HIV in Predominantly Rural Areas of the United States

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

BACKGROUND

Mississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.

PURPOSE

The study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.

METHODS

Semi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.

RESULTS

Data suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.

CONCLUSIONS

Though patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

Behaviors associated with HIV transmission risk among rural sexual and gender minority and majority residents

Multiple rural states and communities experience elevated rates of human immunodeficiency virus (HIV), often associated with diminished healthcare access and increased drug use. Though a substantial proportion of rural populations are sexual and gender minorities (SGM), little is known of this group regarding substance use, healthcare utilization, and HIV transmission behaviors. During May-July 2021, we surveyed 398 individuals across 22 rural Illinois counties. Participants included cisgender heterosexual males (CHm) and females (CHf) (n = 110); cisgender non-heterosexual males and females (C-MSM and C-WSW; n = 264); and transgender individuals (TG; n = 24). C-MSM participants were more likely to report daily-to-weekly alcohol and illicit drug use prescription medication misuse (versus CHf; aOR = 5.64 [2.37-13.41], 4.42 [1.56-12.53], and 29.13 [3.80-223.20], respectively), and C-MSM participants more frequently reported traveling to meet with romantic/sex partners. Further, more C-MSM and TG than C-WSW reported healthcare avoidance and denial due to their orientation/identity (p < 0.001 and p = 0.011, respectively); 47.6% of C-MSM and 58.3% of TG had not informed their provider about their orientation/identity; and only 8.6% of C-MSM reported ever receiving a pre-exposure prophylaxis (PrEP) recommendation. More work is needed to explore the substance use and sexual behaviors of rural SGM, as well as their healthcare interactions, to better target health and PrEP engagement campaigns.

Sociodemographic Characteristics of HIV-Associated Dementia in the South Carolina Alzheimer's Disease Registry

OBJECTIVES

Studies examining the sociodemographic characteristics associated with human immunodeficiency virus (HIV)-associated dementia (HAD) are lacking, especially in the southern United States. The aim of this study was to describe the characteristics of HAD using South Carolina Alzheimer's Disease Registry data, and examine these characteristics across two time periods.

METHODS

Data were obtained from the population-based, South Carolina Alzheimer's Disease Registry from 2000-2006 and 2010-2016 (N = 165,487). Crude and multivariable logistic regression models were applied to determine sociodemographic characteristics associated with HAD by time period.

RESULTS

Younger, Black, Other, men, and urban populations had greater odds of being diagnosed as having HAD in both time periods. For example, compared with individuals aged 85 years and older, individuals aged 18 to 34 had 97 times the odds (adjusted odds ratio 97.0; 95% confidence interval 31.6-297.8) of being diagnosed as having HAD. In 2010-2016, however, nursing facility populations had a greater odds of being diagnosed as having HAD.

CONCLUSIONS

We found that younger populations (younger than 74 years), communities of color, men, urban populations, and nursing facility populations were more likely to have HAD. Future research should focus on the association between HAD and risk for Alzheimer's disease.

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.

HIV pre-exposure prophylaxis awareness, practices, and comfort among urban and rural family medicine physicians

PURPOSE

HIV rates are increasing in rural areas, and adolescents are disproportionately affected. HIV pre-exposure prophylaxis (PrEP) is a daily pill that is effective at preventing HIV; however, PrEP uptake among adolescents is low. PrEP is dependent on primary care providers (PCPs) prescribing it, but research has overwhelmingly sampled urban PCPs. This study compared the PrEP awareness, practices, and comfort between rural and urban family medicine physicians.

METHODS

A total of 256 family medicine physicians in the United States were recruited from a Qualtrics panel to complete an online cross-sectional survey between July 15 and August 9, 2022. Participants completed items assessing their demographic characteristics and PrEP awareness, practices, and comfort. A chi-square test of independence and multiple logistic regression were used to determine rural/urban differences.

FINDINGS

Rural family medicine physicians were less comfortable than urban family medicine physicians in providing sexual risk reduction counseling to adolescents, telling an adolescent patient their HIV test result was HIV positive, and implementing all of the PrEP clinical activities for adolescents.

CONCLUSIONS

Education, skill-building, and collaborative partnership interventions could improve the comfort levels of rural family medicine physicians in implementing the PrEP guidelines for their adolescent patients. Future research is needed to understand the factors that explain the differences in PrEP-related attitudes and practices between urban and rural family medicine physicians. Results from such studies could inform provider-based interventions that ultimately increase PrEP use and decrease HIV rates among rural adolescents.

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.

The impact of carceral churn and healthcare organizations on HIV/AIDS incidence in Arkansas

•Penal and healthcare institutions generate and mitigate community-level health inequality, respectively.•Arkansas Counties with high prison churn and disadvantage have higher rates of HIV/AIDS.•Hospital density moderates effect of prison churn on incidence of HIV/AIDS.

Acceptability and Comfort Regarding Remotely Delivered PrEP Services in Mississippi

Despite the prevalence of human immunodeficiency virus (HIV) in Mississippi, access to pre-exposure prophylaxis (PrEP) is mostly limited to urban areas. Remote PrEP care via telemedicine, HIV self-testing, and prescription mail delivery can improve care in underserved communities. This mixed methods study assessed the acceptability and feasibility of using remote PrEP care, compared to alternatives. This consisted of (1) a cross-sectional survey and (2) interviews. PrEP-eligible adults were recruited from community-based organizations across Mississippi while accessing HIV testing between December 2019 and May 2022. Those surveyed (n = 63) indicated the greatest comfort in receiving PrEP via mail delivery (m = 5.14) and telemedicine (m = 4.89) and least comfort at gyms (m = 3.92). Comfort significantly differed between mail delivery and gyms (F = 2.90; P < .01). Those interviewed (n = 26) expressed relatively high comfort with remote PrEP care citing enhanced accessibility, privacy, simplicity, and quality. Remote PrEP services were acceptable and feasible among our sample, thus, should be expanded in Mississippi to address unmet needs.

