Entry and Retention in Care

Early diagnosis of HIV among PLWHA in rural areas remains all too uncommon. Rural residents are less likely than urban residents to be tested for HIV because of limited access to testing services, stigma, or underestimated risk of infection.22,23 They may also have poorer access to prevention information.

It is hard to contemplate a meaningful solution to this problem without greater access to lifelong comprehensive health care, which, by definition, includes preventive health care. The U.S. Department of Health and Human Services support for health centers in rural areas is an important ingredient for achieving this goal. More information here.

In the absence of broad access to prevention information and testing, rural providers have taken creative steps to reach out. For example, the Wyoming Rural AIDS Prevention Project piloted a peer-led, Internet-based intervention for rural men who have sex with men (MSM) whereby two MSM (one HIV positive and one HIV negative) discuss HIV prevention strategies in online communities. Results show an increase in knowledge, safer sex practices, and self-efficacy among respondents.24

Unfortunately, the pathway to better health for many PLWHA is not cleared by early diagnosis alone. Illustrating this point is the story that Tarsha Taylor, a case manager for the Mississippi Department of Health, tells about one of her clients.

We recently had a woman who was referred to us. She did not know very much about the disease. Her knowledge, attitudes, and behaviors indicated that she was newly diagnosed. In actuality, we discovered that this woman had been diagnosed in 1996. Stigma had kept her out of the system. Once we learned that she had lived with the disease for that amount of time, it explained why her medications were not working.

Transportation

When traditional social networks (e.g., church and civic organizations) are closed to people in rural areas because of discrimination and stigma, providers must work harder to locate and keep clients in care. Intensive case management is essential, as are language and cultural skills and follow-up after missed appointments. But those skills and services mean little if the patient cannot get to the doctor.

Transportation is undoubtedly at or near the top of the list of intractable barriers to care in rural America. Not only is there a lack of public transportation in rural areas, but geographical isolation, rugged topography, and long distances between towns can result in extensive travel to medical and social services.25

For some rural PLWHA, the long distance to a provider is unavoidable, whereas for others, the lack of anonymity in their own small town may discourage them from seeking services locally.26 The distance between HIV providers and rural residents not only is a deterrent for consumers but also can hinder prevention efforts on the part of providers.27 Economic factors also may play a role: Consumers may be unable to take time off from work to travel long distances to appointments, their health may not permit such extended travel, or the cost of travel may be too high.28,29

Providers throughout rural areas of the United States have used their determination and ingenuity to bridge the transportation gulf. Much can be learned from their interventions.

• Sacred Heart Southern Missions AIDS Ministry uses private cars driven by three employees and two volunteers to transport patients. Drivers must sign confidentiality forms, and driver’s insurance is covered by Sacred Heart. “Many patients are multiply diagnosed,” explains Sister Betty Ann. “If they need medical transportation, even if it isn’t for HIV, we’ll take them because we’re all they have.”
• The East Arkansas Family Health Center provides gas reimbursement to consumers for traveling to HIV-related medical appointments. The organization also has a prepaid account with cab companies in West Memphis.
• SHRT has an eight-passenger van, which was purchased as part of the Special Projects of National Significance Oral Health Initiative to assist in bringing patients from their 23-county, entirely rural service area to appointments. The organization also hired a full-time transportation aide using funds from its SPNS grant.
• The Mississippi State Department of Health Mobile Medical Clinic travels to rural areas to reach out to people at highest risk for HIV. Program managers are careful to avoid HIV-specific branding by making no mention of HIV on the van and offering a number of health services unrelated to HIV, such as blood pressure and cholesterol screenings and tests for glucose levels and syphilis. With assistance from private partners, the van has also offered papanicolaou (PAP) tests, clinical breast exams, gonorrhea and chlamydia screenings, digital rectal exams, and prostate-specific antigen (PSA) exams.30,31