Opportunities to Improve Prevention and Services for HIV-Infected Women in Nonurban Alabama and Mississippi

In the United States, an increasing number of HIV/AIDS cases are occurring in persons of minority background, in heterosexual men and women, in nonurban residents, and in the South. Several studies in the rural South have further suggested that there may be key "missed opportunities" in the prevention of HIV as well as gaps in the medical and social services offered to persons with HIV/AIDS in this resource-limited area of the country. This analysis focused on gaps in the primary prevention of HIV infection (i.e., places where women may have received counseling about prevention of HIV infection) and in secondary prevention (i.e., patients' needs for medical and social services after they were discovered to be infected).

This analysis was nested within a larger study that involved interviews and STD testing of HIV-infected residents of nonurban Alabama and Mississippi. Patients seen at 16 HIV clinics who resided outside the single metropolitan statistical area with a population of more than 500,000 persons (Birmingham) were interviewed about the period during which they probably acquired HIV, their needs, and the services provided to them after they were found to be infected with HIV.

The authors wanted to examine HIV-related behaviors and activities before the interviewed patients contracted HIV infection. This "putative period of infection" was defined as either (1) the period from June 1981 to the time when the first AIDS cases were reported in the two states or to the time of a patient's first positive HIV test (often, AIDS diagnosis); or (2) the time from the last negative HIV test to the first positive test for patients who had this information. For these latter patients, a mean "putative infection age" was calculated by taking the midpoint between their last negative HIV test result and their first positive HIV test result and subtracting it from their age at the time of the interview.

Two hundred eleven HIV-infected women receiving HIV-related services and residing in nonurban Alabama and Mississippi completed this interview from January 1995 through September 1998. Of these 211 women, 142 (67 percent) were African-American and 63 (30 percent) were white. The mean age at interview was 33 years (range: 16-69 years). For the 78 (37 percent) patients who had a last negative test followed by a positive one, the estimated mean age at infection was 28.5 years. Of the 189 women who answered, 94 (50 percent) were single, never married; 27 (14 percent) were married; and 68 (36 percent) were separated or divorced.

During the putative period of infection, high-risk behaviors associated with drug use were common. Seventy-three (35 percent) women reported ever using crack or cocaine during this period, and 22 (10.5 percent) reported injection drug use. Of these women, 82 percent reported sharing needles. Fifty women (24 percent) reported trading sex for money or drugs. Thirty-one (30 percent) women who reported using drugs during their putative period of infection also reported being enrolled in some form of drug or alcohol treatment program during this same period. After receiving results from their positive HIV test, 44 (21 percent) women reported that they were not told where they could go to get HIV treatment.

A substantial proportion of these mainly young and African-American HIV-infected women in rural and small-city Alabama and Mississippi had been seen at venues where they may not have received effective prevention counseling before they acquired HIV infection. Whether these "missed opportunities" in primary prevention were the result of no counseling or less than effective counseling at sites where they received previously negative HIV test results cannot be determined. There continue to be additional prevention opportunities even once women are receiving care. Half of these HIV-infected women had been sexually active in the previous month, and 13 percent of all women had needed to be seen for STD evaluation in the 12 months before the study interview. More focus on preventing transmission from HIV-infected persons is warranted, and this should include repeated counseling during routine HIV care.

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