Association between the geographic accessibility of PrEP and PrEP use among MSM in nonurban areas

PURPOSE

The US HIV epidemic has become a public health issue that increasingly affects men who have sex with men (MSM), including those residing in nonurban areas. Increasing access to pre-exposure prophylaxis (PrEP) in nonurban areas will prevent HIV acquisition and could address the growing HIV epidemic. No studies have quantified the associations between PrEP access and PrEP use among nonurban MSM.

METHODS

Using 2020 PrEP Locator data and American Men's Internet Survey data, we conducted multilevel log-binomial regression to examine the association between area-level geographic accessibility of PrEP-providing clinics and individual-level PrEP use among MSM residing in nonurban areas in the United States.

FINDINGS

Of 4,792 PrEP-eligible nonurban MSM, 20.1% resided in a PrEP desert (defined as more than a 30-minute drive to access PrEP), and 15.2% used PrEP in the past 12 months. In adjusted models, suburban MSM residing in PrEP deserts were less likely to use PrEP in the past year (adjusted prevalence ratio [aPR] = 0.35; 95% confidence interval [CI] = 0.15, 0.80) than suburban MSM not residing in PrEP deserts, and other nonurban MSM residing in PrEP deserts were less likely to use PrEP in the past year (aPR = 0.75; 95% CI = 0.60, 0.95) than other nonurban MSM not residing in PrEP deserts.

CONCLUSIONS

Structural interventions designed to decrease barriers to PrEP access that are unique to nonurban areas in the United States are needed to address the growing HIV epidemic in these communities.

Hepatitis C and HIV Screening, Testing, and Risk Perceptions among South-Central Appalachian County Health Department Staff

OBJECTIVES

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are significant public health concerns, especially given the risks for disease interactions. Rates of HCV and HIV are increasing, especially in rural areas. Local health departments (LHDs) play an important role in rural health care, offering screening, testing, and treatment for HCV and HIV. Gaps persist in LHD resources for meeting these demands, especially in Appalachia and the US South.

METHODS

To explore HCV/HIV screening, testing, and treatment approaches and perspectives in south-central Appalachian North Carolina, structured telephone questionnaires were administered to communicable disease nurses and other health department staff directly involved in screening and testing. Mixed-methods data analyses were conducted and triangulated with stakeholders.

RESULTS

Eighteen participants representing 19 counties completed the questionnaire, achieving a saturation sample. Participants reported barriers to screening and testing, including housing insecurity, lack of transportation and insurance, unemployment, and the isolation of living in a rural area. Divergence in perceptions of barriers between public health regions emerged, as did perceptions of who is at risk and use of stigmatizing language about people at risk for HCV/HIV.

CONCLUSIONS

This study highlights the impact of LHD behaviors and perceptions on screening and testing, and offers recommendations to improve HCV/HIV screening and testing accessibility in south-central Appalachia, a high-risk region.

Meeting Kids Where They Are At-A Substance Use and Sexual Risk Prevention Program via Telemedicine for African American Girls: Usability and Acceptability Study

BACKGROUND

Rural African American youth lack access to drug and sexual risk-taking prevention programs available in more urban areas. Recent data indicate that rural youth now use substances at higher rates and at younger ages than their urban peers.

OBJECTIVE

This study aims to evaluate the initial usability and acceptability of a low-cost, technology-based approach to delivering effective, culturally tailored, integrated substance use disorder (SUD) and HIV risk behavior prevention programs to African American female youth to inform the use of this intervention via telemedicine for rural youth.

METHODS

Effective SUD prevention strategies and emotion regulation skills were integrated into an existing evidence-based HIV risk reduction program culturally tailored for African American female adolescents-Sisters Informing, Healing, Living, and Empowering (SIHLE)-and delivered to 39 African American female youth via group telehealth. The evaluation of the resulting program, 12-session SIHLEplus, was completed by 27 girls who also completed self-report measures that assessed sexual risk behaviors (eg, number of partners and age of sex initiation), substance use, exposure to traumatic events, and emotion regulation.

RESULTS

The descriptive and qualitative results of the pilot study demonstrate the initial usability and acceptability of delivering evidence-based prevention successfully via telehealth to help address health disparities in this vulnerable population.

CONCLUSIONS

Although more research is needed, the findings from this study suggest that SIHLEplus has demonstrated initial usability and acceptability.

Stigma, isolation, and depression among older adults living with HIV in rural areas

There is a growing population of ageing individuals living with acquired immunodeficiency syndrome (HIV). Older adults living with HIV often contend with intersecting stigmas including HIV stigma, ageism, and for some, homonegativity and/or racism. Although the HIV stigma literature is quite robust, research on the relationship between HIV stigma, social support, and mental well-being among older adults living with HIV is limited. This study begins to address this gap by examining how intersectional stigma affects social support and mental wellbeing among rural-dwelling older adults living with HIV. Qualitative interviews were conducted by phone with 29 older adults living with HIV, over the age of 50, living in rural areas of the United States. Interviews were transcribed verbatim and analyzed using thematic content analysis in MAXQDA qualitative analysis software. Analysis revealed three primary themes. The first had to do with gossip and non-disclosure of HIV status, which intersected with ageism and homonegativity to exacerbate experiences that fell within the remaining themes of experiences of physical and psychological isolation and loneliness, and shame and silence surrounding depression. The prevalence of social isolation and the effects of limited social support among older adults living with HIV are prominent and indicate a need for tailored interventions within the HIV care continuum for older adults living with HIV.

Influence of Rurality on HIV Testing Practices Across the United States, 2012-2017

In the US, HIV testing has been key in the identification of new HIV cases, allowing for the initiation of antiretroviral treatment and a reduction in disease transmission. We consider the influence of living in a rural area (rurality) on HIV testing between different US regions and states as existing work in this area is limited. Using the 2012-2017 Behavioral Risk Factor Surveillance Systems surveys, we explored the independent role of rurality on having ever been tested for HIV and having a recent HIV test at the national, regional, and state levels by calculating average adjusted predictions (AAPs) and average marginal effects (AMEs). Suburban and urban areas had higher odds and AAPs of having ever been tested for HIV and having a recent HIV test compared to rural areas across the US. The Midwest had the lowest AAPs for both having ever been tested for HIV (17.57-20.32%) and having a recent HIV test (37.65-41.14%) compared to other regions. For both questions on HIV testing, regions with the highest AAPs had the greatest rural-urban differences in probabilities and regions with the lowest AAPs had the smallest rural-urban difference in probabilities. The highest rural-urban testing disparities were observed in states with high AAPs for HIV testing. HIV testing estimates were higher in urban compared to rural areas at the national, regional, and state level. This study examines the isolated influence of rurality on HIV testing and identifies specific US areas where future efforts to increase HIV testing should be directed to.

