Rural Health Research

The Geographic Distribution of AIDS

in the United States:
Is There a Rural Epidemic?
Shari Steinberg, M.S., M.l?H., and Patricia Fleming, Ph.D.

ABSTRACT The goal o f this study wlls to examine where people with acquired immune de-
ficiency syndrome (AIDS) in the United States liw and the degree to which AlDS is present
in rural areas. AIDS cases reported to the Centersfir Disease Control and P r m t w n (CDC)
in 1996 were categorized by metropolitan statistical area (MSA) size and compared to the
general population. Data w e analyzed by region, racelethnicity and risk exposure; AIDS in-
cidence rates m e compared m m time by M S A size. Relatim to the US. population, AIDS
cases were disproportionately black (43 percent us. 11 percent), male (80 percent vs. 48 per-
cent), and from the Northeast (32 percent us. 20 percent). In all regions, a greater proportion
of AIDS cases reside in large MSAs compared with the general population. Risk exposures
d i e little by MSA size, except in the Northeast. The PTopOrtion ofpeople with AIDS who
reside in large MSAs exceeds the proportion of the population in those areas, especially when
racelethnicity is consit&red. AIDS rufes hmR increased in non-MSAs relatiw to,large MSAs,
y t do not indicate that the epidpmic is increasing rapidly in rural areas. F w AIDS cases
are reported from smaller communities, y t require medical and social services that may bur-
den the rural health care system.

A
s the focus of the response to the hu-
man immunodeficiency virus (HIV) and
acquired immunodeficiency syndrome
(m) epidemic increasingly moves to-
ward early testing and treatment, it is
essential to monitor the magnitude and to dmracterize
the population of infected people who require and use
prevention and care resources. Prevention and plan-
ning rely on current trends in HIV and AJDS epide-
miology to maximize access to counseling, testing,
medical and other services among the appropriate
populations. Accurate surveillance for HIV infection
and AIDS can idenbfy new populations at increased
risk for infection and changes in patterns of HIV ex-
posure Analysis of the geographic distribution of
AIDS cases can highlight new areas of incidence as
well as Aanges in other locations that may require
attention.
Although the majority of people with AIDS have
been reported from urban areas, over the course of
We thank Mitzi h4ays jbr her assistance with data generation and mnage-
ment and John Karon fbr his assistance with statistical analyses. FmQr-
ther injbrmation, mtnct: Shari Steinberg, Division of HIVIAIDS P r m -
twn-Sumeillance and Epidemiology, Nationnl Centerjbr HlV STD and
TB P r m t i o n , Centersfirr Disease Conttol and P r m t i o n , 1600 Clifton
Road, Mailstop E 4 7 , Atknfa, GA 30333; e-mail s m 2 @ c d c . p

