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Risks for HIV Infection Among Persons Residing in Rural Areas and Small Cities -- Selected Sites, Southern United States, 1995-1996

The southern region of the United States * accounts for the largest proportion (34%) of the 641,086 acquired immunodeficiency syndrome (AIDS) cases reported through 1997 and for 54% of the 58,689 AIDS cases among persons residing in rural areas (CDC, unpublished data, 1998). This report describes characteristics of persons infected with human immunodeficiency virus (HIV) who reside in rural areas and small cities of the southern United States and indicates that, before infection, there was a low prevalence of perceived risk.

The Supplement to HIV/AIDS Surveillance Project (SHAS) interviews persons who are reported with HIV infection or AIDS to state health departments. Participants must be aged greater than or equal to 18 years and medically able to complete the interview (1). Interviews were conducted during 1995-1996 in selected rural areas and small cities ** of four southern states that participate in SHAS (Delaware, Florida, Georgia, and South Carolina). In all four states, persons with AIDS who met the eligibility criteria were identified from AIDS case reports and were invited, through their health-care provider, to participate; persons with HIV infection but not AIDS were recruited at clinics where they received HIV care. Of all persons reported with AIDS during 1995-1996 from the four states, the percentages who resided in rural areas and small cities at the time of AIDS diagnosis were as follows: Delaware, 19%; Florida, 9%; Georgia, 18%; and South Carolina, 44%.

The survey instrument included questions about sociodemographics, and, for the time before HIV infection was diagnosed, perceived risk for infection, sexual behavior, and substance use. Category of exposure to HIV was determined from the case report form or based on the interview data and assigned according to the CDC surveillance risk hierarchy (2).

Sociodemographic Characteristics of Respondents

Of 956 persons who met all eligibility criteria, 608 (64%) completed the interview (AIDS, 58%; HIV, 42%); 348 (36%) refused or could not be located. Persons who completed the interview were more likely than nonrespondents to have progressed to AIDS (71% versus 52%, p=0.001). Adjusting for disease status, respondents did not differ from nonrespondents by sex, race/ethnicity, and category of exposure to HIV. Of the 608 persons interviewed, 403 (66%) resided in Georgia; 89 (15%), Florida; 67 (11%), South Carolina; and 49 (8%), Delaware.

Most (66%) respondents were men (Table_1). The median age for men was 36 years (range: 19-75 years) and for women was 33 years (range: 18-67 years). Most respondents were non-Hispanic black and of low socioeconomic status (Table_1). Sexual behavior was the most common risk for exposure to HIV (67% for men and 66% for women). Among men, the most common category of exposure was having sex with men (40%); for women, it was heterosexual contact with an at-risk or infected partner (66%) (Table_1).

Risk Behaviors

Respondents were asked, "Before you found out you were infected with HIV or had AIDS, did you think you could become infected with HIV?"; 52% of men and 65% of women believed they could not get infected. The most common reasons were not knowing how HIV was spread (men: 33%, women: 29%), thinking that their sex partners were not infected (women: 35%, men: 27%), and thinking only persons who inject drugs or men who have sex with men are at risk for infection (women: 21%, men: 14%).

High-risk sexual and drug-use behaviors (e.g., exchanging sex for money or drugs, sex with an injecting-drug user, injecting drugs, and using crack cocaine) were common among both men and women (Table_2). However, among men, the prevalence of these behaviors was higher among those from small cities than from rural areas. Among women, there were few differences by geographic area.

Crack cocaine use was higher among persons whose exposure category was injecting-drug use (65%) than among persons whose exposure category was heterosexual contact (35%; p=0.001). Crack cocaine users were more likely than those who had not used crack cocaine to have exchanged sex for money or drugs (57% versus 15%; p=0.001).

Reported by: SA Fann, Georgia Dept of Human Resources. L Conti, Florida Dept of Health. D Smith, South Carolina Dept of Health and Environmental Control. M Herr, Delaware Dept of Health and Social Svcs. Div of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention; and an EIS Officer, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that most respondents were exposed to HIV through sexual transmission and reported high-risk sexual behaviors (e.g., unprotected sex and exchanging sex for money or drugs). However, many respondents reported that, before learning of their infection, they had not known how HIV was spread and had not known their partners' risks for HIV. These findings emphasize the importance of sustained access to counseling and behavioral risk reduction programs for at-risk populations and HIV-infected persons in these geographic areas.

Sexually acquired HIV infection among rural residents has been linked to increased use of crack cocaine and the resultant exchange of sex for drugs (3). In this study, crack cocaine use was even more prevalent among persons whose mode of exposure was injecting-drug use than heterosexual contact. Other factors related to sexual transmission of HIV in these geographic areas are high rates of sexually transmitted diseases (STDs) and alcohol abuse (4).

Further research is needed to understand the differences in the number of cases and type of risk for HIV between residents of rural areas and small cities. These differences may explain the higher rates of AIDS among residents of small cities compared with residents of rural areas. However, the number and rate of AIDS cases in these areas are low compared with larger MSAs in the South.

Most respondents in this study were black, of low socioeconomic status

  • reflecting in part the characteristics of residents of these areas -- and at risk for acquiring HIV through sexual contact. These characteristics are similar to other reports on AIDS in the rural South (4-7). The disproportionately high rate of HIV/AIDS among blacks may be a result of a higher prevalence of certain risk behaviors or a function of sexual networks in which the high prevalence of infection increases the likelihood of contact with an infected partner. The extent to which the prevalence of low socioeconomic indicators in this population are associated with having AIDS or having moved to a rural area that is economically depressed or both is unknown.