HIV conspiracy theory beliefs mediates the connection between HIV testing attitudes and HIV prevention self-efficacy

Objective: High rates of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) can be found in states in both the Appalachian and Southeastern regions of the United States. As infection rates increase, it is imperative to understand factors that improve HIV prevention. The current work explored whether HIV conspiracy beliefs influences the link between HIV testing attitudes and perceived prevention ability. Participants: Four samples were collected during Fall 2013 (N = 373), Spring 2014 (N = 231), Fall 2014 (N = 345), and Spring 2015 (N = 369) at a rural, Southeastern, Appalachian university. Methods: Participants in all samples completed an online survey. Results: Four studies showed that HIV conspiracy theory beliefs mediated the relationship between HIV testing attitudes and HIV prevention self-efficacy. Conclusions: HIV conspiracy theory beliefs at least partially explain the connection between testing attitudes and HIV prevention self-efficacy. Results have implications for the role of HIV testing attitudes, beliefs, and self-efficacy.

National estimates of case-mix, mortality, and economic outcomes among inpatient HIV/AIDS mono-infection and hepatitis C co-infection cases in the US

RATIONALE, AIMS, AND OBJECTIVES

To assess inpatient clinical and economic outcomes for AIDS/HIV and Hepatitis C (HCV) co-infection in the United States from 2003 to 2014.

METHOD

This historical cohort study utilized nationally representative hospital discharge data to investigate inpatient mortality, length of stay (LoS), and inflation-adjusted charges among adults (≥18 years). Outcomes were analysed via multivariable generalized linear models according to demographics, hospital and clinical characteristics, and AIDS/HIV or HCV sequelae.

RESULTS

Overall, 17.8% of the 2.75 million estimated AIDS/HIV inpatient cases involved HCV from 2003 to 2014, averaging 48.5 ± 9.0 years of age and 68.0% being male. Advanced sequalae of AIDS and HCV incurred a LoS of 10.3 ± 11.9 days, charges of $88 789 ± 131 787, and a 16.9% mortality. Many cases involved noncompliance, tobacco use disorders, and substance abuse. Although mortality decreased over time, multivariable analyses indicated that poorer outcomes were generally associated with more advanced clinical conditions and AIDS-associated sequalae, although mixed results were observed for specific manifestations of HCV. Rural residence was independently associated with a 3.26 times higher adjusted odds of mortality from 2009 to 2014 for HIV/HCV co-infection (P < 0.001), although not for AIDS/HCV (OR = 1.38, P = 0.166).

CONCLUSION

Given the systemic nature and modifiable risks inherent within coinfection, more proactive screening and intervention appear warranted, particularly within rural areas.

Repeat Human Immunodeficiency Virus Testing by Transmission Risk Group and Rurality of Residence in North Carolina

BACKGROUND

Understanding of repeat human immunodeficiency virus (HIV) testing (RHT) is limited and the impact of rural residence as a potential barrier to RHT is unknown. Rural populations are of particular interest in the Southeastern United States because of their disproportionate HIV burden.

METHODS

We used HIV surveillance data from publicly funded HIV testing sites in North Carolina to assess repeat testing by transmission risk group and residential rurality in a retrospective cohort study. Linear binomial regression models were used to estimate adjusted, 1-year cumulative incidences and cumulative incidence differences comparing RHT within transmission risk populations by level of rurality.

RESULTS

In our total study population of 600,613 persons, 19,275 (3.2%) and 9567 (1.6%) self-identified as men who have sex with men (MSM) and persons who inject drugs (PWID), respectively. A small minority, 13,723 (2.3%) resided in rural ZIP codes. Men who have sex with men were most likely to repeat test (unadjusted, 1-year cumulative incidence after an initial negative test, 16.4%) compared with PWID (13.2%) and persons who did not identify as either MSM or PWID (13.6%). The greatest effect of rurality was within PWID; the adjusted, 1-year cumulative incidence of RHT was 6.4 (95% confidence interval, 1.4-11.4) percentage points higher among metropolitan versus rural PWID.

CONCLUSIONS

One-year cumulative incidence of RHT was low among all clients of publicly funded HIV testing sites in North Carolina, including MSM and PWID for whom annual testing is recommended. Our findings suggest a need for public health efforts to increase access to and support for RHT, particularly among rural PWID.

HIV/HCV Co-infection: Burden of Disease and Care Strategies in Appalachia

PURPOSE OF REVIEW

The purpose of this review is to address infection with HIV and hepatitis C in the Appalachian region of the USA and the driving forces underlying this epidemic. We seek to discuss epidemiology of disease and the possible interventions to reduce incidence and burden of disease in this resource-limited area.

RECENT FINDINGS

The rise of the opioid crisis has fueled a rise in new hepatitis C infection, and a rise in new HIV infection is expected to follow. Injection drug use has directly contributed to the epidemic and continues to remain a risk factor. Men who have sex with men remains a significant risk factor for HIV acquisition as well. Progress has been made in the battle against HIV and, to a lesser extent, hepatitis C, but much more can be done. Limited data on co-infection with HIV/HCV are currently available for this at-risk region, but it is clear that Appalachia is highly vulnerable to co-infection outbreaks. A multipronged approach that includes advances in assessment of co-infection and education for both patients and clinicians can help to recognize, manage, and ideally prevent these illnesses.