StembergandFlaning 11 wmts 2000

the epidemic, there have been repeated warnings
about the spread of AIDS into rural areas, some with
claims of impending epidemic conditions. As early as
1988, reports alleged that AIDS was spreading beyond
the original urban epicenters at an alarming rate (Cen-
ters for Disease Control and Prevention [CDC], 1989;
Gardner, et al., 1989; Lieb, et al., 1988; Verghew et al.,
1989). Lam and Liu (1994) referred to AIDS in the
United States as pandemic. However, some of these
small, localized studies were interpreted as reflecting
larger regions or the entire country and predicted
rampant AIDS throughout the country.
To examine where people with AIDS live and the
degree to which AIDS is pervading rural areas, the
distribution of recently reported cases of AIDS by
place of residence was compared with the distribution
of the general population in the United States. AIDS
rates were examined by racial/ethnic disparities and
by region and metropolitan area status to look at the
magnitude of the epidemic in urban and rural areas
of the United States.
Methods
In the united States, active surveillance for AIDS cas-
es is conducted in all states and US. territories; cases
are reported to the Centers for Disease Gmtrol and
Prevention (CDC) by state and local health departments
on a standard confidential case report form. Data are
abstracted from a person's medical record by providm
or trained health department personnel. City and coun-
ty of residence at the time of diagnosis, age, sex, race/
ethnicity and mode of exposure are awerkmd . for
each case AIDS cases in adults and adolescents 13
years of age and older reported to CDC in 1996 from
the 50 states and the District of Columbia were includ-
ed in these analyses. Ofthe cases reported in 1996,53
percent were diagnosed that year; 32 percent were di-
agnosed in 1995,14 percent in 1990 to 1994, and the
remainder--less than 1 percent--before 1990.
Counties in the United States that fulfill certain
population and economic criteria are designated by
the office of Management and Budget as metropolitan
statistical areas (MAS).These designations were u p
dated in 1996. Counties were categorized as part of an
MSA of more than 500,000 population, part of an
MSA of 50,OOO to 500,OOO population, or non-MSA.
AIDS cases were similarly categorized by the person's
county of residence at initial diagnosis. Postcensal
population estimates are calculated by the US.Bureau
12
of the Census and include tabulations of the U.S. pop
ulation by sex, race/ethnicity, age, region and MSA
designation. Estimates of the adult and adolescent
population of the United States were provided by the
Population Division of the U.S. Bureau of the Census.
To examine risk exposure characteristics by MSA
population, data were used from AIDS cases diag-
nosed in 1996 and adjusted for reporting delays. Be-
cause recently reported cases have a high percentage
of missing risk data until further investigations are
completed, cases reported without an identifed risk
were assigned to a risk group based on historic pat-
terns of risk exposure redistribution after investigation
(CDC,1996).
The addition of HN-related severe immunodeficiency
to the AlDs surveillance case definition in 1993 caused
a large increase in the number of AIDS cases reported
since then and made it impossible to compare unad-
justed AIDS case data reported before and data report-
ed after 1993. To look for changes in the geographic
distribution of cases while controlling for the effect of
the change in the AIDS case definition, the ratio of the
annual estimated rate of diagnosis of AIDSopportunis-
tic illness in large MSAs (5OO,OOO+ population) to the
compondmg rate in medium-sized MSAs (50,OOO to
s00,OOO population) and non-MSAs were computed by
using data based on estimates of the incidence of
AIDS-opportunistic illness (Karon, et aL, 1997; Neal, et
aL, 1997). The corresponding rate ratios for medium
=As and non-MSAs also were computed. Regression
with Gaussian error structure and inverse variance
weights were used to model the logarithm of these an-
nual rate ratios for 1990 to 1996 as a linear function of
time The si@cance of the time trend based on the t
statistic with five degrees of freedom for the coefficient
of time was evaluated.
The United States has four Census Bureau regions-
Northeast, Midwest, South and West. Although Puerto
Rico and the US.territories report AIDS cases to
CDC, they are not part of the four census regions and
