Suburban and rural populations are those living in regions at some degree of remove from major cities. Although some may reside in metropolitan areas in relatively close proximity to cities, there are often substantial differences in lifestyle and socioeconomic status between urban and nonurban populations. With some justification, AIDS has been identified largely as a disease of the major urban centers. Indeed, the first personal contact that many people in suburban and rural areas have had with the epidemic occurred when a friend, neighbor, or relative with AIDS returned from a large city to the family home. Nonetheless, the urban/nonurban dichotomy has been diminished over time by the pervasive spread of the epidemic.
In the early 1980s, suburban and rural populations were generally considered to be at low risk for HIV infection according to population-based estimates that identified HIV infections more often among urban populations, particularly gay men and injecting drug users. Ongoing migration among urban, suburban, and rural areas, however, has eliminated environmentally based disease barriers, if they ever really existed. Specific risk behaviors have become the necessary focus, regardless of place of residence. Likewise, membership in high-risk groups has become less determinant of potential HIV infection than participation in high-risk activities, wherever they occur.
Nevertheless, research has indicated that many people living in suburban and rural areas have continued to overlook, ignore, or deny their potential risk. Some believe that HIV/AIDS is a problem for other people, and they may trust sexual partners unquestioningly. It is clear that the number of AIDS cases outside of urban metropolitan areas has been increasing. Shifts from urban-to-rural or rural-to-urban living, coupled with low socioeconomic status for women, have accompanied increases in HIV infections. In September 1990, the National Commission on AIDS reported a 37 percent increase in the number of AIDS cases in rural areas, making special note of increases among heterosexual women. Between 1993 and 1995, HIV infections resulting from heterosexual transmission increased proportionately. Worldwide, estimates have suggested that 75 percent of the 10 to 12 million HIV-seropositive adults were infected through heterosexual intercourse.
Special populations in more isolated rural environments were identified as of special concern for HIV infection, including sexually active and substance-abusing migrant and seasonal farmworkers and native populations moving back and forth between urban areas and tribal reservations. It was feared that the introduction and spread of HIV infection into more isolated populations could, in time, have a potentially catastrophic effect. AIDS outreach programs to aboriginal populations in Canada have been particularly successful through video and community health education and outreach, providing effective community-based interventions throughout the country. Successful rural HIV interventions take great efforts to ensure that their message is culturally relevant and sensitive and can be integrated with local community beliefs and practices.
However, with some exceptions, the development of HIV-related programs in suburban and rural areas has not kept up with the increases in the number of infections. Efforts at HIV education and prevention have been less common in suburban or rural areas and frequently have faced strong opposition among community and religious groups. In most locations, HIV education in rural and suburban schools is not mandatory but, like sex education, is voluntary and requires parental approval. Prevention activities including free condom and needle and syringe distribution were nonexistent in rural areas for most of the 1980s and were still uncommon in the mid-1990s.
Research has shown that health providers in rural areas, being unfamiliar with the specifics of HIV/AIDS, often misdiagnosed HIV-related disease and failed to recognize symptoms.
Initially, HIV-related treatment was unavailable outside of urban areas, forcing many to travel great distances to obtain health care. Since 1992, community trials and experimental treatment consortia have made it easier to obtain drugs for those living outside major epicenters and metropolitan areas. Computerized databases have also made information on AIDS treatment and care more easily accessible. Research has shown that AIDS deaths in urban hospitals have decreased significantly since 1986; many patients have spent their last days in their homes or in community settings.
Changes have taken place in hospital use for end-stage AIDS, with palliative care and death increasingly taking place among family and friends in rural or suburban areas.
Although treatment and educational improvements have occurred in suburban and rural areas since the 1980s, serious problems, including the general public's fear of contagion, have continued unabated in many places. While many have been able to live with HIV in anonymity in rural areas, others whose infection was publicly known have been subject to prejudicial treatment and have been victims of violence. Acceptance and tolerance have not been the norm.
Health service providers in suburban and rural areas face challenges in delivering HIV/AIDS medical care and treatment, training other providers and community groups on prevention, and developing referral networks and support services. Environmental and ecocultural factors have a great influence on AIDS prevention and treatment and on the quality of life for those with HIV/AIDS. Community-based HIV educational interventions are essential for making the disease seem personally relevant and for countering hysteria. These must be visible and accessible in suburban and rural areas to prevent future infections and to make life easier for those already living there with HIV/AIDS.
G. Cajetan Luna, M.A. is Executive Director at ARIS of Santa Clara County, California.
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Cohn, S. E., J. D. Klein, J. E. Mohr, et al., "The Geography of AIDS: Patterns of Urban and Rural Migration," Southern Medical Journal 87 (1994), pp. 599-606.
Lam, N. S., and K. B. Liu, "Spread of AIDS in Rural America, 1982-1990," Journal of Acquired Immune Deficiency Syndromes 7 (1994), pp. 485-490.
Luna, G. C., and M. J. Rotheram-Borus, "Youth Living with HIV in the Suburbs," Los Angeles: Department of Psychiatry, University of California, Los Angeles, 1995.
Verghese, A., My Own Country: A Doctor's Story, New York: Vintage, 1994.