Racial Discrimination, Protective Processes, and Sexual Risk Behaviors Among Black Young Males

Racial discrimination is a documented risk factor for sexual risk behaviors among young Black men. Mechanisms of effect and protective processes remain to be investigated. This study examined the mediating effect of emotional distress, self-regulation, and substance use on the association between racial discrimination and sexual risk behaviors. Sexual risk behaviors included in this study were inconsistent condom use and sexual concurrency (sexual partnerships that overlap overtime). The protective effect of protective social ties was also investigated. A sample of 505 heterosexually active men aged 19-22 years were recruited and surveyed for 3 time points. Men answered questions on racial discrimination, sexual risk behaviors, emotional distress, self-regulation, and substance use. Mediation and moderation models were tested. Racial discrimination (T1) significantly and positively predicted emotional distress (T2). Emotional distress, substance use, and self-regulation partially mediated the association between racial discrimination and sexual risk behaviors. Protective social ties attenuated the effects of emotional distress on substance use and self-regulation. Racial discrimination is an important context for sexual risk behaviors. Minority stress may translate to sexual risk behavior through psychosocial mediators, such as emotional distress, self-regulation, and substance use. Protective social ties may buffer against emotional distress to reduce substance use and increase self-regulation. The findings of this study can provide new insights through the investigation of risk and protective processes that influence sexual risk behaviors among young Black men.

Primary brain and other central nervous system tumors in Appalachia: regional differences in incidence, mortality, and survival

BACKGROUND

The Appalachian region is a large geographic and economic area, representing 7.69% of the United States (US). This region is more rural, whiter, older, and has a higher level of poverty as compared to the rest of the US. Limited research has been done on primary brain and other central nervous system tumors (PBT) epidemiology in this region. In this analysis we characterize incidence, mortality, and survival patterns.

METHODS

Data from 2006 to 2015 were obtained from the central brain tumor registry of the US (provided by CDC and NCI). Appalachian counties were categorized using the Appalachia Regional Council scheme. Overall and histology-specific age-adjusted incidence and mortality rates per 100,000 population were generated. 1-, 5-, and 10-year relative survival (RS) was estimated using CDC national program of cancer registry data from 2001 to 2014.

RESULTS

Overall PBT incidence within Appalachia was 22.62 per 100,000, which is not significantly different from the non-Appalachian US (22.77/100,000, p = 0.1189). Malignant incidence was 5% higher in Appalachia (7.55/100,000 vs. 7.23/100,000, p < 0.0001), while non-malignant incidence was 3% lower (15.07/100,000 vs. 15.54/100,000, p < 0.0001). 5-year RS for malignant PBT was lower (31.4% vs. 36.0%), and mortality due to malignant PBT was higher in Appalachia (4.86/100,000 vs. 4.34/100,000, p < 0.0001).

CONCLUSION

Appalachia has increased malignant and decreased non-malignant PBT incidence, and poorer survival outcomes for malignant PBT compared to the non-Appalachian US.

Patterns of Alcohol Use Among Patients Living With HIV in Urban, Large Rural, and Small Rural Areas

BACKGROUND

For people living with HIV (PLWH), alcohol use is harmful and may be influenced by unique challenges faced by PLWH living in rural areas. We describe patterns of alcohol use across rurality among PLWH.

METHODS

Veterans Aging Cohort Study electronic health record data were used to identify patients with HIV (ICD-9 codes for HIV or AIDS) who completed AUDIT-C alcohol screening between February 1, 2008, and September 30, 2014. Regression models estimated and compared 4 alcohol use outcomes (any use [AUDIT-C > 0] and alcohol use disorder [AUD; ICD-9 codes for abuse or dependence] diagnoses among all PLWH, and AUDIT-C risk categories: lower- [1-3 men/1-2 women], moderate- [4-5 men/3-5 women], higher- 6-7]), and severe-risk [8-12], and heavy episodic drinking (HED; ≥1 past-year occasion) among PLWH reporting use) across rurality (urban, large rural, small rural) and census-defined region.

FINDINGS

Among 32,699 PLWH (29,540 urban, 1,301 large rural, and 1,828 small rural), both any alcohol use and AUD were highest in urban areas, although this varied across region. Predicted prevalence of any alcohol use was 54.1% (53.5%-54.7%) in urban, 49.6% (46.9%-52.3%) in large rural, and 50.6% (48.3%-52.9%) in small rural areas (P < .01). Predicted prevalence of AUD was 14.4% (14.0%-14.8%) in urban, 11.8% (10.0%-13.5%) in large rural, and 12.3% (10.8%-13.8%) in small rural areas (P < .01). Approximately 12% and 25% had higher- or severe-risk drinking and HED, respectively, but neither differed across rurality.

CONCLUSION

Though some variation across rurality and region was observed, alcohol-related interventions are needed for PLWH across all geographic locations.

Stigma and Spiritual Well-being among People Living with HIV/AIDS in Southern Appalachia

The Appalachian South is disproportionately affected by HIV/AIDS. Partly due to the negative connotation that this disease carries in religiously conservative areas, HIV-related stigma remains a critical barrier to HIV care in the South. However, spirituality is a well-documented, effective coping mechanism among persons living with HIV/AIDS (PLWH). The purpose of this study was to examine the relationship between HIV-related stigma and spiritual well-being among a sample of PLWH (n = 216) in Appalachian counties of Tennessee and Alabama using the HIV Stigma Scale and the Spiritual Well-being Scale. Overall, disclosure of HIV status was the most highly reported stigma concern. Women reported higher levels of stigma and religious well-being than men. While existential well-being was negatively correlated with stigma, no significant overall correlation was found between religious well-being and stigma. Our findings reveal the importance of defining theology and differentiating between cultural religious conditioning and internalized beliefs.

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.

Pathways to HIV-Related Behavior Among Heterosexual, Rural Black Men: A Person-Centered Analysis

We investigated the psychosocial mechanisms linking personal and contextual risk factors to HIV-related behavior among 498 rural Black men. We characterized HIV-related behavior in terms of profile groups and hypothesized that contextual and personal risk factors (childhood adversity, community disadvantage, incarceration, and racial discrimination) would predict HIV-related behavior indirectly via two psychosocial mechanisms: impulsivity and negative relational schemas. Study results documented three HIV-related behavior profile groups. The Safer group reported low levels of risky behavior. The Risk-Taking group reported inconsistent condom use and elevated substance use. The Multiple Partners group reported the highest numbers of partners and relatively consistent condom use. Risk factors predicted profile groups directly and indirectly through psychosocial mechanisms. Impulsivity mediated the association between community disadvantage and membership in the risk-taking group. Negative relational schemas mediated the associations of childhood experiences and community disadvantage with membership in the multiple partners group. Specificity in pathways suggests the need for targeted interventions based on multidimensional characterizations of risk behavior.