were exduded from these analyses. Racespecific anal-
yses were limited to white, black and Hispanic people,
because the small proportion of cases among other
races/ethnicities, when stratified by region, MSA size
or other variables, did not allow for meaningful com-
parisons. People of all races and ethnicities were in-
cluded in the totals.
Results
In 1996,66,158 adults and adolescents were report-
ed with AIDS in the United States. Compared with
Vd.16, No.1
 the distribution of the adult population, ATDS cases
were disproportionately reported from the Northeast Table 1. Reported Adolescent and Adult AIDS
(32 percent of cases vs. 20 percent of the general p o p Cases and Percentage Distributions of
ulation); more of the cases were in people who were AIDS Cases and the Adolescent and Adult
Hispanic (16 percent vs. 9 percent) or black, non-His- Population in the United States and
panic (43 percent vs. 11 percent) and male (80percent District of Columbia, 1996.
vs. 48 percent; Table 1).
Of the AIDS cases, 83 percent were in people from
MSAs with populations of more than soO,O00, al- AIDS
though only 62 percent of the general population re- U.S. Rate
sides in those areas. Overall, the annual AIDS rate in Poplation per
these areas was 42 per l00,OOO population. Smaller AIDS (N= 100,OOO
(N=66,158) 212,379,502) Population
MSAs,hawever, had 10 percent of AIDS cases,com-
pared with 18 percent of the population (rate=18 per
lO0,OOO). Seven percent of people with AIDS and 20 (Per- (Per-
(Number) centage) centage)
percent of the population live in non-MSAs (rate=lO
per lO0,OOo). Region'
One-third of AIDS cases from the large MsAs were Northeast 20,831 32 20 49.4
reported from the Northeast (N=19,059); another Midwest 6,772 10 24 13.5
third (N=18,716) were from the South pable 2). This south 25,476 39 35 34.2
is somewhat comparable to the distribution of the West 13,079 20 22 28.6
population in large MSAs; 25 percent are in the Racelethnidty
Northeast and 30 percent in the South. AIDS cases White 26,199 40 76 16.3
from the large MSAs, however, are disproportionately Black 28,307 43 11 11 7.4
Hispanic 10,726 16 9 54.8
in people of minority race / ethnjaty; 43 percent of the
Other 926 1 4 11.1
cases are in blacks who comprise 13 percent of the
SeX
population. Of the cases, 18 percent were in Hispanics
Male 52,902 80 48 48.1
who comprise 12 percent of the general population. Female 13,256 20 52 12.9
In non-MSAs, the same racial and ethnic disparity
Metropolitan Statistical h a (MSA)
is found. Of the cases,41 percent are in blacks
m O,OO + 54,597 83 62 41.6
(N=1,777) and 8 percent are in Hispanics (N=343). Of 50,OOO to s00,OOO 6,738 10 18 17.7
the general non-WA population, 8 percent is black Non-MSA 4,336 7 20 10.1
and 4 percent is Hispanic. The south has the highest
proportion (58 percent) of nonmetropoolitan AIDS cas-
1. Northeast=Connecticut,Maine, Massachusetts, New
es, althaugh the rate in the non-MSA South (14 per
Hampshue, New Jersey, New York, Pennsylvania, Rhode Island
100,OOO) is similar to that in the non-MsA Northeast and Vermont; Midwest=Illinois, Indiana, Iowa,Kansas,
(13 per lO0,OOo). Michigan, Minnffota, Missouri, Nebraska, North Dakota, Ohio,
AlDs rates differ by race, age and location; however, South Dakota and Wisconsin; South=Alabama, Arkansas,
Delaware, District of Columbia, Florida, Georgia, Kentucky,
some pattems are evident. Rates are generally highest Louisiana, Maryland, Mississippi, North Carolina, Oklahoma,
in the large MsAs within each race, age group and re- South Carolina,-T Texas, V u G a and Wst Virginia;
gion. For whites, rates are lowest in the Midwest; rates West=Alaska, MOM, California, Colorado, Hawaii, Idaho,
for whites in the other three regions are similar in Montana, Nevada, New Mexico, Oregon, Utah,Washington and
each corresponding MSA population category. Rates Wyoming.
for blacks are 3 to 32 times higher than rates for
whites; rates for Hispanics fall between those for
blacks and whites in nearly every location. The North-
east has the highest rates for minority races/ethnia-
ties, regardless of MSA size. Rates within each MSA were lowest for people older than 65 years of age at
and region category were highest for people 30 to 49 the time of AIDS diagnosis.
years of age at diagnosis, followed by people 13 to 29 Despite some of the lower rates in the South, one
years of age and people 50 to 64 years of age, and must consider the number of cases to realize the effect

