mental health services use by degree of rurality, efforts are needed to assess and address the specific mental health and other needs of HIV-infected individuals in rural areas.

The epidemiology of HIV/AIDS in women in the southern United States

OBJECTIVE

We reviewed data from multiple sources to examine distinguishing features of the HIV epidemic among women in the South.

GOAL

The goal of this study was to identify HIV and sexually transmitted disease (STD) prevention research priorities in the South.

STUDY DESIGN

Cases of HIV/AIDS and STDs were analyzed to compare rates by region and rates in urban versus rural areas. Data from interviews of persons reported with HIV/AIDS from rural areas in 4 southern states compared social and behavioral characteristics of men versus women.

RESULTS

The South is characterized by high AIDS and STD rates. The epidemic among southern women is distinguished by the predominance of heterosexually acquired infection, the disproportionate impact on blacks, the high proportion residing in rural areas, and multiple high-risk behaviors.

CONCLUSIONS

Research to identify determinants of high-risk sex and drug-using behaviors among poor, minority men and women in less urban and rural southern regions is needed.

Mental Health Differences Between Rural and Urban Men Living with HIV Infection in Various Age Groups

Despite the disproportionate increase in rural, Southern residents and older persons during the third era of the HIV/AIDS epidemic, no known study has examined whether older, rural men living with HIV infection face a double jeopardy and have poorer psychosocial profiles than other subgroups of men. We investigated whether area of residence (rural, urban), age (young, middle-age, old), and the interaction of residence and age would be related to mental health factors by using two measurement methods to categorize rural and urban residence (US Census Bureau classification and The Office of Rural Health Policy's, Rural Urban Commuting Area Codes [RUCAs]). We conducted 2-3 hour-long, face-to-face interviews with all but 43 patients who met the study criteria and kept their clinic appointments at three different types of healthcare facilities (i.e., VA, university clinic, public health department) over a 20-month period. The sample consisted of 226 men living in the southeastern US. Rural and urban men of various age groups did not differ in socioeconomic factors, travel distance to clinics, use of medications, satisfaction with care, types of severe stressors, and confidentiality concerns. Using two methods to categorize area of residence, we found that rural men as compared to urban men had similar levels of total stress, AIDS-related stress, social support, active coping and avoidance coping, but higher rates of risk for depression. Rural men had higher levels of non-AIDS-related stress only when the US Census Bureau's categorization was used, which highlights the importance of carefully selecting and describing methods to categorize rural versus urban residence.

Review: use of health care services among persons living with HIV infection: state of the science and future directions

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.

Recruitment of physician offices for an office‐based adolescent smoking cessation study

Physician office settings play an important role in tobacco cessation intervention. However, few tobacco cessation trials are conducted at these sites, in part because of the many challenges associated with recruiting community physician offices into research. The present study identified and implemented strategies for recruiting physician offices into a randomized clinical trial of tobacco screening and cessation interventions with adolescent patients. A total of 30 community physicians participated in focus groups to elicit their perceptions of facilitators of and barriers to initial engagement of physician practices and the subsequent enrollment of the practices in long-term research projects. Physicians identified facilitators such as (a) the involvement of office staff in the recruitment process and (b) on-site presentations of the study's background and aims. Some of the barriers identified were time commitment concerns and the lack of incentives in exchange for participation. These focus group findings were then integrated with theory-based and empirically driven recruitment strategies for a 12-month randomized tobacco intervention trial with adolescent patients. Of 185 office practices approached to participate (screened from a pool of 273 practices), 103 agreed to on-site presentations of the study. Subsequently, almost all of the practices (101) that received the presentation agreed to enroll in the study. Conclusions are that (a) recruitment is a multicomponent process, (b) the processes of communication, engagement, and enrollment must be carefully planned and implemented to achieve maximal results, and (c) the development of effective strategies for recruiting health care provider practices presents an important infrastructure for testing adolescent smoking cessation interventions.

Moving for care: findings from the US HIV Cost and Services Utilization Study

This paper examines sociodemographic and HIV-related factors associated with moving post-HIV diagnosis for non-care- and care-related reasons (versus never moving post-HIV diagnosis). Distinctions are made between those who move for informal care only, formal care only, or informal and formal care. Data come from the nationally representative US HIV Cost and Services Utilization Study (N=2,864). Overall, 31.8% moved at least once post-HIV diagnosis and 16.3% moved most recently for care. Among those who moved for care, 32.6% moved for informal care only, 26.8% for formal care only, and 40.6% moved for both. Post-HIV diagnosis moves for reasons unrelated to care were less likely among African Americans and older persons, and more likely among those with longer durations positive. Moves for care were less likely among African Americans, older persons, and persons with higher educational attainments, while they were more likely among those with an AIDS diagnosis and longer durations HIV-positive. Among those who moved for care, women and persons with higher incomes were less likely to move for formal or mixed care than informal care only. Given that moving for care may reflect disparities in access to care and unmet needs, additional analyses with more detailed data are warranted.

Lipid screening in HIV-infected veterans

BACKGROUND

Lipid screening is recommended for patients taking protease inhibitors (PIs).

METHODS

We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs).

RESULTS

Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0-1.5), diabetic (RR = 1.2, confidence limits: 1.1-1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3-1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79-1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75-0.95).

CONCLUSIONS

Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.

Variations in rural AIDS epidemiology and service delivery models in the United States

This article reviews AIDS surveillance data and the rural health literature to summarize what is known about the rural AIDS epidemic, characteristics of rural environments that affect HIV service delivery, and approaches that rural areas are using to address the health and support service needs of HIV-positive residents. During 1999, nonmetropolitan (non-MSA) adult/adolescent AIDS rates were highest in the South (11 per 100,000) and Northeast (9 per 100,000). The South had the highest non-MSA proportion of adult/adolescent AIDS cases (12%), followed by the North Central region (9%), the West (4%), and the Northeast (3%). Variations in rural HIV/AIDS epidemiologic patterns and the demographic, socio-economic, and cultural characteristics of rural environments are likely to require different levels of resource investment and different methods of organizing and delivering HIV services. Currently, many HIV-positive rural residents are traveling to metropolitan areas for medical care because of concerns about confidentiality or a lack of confidence in the HIV management capabilities of local physicians. Rural communities are attempting to address these problems by developing the HIV care capacity of existing clinics, building local networks of physicians with HIV management experience, and cultivating "shared care" arrangements with urban-based specialists.