What about Us? Economic and Policy Changes Affecting Rural HIV/AIDS Services and Care

Health care budgets and policies are chief drivers in the delivery and access to health services. Place is also a factor that affects patient and provider experiences within the health care system. We examine the impact of policy changes and subsequent budget cuts on rural HIV/AIDS care, support services, and prevention. We interviewed 11 social workers, case managers, and outreach workers who serve rural people living with HIV/AIDS. We conducted telephone interviews inquiring about the effect of economics and policies on direct practice with rural clients. We analyzed data using a content analysis approach. We found several themes from the data. Ryan White funding and policy changes shifted direct practice to a medical case management model. Changes in federal and state poverty levels affected client eligibility for the AIDS Drugs Assistance Program. Policy banning financial support for syringe service programs hindered prevention efforts to reduce HIV/AIDS transmission. Ancillary services were reduced, such as housing assistance, transportation, and emergency financial assistance. In conclusion, we highlight the importance of place-based policies to improve access to healthcare and services. We also provide recommendations for greater inclusion in HIV/AIDS-related policy development, care, and service planning for rural workers.

Provider and Administrator Experiences With Providing HIV Treatment and Prevention Services in Rural Areas

Using Andersen's behavioral model of health services use, this study analyzes data from 62 semistructured interviews of providers and administrators at health clinics and social service agencies in rural Florida. Andersen's model addresses predisposing, enabling, and need factors that influence health services use. ATLASti was used to code all interviews and to extract HIV-related themes. The aim of this study was to: (1) add a new dimension to the literature on HIV care services in rural areas, (2) reveal factors that impact ability to provide care to PLWH in rural areas, and (3) suggest ways in which providers and administrators may address any unmet health care needs of PLWH. Respondents perceived systems factors to be more important determinants of access to care for individuals living with HIV and supported ongoing trainings that would increase staff understanding of the needs of people living with HIV.

Understanding HIV-Related Stigma Among Women in the Southern United States: A Literature Review

Societal stigmatization of HIV/AIDS due to assumptions about transmission and associated behaviors plays a substantial role in the psychosocial well-being of people living with this chronic illness, particularly for women in traditionally conservative geographic regions. Known for social conservatism, the Southern United States (US) holds the highest incidence rate of HIV infection in the US. A systematic search of four databases was used to identify 27 relevant scientific articles pertaining to HIV-related stigma among women living with HIV/AIDS in the Southern US. These studies revealed a rudimentary understanding of stigma sources, effects, and stigma-reduction interventions in this population. Due to the cultural specificity of stigma, further differentiation of stigma in discrete sectors of the South as well as a dialogue about the moral implications of stigma is necessary to lay the groundwork for patient-centered interventions to mitigate the destructive effects of stigma experienced by women in this region.

Infectious and Non-infectious Etiologies of Cardiovascular Disease in Human Immunodeficiency Virus Infection

Background:

Increasing rates of HIV have been observed in women, African Americans, and Hispanics, particularly those residing in rural areas of the United States. Although cardiovascular (CV) complications in patients infected with human immunodeficiency virus (HIV) have significantly decreased following the introduction of antiretroviral therapy on a global scale, in many rural areas, residents face geographic, social, and cultural barriers that result in decreased access to care. Despite the advancements to combat the disease, many patients in these medically underserved areas are not linked to care, and fewer than half achieve viral suppression.

Methods:

Databases were systematically searched for peer-reviewed publications reporting infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients. Relevant articles cited in the retrieved publications were also reviewed for inclusion.

Results:

A variety of outcomes studies and literature reviews were included in the analysis. Relevant literature discussed the manifestations, diagnosis, treatment, and outcomes of infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients.

Conclusion:

In these medically underserved areas, it is vital that clinicians are knowledgeable in the manifestations, diagnosis, and treatment of CV complications in patients with untreated HIV. This review summarizes the epidemiology and causes of CV complications associated with untreated HIV and provide recommendations for management of these complications.

Condom Use in the Context of Main and Casual Partner Concurrency: Individual and Relationship Predictors in a Sample of Heterosexual African American Men

Researchers have identified engagement in sexual concurrency, particularly when condom use is inconsistent, as a risk factor for HIV and other sexually transmitted infections. This risk is particularly salient in rural communities in which dense interconnection of sexual networks can promote the spread of sexually transmitted infections. The authors investigated individual and relationship factors that predict inconsistent condom use in the context of main and casual partner sexual concurrency among 176 rural African American men. The individual psychosocial factors investigated included impulsivity and anger/hostility. Relationship variables included fidelity expectations, criticism from partners, and relationship control in both main and casual relationships. No individual risk factors were associated with main partner inconsistent condom use; however, impulsivity and anger/hostility positively predicted inconsistent condom use with a casual partner. Relationship control in the main partnership predicted inconsistent condom use with the main partner. Criticism from the main partner positively predicted inconsistent condom use with a casual partner. Finally, expectations for a casual partner's fidelity positively predicted inconsistent condom use with that partner. These findings underscore the importance of considering the influence of one sexual partnership on behavior in another and of taking this complexity into account in the development of preventive interventions.

Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013

The Democratic Republic of the Congo (DRC) has one of the lowest HIV prevalence in sub-Saharan Africa, estimated at 1.1% [0.9-1.3] of adults aged 15-49 in 2013 (UNAIDS). Within the 2 million km(2) country, however, there exists spatial variation in HIV prevalence, with the highest HIV prevalence observed in the large cities of Kinshasa and Lubumbashi. Globally, HIV is an increasingly rural disease, diffusing outwards from urban centers of high HIV prevalence to places where HIV was previously absent or present at very low levels. Utilizing data collected during Demographic and Health Surveillance (DHS) in 2007 and 2013 in the DRC, we sought to update the map of HIV prevalence in the DRC as well as to explore whether HIV in the DRC is an increasingly rural disease or remains confined to urban areas. Bayesian kriging and regression indicate that HIV prevalence in rural areas of the DRC is higher in 2013 than in 2007 and that increased distance to an urban area is no longer protective against HIV as it was in 2007. These findings suggest that HIV education, testing and prevention efforts need to diffuse from urban to rural areas just as HIV is doing.