StairbergandFleming 13 wmter 2000

Table 2. Reported Adolescent and Adult AIDS Table 2. Continued.
Cases and Percentage Distributions and the
Adolescent and Adult Population and
AIDS Rates per lOOp00 Population in the MSA US.Population
United States by Region, MSA Population ~~~

and RaceEthnicity? Percent- Percent-

Number age Cases age Rate

MSA US.Population 50,Ooo to soo,o0o N=1,007 N =7,317,131

White 679 67 78 12
Black 143 14 2 83
Percent- Percent- Hispanic 157 16 15 15
Number age Cases age Rate Non-MSA N=512 N =6,267,060
White 349 68 80 7
Northeast Black 33 6 1 60
m,o0o+ N=19,059 N=32,991,864 Hispanic 89 17 11 13
White 5,282 28 75 21
Black 8,743 46 12 223
Hispanic 4,818 25 9 156 Note: MSA=metropolitan statistical area.
50,OOo to 500,ooo N=1,178 N=4,741,641 1. Data for people with other and unknown races are included in
White 442 38 91 10 the totals.
Black 495 42 5 216
Hispanic 227 19 3 152
Non-MSA N=558 N =4,4O2,681
White 303 54 % 7
Black 140 25 1 222
Hispanic 111 20 1 202 that HIV and AIDS may have on a region and its
Midwest population. The South, with 16 states and the District
5oo,OOo+ N =5,280 N=26,831,163 of Columbia, has the largest number of non-MSA
White 2,306 44 79 11 AIDS cases, along with the largest non-MSA popula-
Black 2,546 48 14 66
365 7 4 31
tion and the greatest proportion of black residents (54
Hispanic
50,Ooo to 500,000 N=803 N =9,871,772 percent). The 2,586 non-MSA AIDS cases, nearly four
White 568 71 91 6 to five times as many as in any other region, are
Black 195 24 5 37 spread over a large area and population and result in
Hispanic 32 4 2 18
Non-MSA N=680 N=13,379,065
relatively low rates. The large number of cases, how-
White 476 70 % 4 ever, can severely affect many small towns and com-
Black 161 24 2 77 munities across the rural South.
Hispanic 36 5 1 22 To look for movement of AIDS from the urban cen-
South ters to the rural landscape, the ratio of AIDS rates b e
5oo,OOo+ N=18,716 N=39,262,739 tween MSAs of more than 500,000 population and
White 6,249 34 69 24
10,159 18 141
non-MSAs and between MSAs with 50,000 to 500,000
Black 54
Hispanic 2,207 11 10 50 population and non-MSAs from 1990 through 1996
50,OOo to 500,ooo N=3,750 N=16,173,211 (Table 3) were calculated. From 1990 through 1996, the
White 1,511 40 74 13 annual rate ratio of large MSAs compared with non-
Black 1,921 51 16 72
Hispanic 291 8 8 22
MSAs decreased steadily; the rate ratio decreased
Non-MSA N=2,586 N =19,011,587 from 5.6 in 1990 to 4.2 in 1996 (t statistic -8.8,
White 1,020 39 78 7 P~0.001).The rate ratio of the annual AIDS rates in
Black 1,443 56 17 45 smaller MsAs compared with non-MSAs was relative-
Hispanic 107 4 4 15
ly constant during 1990 through 1993 (2.1 to 2.2) but
west was somewhat lower (1.8 to 1.9) during 1994 through
500,ooo+ N=ll,542 N=32,129,588
White 6,714 58 61 34
1996.
Black 2,019 17 6 101 Data on HIV risk exposure, categorized as men who
Hispanic 2,411 21 22 35 have sex with men, injection drug use and heterosexu-
al contact, were complete for nearly 85 percent of cas-