The findings in this report are subject to at least two limitations. First, HIV-infected persons may be reluctant to seek confidential HIV testing or disclose their risk behaviors because of confidentiality concerns or lack of anonymity (8). Second, because participants were recruited from selected states, the findings from this report may not be generalizable to other rural areas and small cities in the southeast or other areas in the United States.

This report highlights the need for HIV-education efforts in rural areas and small cities. Behavioral interventions can be effective in HIV prevention (9); however, programs that have been designed for urban areas will need to be adapted for use in rural areas. Routinely offering HIV counseling and testing at STD clinics, substance abuse treatment programs, and in prenatal care and other medical settings can reduce the number of missed opportunities for HIV prevention among persons at risk and help prevent further increases in HIV/AIDS in rural areas and small cities.


  1. Buehler JW, Diaz T, Hersh BS, Chu SY. The Supplement to HIV/AIDS Surveillance Project: an approach for monitoring HIV risk behaviors. Public Health Rep 1996;111(suppl 1):133-7.

  2. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, CDC, 1997;9(2).

  3. Whyte BM, Carr JC. Comparison of AIDS in women in rural and urban Georgia. South Med J 1992;85:571-8.

  4. Berry DE. The emerging epidemiology of rural AIDS. J Rural Health 1993;9:293-304.

  5. Verghese A, Berk SL, Sarubbi F. Urbs in Rure: Human immunodeficiency virus infection in rural Tennessee. J Infect Dis 1989;160:1051-5.

  6. Roberts NE, Collmer JE, Wispelwey B, Farr BM. Urbs in Rure redux: changing risk factors for rural HIV infection. Am J Med Sci 1997;314:3-10.

  7. Rumley RL, Shappley JC, Waivers LE, Esinhart JD. AIDS in rural eastern North Carolina-patient migration: a rural AIDS burden. AIDS 1991;5:1373-8.

  8. Thomas JC, Schoenbach VJ, Weiner DH, Parker EA, Earp JA. Rural gonorrhea in the southeastern United States: a neglected epidemic? Am J Epidemiol 1996;143:269-77.

  9. National Institutes of Health. Interventions to prevent HIV risk behaviors: NIH consensus statement. Washington, DC: US Department of Health and Human Services, National Institutes of Health, 1997;15:1-41.

Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. ** For this project, "rural" was defined as a nonmetropolitan statistical area (MSA) and small city as an MSA with a population of less than 250,000.

Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Sociodemographic characteristics of persons with HIV/AIDS, by sex --
selected sites, Southern United States, 1995-1996
                                        Men            Women
                                   ------------     -------------
Characteristic                     No.     (%)      No.     (%)
Disease status*
 AIDS                              247    ( 62)     107    ( 52)
 HIV infection                     154    ( 38)     100    ( 48)

 Non-Hispanic black                251    ( 63)     176    ( 85)
 Non-Hispanic white                124    ( 33)      23    ( 11)
 Other+                             16    (  4)       8    (  4)

 >=12 years                        258
 <12 years                         142    (

Employment status*
 Employed                          100    ( 25)      27    ( 13)
 Unemployed                        301    ( 75)     180    ( 87)

Household income*
 <$10,000                          234    (
 >=$10,000                         165    (

State of residence*
 Delaware                           41    ( 10)       8    (  4)
 Florida                            67    ( 17)      22    ( 11)
 Georgia                           245    ( 61)     158    ( 76)
 South Carolina                     48    ( 12)      19    (  9)

Exposure category
 Men who have sex
  with men (MSM)                   158    ( 40)      --       --
 Injecting-drug use (IDU)           62    ( 16)      35    ( 17)
 MSM and IDU                        24    (  6)      --       --
 Heterosexual contact              105    ( 27)     136    ( 66)
 Other&                             47    ( 12)      35    ( 17)

Total@                             401    (100)     207    (100)
* p<0.05
+ Numbers for racial/ethnic groups other than black and white were too small for meaningful
& Includes no identified risk, blood transfusion, and hemophilia.
@ Columns may not add to total because of missing data.

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Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2. Risk behaviors of persons with HIV/AIDS, by sex -- selected sites, Southern
United States, 1995-1996
                                            Men            Women
                                       ------------     -------------
                                       No.      (%)     No.      (%)
Unprotected sex with opposite-sex
 Yes                                   273    ( 69)     202    ( 98)
 No                                    124    ( 31)       5    (  2)

Unprotected sex with
 same-sex partner*
 Yes                                   174    ( 44)      19    (  9)
 No                                    223    ( 56)     188    ( 81)

Sex with injecting-drug user*
 Yes                                    79    ( 20)      48    ( 23)
 No                                     91    ( 23)      30    ( 14)
 Don't know                            228    ( 57)     129    ( 62)

Sex with HIV positive partner*
 Yes                                   125    ( 31)      90    ( 43)
 No                                    172    ( 43)      63    ( 30)
 Don't know                            101    ( 25)      54    ( 26)

STD+ visit during previous 10 years
 Yes                                   205    ( 51)     113    ( 55)
 No                                    195    ( 49)      94    ( 45)

Gave money or drugs for sex*
 Yes                                   108    ( 27)      10    (  5)
 No                                    286    ( 73)     196    ( 95)

Received money or drugs for sex*
 Yes                                    48    ( 12)      52    ( 25)
 No                                    348    ( 88)     155    ( 75)

Possible problem with alcohol
 Yes                                   141    ( 35)      63    ( 30)
 No                                    260    ( 65)     144    ( 70)

Injected drugs
 Yes                                    62    ( 16)      29    ( 14)
 No                                    334    ( 84)     178    ( 86)

Used crack cocaine
 Yes                                   150    ( 37)      87    ( 42)
 No                                    251    ( 63)     120    ( 58)

Total&                                 401    (100)     207    (100)
* p<0.05
+ Sexually transmitted disease.
& Columns may not add to total or 100% because of missing data.

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