Racial Discrimination and HIV-related Risk Behaviors in Southeast Louisiana

OBJECTIVES

We examined the relationship between cumulative experiences of racial discrimination and HIV-related risk taking, and whether these relationships are mediated through alcohol use among African Americans in semi-rural southeast Louisiana.

METHODS

Participants (N = 214) reported on experiences of discrimination, HIV sexual risk-taking, history of sexually transmitted infection (STI), and health behaviors including alcohol use in the previous 90 days. Experiences of discrimination (scaled both by frequency of occurrence and situational counts) as a predictor of a sexual risk composite score as well as a history of STI was assessed using multivariate linear and logistic regression, respectively, including tests for mediation by alcohol use.

RESULTS

Discrimination was common in this cohort, with respondents confirming their experience on average 7 of the 9 potential situations and on more than 34 separate occasions. After adjustment, discrimination was significantly associated with increasing sexual risk-taking and lifetime history of STI when measured either by frequency of occurrence or number of situations, although there was no evidence that these relationships were mediated through alcohol use.

CONCLUSIONS

Cumulative experiences of discrimination may play a significant role in sexual risk behavior and consequently increase vulnerability to HIV and other STIs.

Disparities in Temporal and Geographic Patterns of Declining Heart Disease Mortality by Race and Sex in the United States, 1973-2010

BACKGROUND

Examining small-area differences in the strength of declining heart disease mortality by race and sex provides important context for current racial and geographic disparities and identifies localities that could benefit from targeted interventions. We identified and described temporal trends in declining county-level heart disease mortality by race, sex, and geography between 1973 and 2010.

METHODS AND RESULTS

Using a Bayesian hierarchical model, we estimated age-adjusted mortality with diseases of the heart listed as the underlying cause for 3099 counties. County-level percentage declines were calculated by race and sex for 3 time periods (1973-1985, 1986-1997, 1998-2010). Strong declines were statistically faster or no different than the total national decline in that time period. We observed county-level race-sex disparities in heart disease mortality trends. Continual (from 1973 to 2010) strong declines occurred in 73.2%, 44.6%, 15.5%, and 17.3% of counties for white men, white women, black men, and black women, respectively. Delayed (1998-2010) strong declines occurred in 15.4%, 42.0%, 75.5%, and 76.6% of counties for white men, white women, black men, and black women, respectively. Counties with the weakest patterns of decline were concentrated in the South.

CONCLUSIONS

Since 1973, heart disease mortality has declined substantially for these race-sex groups. Patterns of decline differed by race and geography, reflecting potential disparities in national and local drivers of these declines. Better understanding of racial and geographic disparities in the diffusion of heart disease prevention and treatment may allow us to find clues to progress toward racial and geographic equity in heart disease mortality.

Impact of a community popular opinion leader intervention among African American adults in a southeastern United States community

We examine the impact of an adapted community popular opinion leader (C-POL) intervention targeting alcohol-using social networks in Southeast Louisiana. A pre-post C-POL was conducted between October 2009 and April 2013, targeting alcohol users. A total of 65 popular opinion leaders were recruited, trained, and deployed into their social networks to diffuse intervention messages. Anonymous community surveys conducted within the venues among 99 male and female participants at baseline and 197 at 6 months to 1 year later revealed significant behavioral and knowledge changes. Average sexual risk score based on 7 sexual risk items declined from 15.3 to 11.9 (p<0.001); the number of vaginal and anal sex partners in the last year decreased from 11.3 to 7.7 and 3.9 to 2.3, respectively (p<0.01); and HIV knowledge score (based on % correct) increased from 67.2 to 76.8% (p<0.001). Findings add to the evidence base surrounding peer interventions.

Loneliness, HIV-related stigma, and condom use among a predominantly rural sample of HIV-positive men who have sex with men (MSM)

Most previous studies of the sexual behaviors of men who have sex with men (MSM) living with HIV are based on samples recruited within relatively urban and suburban areas of the United States. Using an internet-based questionnaire, we assessed HIV-related stigma, loneliness, and event-level sexual behaviors in a sample of HIV positive MSM (n = 100) residing within a largely rural area in the Midwestern United States. HIV-related stigma was correlated with loneliness (r = 0.619, p < 0.01). Loneliness was negatively associated with condom usage with the most recent partner of unknown status (p < 0.05). Namely, a 1-unit increase in the UCLA loneliness score was met with a 10% decrease in odds of condom usage. Further studies are warranted that explore loneliness, within the context of HIV-related stigma, among HIV-positive MSM residing in rural areas. More refined data will inform clinical and social service practice, as they provide much-needed information on sexual health outcomes and experiences of an often underserved and under studied population.

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.

Efficacy of an Educational Intervention to Increase Consent for HIV Testing in Rural Appalachia

This study sought to assess barriers and enhance readiness to consent to home and Planned Parenthood HIV testing among 60 out-patients from a mental health and substance abuse clinic in rural Appalachia. Testing barriers included not knowing where to get tested, lack of confidentiality, and loss of partners if one tested sero-positive. The intervention yielded lowered HIV stigma, increase in HIV knowledge, and agreement to take the HIV home test. These results are encouraging because they suggest that a brief educational intervention is a critical pathway to the success of the National Institutes on Drug Abuse's Seek, Test, Treat, and Retain initiative in poor rural counties.

A mixed-methods study of condom use and decision making among adolescent gay and bisexual males

Young men who have sex with men have the highest rates of new HIV infections in the U.S., but they have been understudied relative to other populations. As a formative step for the development of a text messaging HIV prevention intervention, this mixed methods study aimed to understand how adolescent gay and bisexual males (AGBM) make decisions about condom use and factors that may differ based on age, sexual experience, and rural versus urban residency. Four online, asynchronous focus groups were conducted with 75 14-18 year old AGBM across the U.S. Qualitative analyses uncovered themes related to relationship influences on condom use (e.g. marriage, trust), access issues, and attitudes and experiences that both encouraged as well as discouraged condom use. Mixed methods analyses explored differences between groups in endorsement of themes. For example, younger and sexually experienced participants were more likely to report the cost of condoms was prohibitive and sexually experienced and rural youth were more likely to describe being influenced by emotional aspects of the relationship. These data highlight both opportunities for as well as the importance of tailoring HIV prevention programs for sub-groups of AGBM.