14 VoL 16, No. 1

 tween regions, races or size of MSA. Within each
Table 3. Adolescent and Adult AIDS Rates per race group, the proportion of cases with injection
lo0,OOO Population and Rate Ratios of drug use as the risk category was highest in the larg-
Reported A I D S Cases' by Size of Person's er MSAs and similar in the smaller and non-MSAs.
Place of Residence, 1990-1996. A greater proportion of cases was attributed to injec-
tion drug use than to heterosexual contact (53 per-
cent vs. 41 percent) among white women from large
AIDS Rate per
MSAs in the Northeast. In all other race, region and
100,000 Population Rate Ratio MSA size categories, the proportion of cases among
women due to heterosexual contact either exceeded
injection drug use or was comparable; no patterns
Medium
Year of Large Medium Non- Large MSA: MSA: were discernible
Report MSA MSA MSA Non-MSA Non-MSA
~~~ ~~ ~

1990 27.9 10.6 5.0 5.6 2.1

1991 28.8 11.3 5.4 5.3 2.1 DisMsssion
1992 29.8 12.1 5.9 5.1 2.1
1993 66.4 27.9 12.8 5.2 2.2 The geographic distribution of AIDS cases bears
1994 50.2 19.6 10.3 4.9 1.9
1995 46.6 19.9 10.6 4.4 1.9 both similarities and differences to the distribution of
1996 47.6 20.0 11.4 4.2 1.8 the general population. Most people live in large cit-
t statistic -8.8 -.4.3 ies, and most people who have A D S reside in large
P value 0.0003 0.008 cities. More than one-third of the population lives in
the South, as defined by the Census Bureau, and more
than one-third of cases are in the South. Yet within
Note: MSA=metropolitan statistical area; large MSA=500,000+
population; medium MSA=50,000 to 500,ooO population. each region, the proportion of people that has AIDS
1. AIDS data were estimated based on AIDSopportunistic illness and lives in large MSAs exceeds the proportion of the
diagnosis incidence with adjustments for reporting delays. general population in those areas, and the proportion
of people with AIDS in non-MSAs is lower than that
of the population. The result is disproportionately
high rates in large MSAs. The disparity between the
distribution of people with AIDS and the general pop
es before assignment of risk for cases without risk in- ulation is most pronounced when race/ ethnicity is
formation. The distribution of AIDS cases between considered.
these exposure categories did not differ greatly by size Rates among blacks were uniformly higher than
of the place of residence for each race/ethnic group or among the other racial / ethnic groups in all regions
region; however, a pattern was evident (Table 4). Ex- and sizes of place of residence. This has been ex-
cept in the Northeast, within each race and region, the plained as being due to a higher prevalence of behav-
proportion of men who reported sex with men as iors among black people that place one at risk for ac-
their risk exposure was greatest in the larger MSAs quiring HN infection (Greenland, et al., 1996; Prevots,
(range, 39 percent to 76 percent), lower or the same in et al., 1996; Thomas, et al., 1995) or a higher preva-
the smaller MSAs (36 percent to 72 percent), and low- lence of HIV infection in the black population, which
est in the non-MSAs (39 percent to 67 percent), al- increases the likelihood of sexual or other high-risk
though some of the differences were small. The pro- contact with an infected person (Holmes, et al., 1997;
portion of cases among male injection drug users was Karon, et al., 1996).
considerably lower among whites than the other ra- High AIDS rates among blacks in some areas are
aal/ethnic groups and higher in the Northeast than indicative of the uneven distribution of the population
the other regions. Heterosexual contact was most fre- In states in the Northeast, the Midwest and the West,
quently reported in the South compared with the oth- the number of AIDS cases among all minorities in
er regions and among black and Hispanic men com- non-MSAs is relatively low. Yet these areas also have
pared with white men; there was no association with relatively few black residents, whik results in higher
MSA size AlDs rates. In contrast, in the South, the rates are
Exposure categories for women differed little be- lower than in the larger MSAs, although the number
Table 4. Percentage Distriiutions of Risk Exposure for Estimated' Adolescent and Adult AIDS Cases
Diagnosed in 1996, by Sex, Region, RaceEthniaty, and MSA Population S i z e

Men Women

N MSM 1DU Het Other N 1DU Het Other

Northeast
MSA soO,OOO+ 12,511 39 45 11 5 5,033 46 51 3
MSA 50,OOO to 500,OOO 772 36 48 8 9 236 44 52 4
Non-MSA 322 43 40 7 9 76 39 57 4
Midwest
MSA 5oo,OOO+ 3,652 69 18 6 8 730 40 57 3
MSA 50,OOO to 5oo,ooO 665 66 18 7 9 91 20 74 6
Non-MSA 485 59 23 8 10 88 28 68 4
south
MSA 5OO,OOO+ 14,087 58 22 13 7 4,181 35 61 3
MSA 50,OOO to 500,OOO 2,767 58 19 13 9 838 26 69 5
Non-MSA 1,902 52 22 15 11 577 25 71 5
West
MSA 5OO,OOO+ 8,619 76 12 3 9 1,069 38 55 7
MSA 50,OOO to 500,000 883 66 17 4 14 99 31 59 10
Non-MSA 3% 62 19 7 13 60 47 50 3
White
MSA 5oo,OOO+ 15,066 76 12 4 8 1,899 45 49 5
MSA 50,OOO to 5OO,O00 2,528 72 13 5 11 387 31 63 5
Non-MSA 1,512 67 14 7 12 290 33 63 4
Black
MSA 5OO,OOO+ 15,926 42 38 14 7 7,056 41 56 3
MSA 50,OOO to 5oo,OOO 1,933 41 33 17 9 767 28 67 5
Non-MSA 1,307 39 32 18 10 455 25 71 4
Hispanic
MSA 5oo,OOO+ 7,247 50 34 10 6 1,921 37 60 4
MSA 50,OOO to 500,OOO 566 48 33 15 4 97 32 64 4
Non-MSA 235 40 42 10 9 40 29 67 4

Note: MSA=metropolitan statistical arra; MSM=men who have sex with men; IDU=inje&on drug use; Het=heterosexual contact. Other
includes MSM-IDU (menonly), adult hemophilia, adult transfusion and adult risk undetermined.
1. Data are adjusted for reporting delays and the redistribution of unreported mode of exposure Totals include all race/ethniaty and risk
groups. Percentages given are row percentages.

of cases among blacks is rather high. Both the absolute
and the proportional burden of the epidemic in any