Connecting race and place: a county-level analysis of White, Black, and Hispanic HIV prevalence, poverty, and level of urbanization

OBJECTIVES

We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization.

METHODS

Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black-White and Hispanic-White prevalence rate ratios (PRRs) across levels of urbanization and poverty.

RESULTS

We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black-White and Hispanic-White PRRs were not statistically different from 1.0 at high poverty rates (Black-White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic-White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty.

CONCLUSIONS

The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.

Healthcare provider attitudes, practices, and recommendations for enhancing routine HIV testing and linkage to care in the Mississippi Delta region

The Mississippi Delta region is one of the communities most heavily impacted by HIV/AIDS in the United States. To understand local provider attitudes and practices regarding HIV testing and care, we conducted 25 in-depth qualitative interviews with local primary care providers and infectious disease specialists. Interviews explored attitudes and practices regarding HIV testing and linkage to care. Most providers did not routinely offer HIV testing, noting financial barriers, financial disincentives to offer routine screening, misperceptions about local informed consent laws, perceived stigma among patients, and belief that HIV testing was the responsibility of the health department. Barriers to enhancing treatment and care included stigma, long distances, lack of transportation, and paucity of local infectious disease specialists. Opportunities for enhancing HIV testing and care included provider education programs regarding billing, local HIV testing guidelines, and informed consent, as well as telemedicine services for underserved counties. Although most health care providers in our study did not currently offer routine HIV testing, all were willing to provide more testing and care services if they were able to bill for routine testing. Increasing financial reimbursement and access to care, including through the Affordable Care Act, may provide an opportunity to enhance HIV/AIDS services in the Mississippi Delta.

Risky sex in rural America: longitudinal changes in a community-based cohort of methamphetamine and cocaine users

BACKGROUND AND OBJECTIVES

This study examined the longitudinal associations between stimulant use and sexual behaviors.

METHODS

Data are from a 3-year community-based study of 710 rural stimulant users. Past 30-day crack cocaine, powder cocaine, and methamphetamine use and sexual behaviors (any sex, inconsistent condom use, and multiple sexual partners) were assessed through in-person interviews every 6 months.

RESULTS

GEE analyses revealed that the odds of having sex remained steady over time, with crack cocaine and methamphetamine use positively associated with having sex. The odds of multiple sexual partners declined, but the odds of inconsistent condom use remained steady over time. Crack cocaine use was positively associated with multiple sexual partners, whereas powder cocaine use was negatively associated with inconsistent condom use.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Many rural stimulant users could potentially benefit from safe sex educational programs. Such efforts could reduce the incidence of HIV and other STIs in rural America.

Neighborhoods and HIV: a social ecological approach to prevention and care

Neighborhood factors have been linked to HIV risk behaviors, HIV counseling and testing, and HIV medical care. However, the social-psychological mechanisms that connect neighborhood factors to HIV-related behaviors have not been fully determined. In this article we review the research on neighborhood factors and HIV-related behaviors, approaches to measuring neighborhoods, and mechanisms that may help to explain how the physical and social environment within neighborhoods may lead to HIV-related behaviors. We then discuss organizational, geographic, and social network approaches to intervening in neighborhoods to reduce HIV transmission and facilitate HIV medical care with the goal of reducing morbidity and mortality and increasing social and psychological well-being.

A Qualitative Study of Barriers to the Utilization of HIV Testing Services Among Rural African American Cocaine Users

This qualitative study is about barriers to the utilization of HIV testing as perceived by African Americans who have recently used cocaine and who live in the rural Delta region of Arkansas. Affordability, physical accessibility, and geographic availability were not perceived as barriers to HIV testing in this sample, yet acceptability was still perceived as poor. Acceptability due to social mores and norms was a major barrier. Many said testing was unacceptable because of fear of social costs. Many were confident of being HIV-negative based on risky assumptions about testing and the notification process. Small-town social and sexual networks added to concerns about reputation and risk. System approaches may fail if they focus solely on improving access to HIV services but do not take into consideration deeply internalized experiences of rural African Americans as well as involvement of the community in developing programs and services.

HIV diagnosis and testing: what every healthcare professional can do (and why they should)

Over the last thirty years, the human immunodeficiency virus (HIV) epidemic has matured. In the United States, HIV has changed from an explosive outbreak to an endemic disease; currently, an estimated 1.1 million people are infected with HIV, including a substantial number who are unaware of their status. With recent findings demonstrating the high transmissibility of HIV early in infection, and the potential benefit of early initiation of treatment, it is essential to identify as many infected individuals as possible. The Centers for Disease Control and Prevention (CDC) has expanded HIV testing to include any healthcare setting, including dental offices. Testing advances, including oral testing, have reduced the window period of HIV infection. Dental care represents a key, reliable, independent, and confidential link between the healthcare system and the general population that has been under-utilized in the effort to control the HIV epidemic. HIV testing is straightforward, and knowledge of the types of testing will afford dentists an important opportunity to help advance and preserve the health of their patients and to promote the public health of their community. Here, we review the basics of HIV testing and discuss new changes in the approach to HIV diagnostics.

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.

Condom use among sexually active rural high school adolescents personal, environmental, and behavioral predictors

Adolescents who engage in unprotected intercourse are at risk of pregnancy and sexually transmitted infection (STI). Although adolescents in rural areas participate in levels of sexual risk taking similar to that of nonrural youth, few data are available identifying factors that influence condom use among rural adolescents. The purpose of this study is to determine the predictive value of selected personal, environmental, and behavioral factors for condom use among rural adolescents in grades 9-12. A cross-sectional survey was conducted among sexually active youth (N = 613), ages 14-19, in three rural school districts in the Northeast. Using logistic regression, identified predictors for condom use include personal standards (odds ratio [OR] = 2.45; confidence interval [CI]: [2.39, 6.47]), condom use goals (OR = 1.32; CI [1.21, 1.45]), condom use at first intercourse (OR = 3.93; CI [2.39, 6.47]) and male gender. School nurses are encouraged to incorporate identified predictors of condom use when considering interventions promoting safer sexual behaviors among rural youth.

Community-based HIV clinical trials: an integrated approach in underserved, rural, minority communities

BACKGROUND

Although racial and ethnic minorities have disproportionately high rates of HIV infection, these groups are underrepresented in HIV-related clinical trials. This illustrates the need for more innovation in attempts to engage underrepresented populations in calls for interdisciplinary and translational research.

OBJECTIVES

Eleven focus groups and 35 interviews were conducted with people living with HIV/AIDS (PLWHA) to explore the perspectives of rural community leaders, service providers, and PLWHA about bringing HIV-related research, including clinical trials, into rural communities.

METHODS

Over a period of 3 months in spring 2007, we collected qualitative data from three sources: Community leaders, service providers, and PLWHA. Text data were analyzed using the constant comparative method and content analysis techniques of theme identification.

RESULTS

Respondents want an integrated approach to HIV research that builds trust, meets community needs, and respects their values. They conceptualize HIV research as part of a broader spectrum of HIV testing, prevention, and care, and suggest integrating HIV trials with existing community services, organizations, and structures, engaging various segments of the community, and conducting research using a personal approach.

CONCLUSIONS

These findings support calls for more relevant, translational, and engaged research. An integrated approach may be an important innovation to transform the research enterprise to meet these goals and more directly improve the health of individuals.

Integrating condom skills into family-centered prevention: efficacy of the Strong African American Families-Teen program

PURPOSE

The Strong African American Families-Teen (SAAF-T) program, a family-centered preventive intervention that included an optional condom skills unit, was evaluated to determine whether it prevented unprotected intercourse and increased condom efficacy among rural African American adolescents. Ancillary analyses were conducted to identify factors that predicted youth attendance of the condom skills unit.

METHODS

Sixteen-year-old African American youths (N = 502) and their primary caregivers were randomly assigned to SAAF-T (n = 252) or an attention control (n = 250) intervention. SAAF-T families participated in a 5-week family skills training program that included an optional condom skills unit. All families completed in-home pretest, posttest, and long-term follow-up interviews during which adolescents reported on their sexual behavior, condom use, and condom efficacy. Because condom use was addressed only in an optional unit that required caregiver consent, we analyzed efficacy using complier average causal effect analyses.

RESULTS

Attendance in both SAAF-T and the attention control intervention averaged 4 of 5 sessions; 70% of SAAF-T youth attended the condom skills unit. Complier average causal effect models indicated that SAAF-T was efficacious in reducing unprotected intercourse and increasing condom efficacy among rural African American high school students. Exploratory analyses indicated that religious caregivers were more likely than nonreligious caregivers to have their youth attend the condom skills unit.

CONCLUSIONS

Results suggest that brief condom skills educational modules in the context of a family-centered program are feasible and reduce risk for sexually transmitted infections and unplanned pregnancies.

The strong African American families-teen trial: rationale, design, engagement processes, and family-specific effects

This study addresses two limitations in the literature on family-centered intervention programs for adolescents: ruling out nonspecific factors that may explain program effects and engaging parents into prevention programs. The Rural African American Families Health project is a randomized, attention-controlled trial evaluating the efficacy of the Strong African American Families-Teen (SAAF-T) program, a family-centered risk-reduction intervention for rural African American adolescents. Rural African American families (n = 502) with a 10th-grade student were assigned randomly to receive SAAF-T or a similarly structured, family-centered program that focused on health and nutrition. Families participated in audio computer-assisted self-interviews at baseline and 6-month follow-up. Program implementation procedures yielded a design with equivalent doses, five sessions of family-centered intervention programming for families in each condition. Of eligible families screened for participation, 76% attended four or five sessions of the program. Consistent with our primary hypotheses, SAAF-T youth, compared to attention-control youth, demonstrated higher levels of protective family management skills, a finding that cannot be attributed to nonspecific factors such as aggregating families in a structured, interactive setting.

Classroom Goal Structures and HIV/Pregnancy Prevention Education in Rural High School Health Classrooms

Over 5,000 adolescents enrolled in required rural high school health courses reported their perceptions of mastery and extrinsic goal structures in their health classrooms. Data were collected from all students at three time points (prior to HIV/pregnancy instruction, three months after instruction, and one year after instruction). Results indicated that classroom goal structures were related to both proximal and distal knowledge, attitudes, intentions, and efficacy beliefs. Results in particular indicate that the perception of a mastery goal structure in health education classrooms fosters knowledge, improved attitudes, enhanced efficacy beliefs, and lower intentions to have sexual intercourse.

Intervention induced changes on parenting practices, youth self-pride and sexual norms to reduce HIV-related behaviors among rural African American youths

AIDS is the leading killer of African Americans between the ages of 25 and 44, many of whom became infected when they were teenagers or young adults. The disparity in HIV infection rate among African Americans youth residing in rural Southern regions of the United States suggests that there is an urgent need to identify ways to promote early preventive intervention to reduce HIV-related risk behavior. The Strong African American Families (SAAF) program, a preventive intervention for rural African American parents and their 11-year-olds, was specially designed to deter early sexual onset and the initiation and escalation of alcohol and drug use among rural African American preadolescents. A clustered-randomized prevention trial was conducted, contrasting families who took part in SAAF with control families. The trial, which included 332 families, indicated that intervention-induced changes occurred in intervention-targeted parenting, which in turn facilitated changes in youths' internal protective processes and positive sexual norms. Long-term follow up assessments when youth were 17 years old revealed that intervention-induced changes in parenting practices mediated the effect of intervention-group influences on changes in the onset and escalation of risky sexual behaviors over 65 months through its positive influence on adolescents' self-pride and their sexual norms. The findings underscore the powerful effects of parenting practices among rural African American families that over time serve a protective role in reducing youth's risk behavior, including HIV vulnerable behaviors.