area should be considered in assessing the effect of
AIDS and the needs for treatment, prevention and so-
cial S e M C e s .
In general, AIDS rates in large MSAs exceed or a p
proximate the rates in smaller MSAs and non-MSAs
in all regions of the country for all racial/ethnic
groups. Although the rates will likely remain highest
in the aties, there has been a trend of increasing rates
in the non-MSAs relative to the rates in large MAs.
This trend, though statistically sipficant, points not
so much to a burgeoning epidemic of rural AIDS as to
a slow infiltration of the virus into some smaller com-
munities in the United States.
By definition, non-MSAs have smaller populations

16 Vd.16, No. 1
and may offer a more limited range of medical and
social services (Smith, 1990). Access to care and re-
saurces is critical for HIV-infected people Better ac-
cess to medical services has been associated with few-
er hospitalizations (Cunningham, et al., 1996). AIDS
patients of more experienced physicians have longer
survival times (Kitahata, et al., 1996), and patients ad-
mitted to hospitals with more AIDS admissions have
lower mortality rates than do patients admitted to
hospitals with fewer AIDS admissions (Stone, et al.,
1992; Turner and Ball, 1992). A study of HIV/AIDS
medical care showed that 68 percent of physicians in
small and non-MSA counties in California, although
their experience may be limited, had seen an HIV-in-
fected patient and were providing care (Lewis, 1996).
Rural residents travel to larger places for medical care
for reasons of confidentiality in obtaining care, con-
cerns about prejudice in rural communities (Helms,
1993), or a lack of primary care physicians or provid-
ers with experience in treating HN infection (Berry, et
al., 1996; Graham, et al., 1995; Rx for Rural AIDS,
1995). Some communities, however, have created pro-
grams to address their AIDS problems and have orga-
nized networks of services and HIV care for affected
residents (Fiscus, et al., 1996; McKinney, 1993; Rx for
Rural AIDS, 1995). Continued increases in the num-
ber of people with HIV/AIDSoutside urban areas,
along with increased survival times for those in treat-
ment, could place a sigruficant burden on the rural
health system and negatively affect those who are
infected.
Information on where someone became infected or
where that person may have moved after infection is
not available in the nationwide surveillance system;
the data are limited to the persons place of residence
reported at the time of AIDS diagnosis. The data do
not directly measure if people with HIV or AIDS in
rural areas are receiving appropriate health services.
Investigators of smaller studies have confirmed migra-
tion before or after HIV infection or AIDS diagnosis,
generally in early studies of movement from urban to
rural areas after diagnosis (Cohn, et al., 1994; Davis
and Stapleton, 1991; Verghese 1989). others have re-
ported increases in the number of AIDS patients in-
fected in rural areas (Roberts, et al., 1997; Rumley, et
al., 1991). Although the effect of potential misclassifi-
cation due to migration after diagnosis cannot be
quantified, we assume that we slightly overestimate
the number of cases in larger cities and underestimate
that in smaller cities and rural areas. According to one
study (Buehler, et al., 1995), at least 10 percent of peo-
ple reported with AIDS who died had moved be-
Steinberg and Fleming
tween diagnosis and death. O f these people, the pro-
portion of interstate moves was greatest among those
initially from large cities, and most of the moves, both
inter- and intrastate, were to large metropolitan areas,
regardless of the sue of the initial place of residence
The net result was a small relative decrease in large
metropolitan areas and a larger relative increase in
nonmetropolitan areas, although the absolute changes
were comparable Migration can pose a practical prob-
lem as some governmental AIDS funds are allocated
on the basis of the number of cases. Migration after
diagnosis can increase the burden of providing servic-
es at the destination, which may lack the appropriate
allocation of resources.
Our data are also limited by their timeliness: AIDS
diagnosis generally lags behind HIV infection diagno-
sis. Data on recently infected people are not available
through AIDS case surveillance. HN case surveillance
would provide data to better characterize recent ina-
dence trends, as well as where treatment, seMces and
prevention efforts are needed. AIDS incidence among
populations infected with HIV will depend on access
to treatment and the long-term effectiveness of thera-
pies. The assessment of changes in rural AIDS inci-
dence is complicated by the lack of knowledge of the
balance between changes in HIV incidence and issues
of access to care and treatment. Trends in AIDS inci-
dence over time were not analyzed because the data
cover a time when AIDS incidence was growing ev-
erywhere; instead, the relative impact of AIDS in ur-
ban and rural areas was examined.
Alhmgh the data confirm the presence of HIV and
AIDS in rural communities across the United States,
they do not suggest a rampant spread of ATDS to ru-
ral areas. There are some communities with relatively
high AIDS rates, especially those that have been af-
fected by interacting epidemics of sexually transmitted
diseases and drug use. These areas face difficult Cfial-
lenges to provide adequate care, confidentiality and
services to the affected populations. Every communi-
ty-urban, suburban or nonurban-should be aware
of the likelihood that HIV infection is present in the
population and plan accordingly to ensure the oppor-
tunity for confidential testing, treatment and services.
However, repeated reports of alarming proportional
increases in AIDS cases in rural areas do not allow for
appropriate planning or resource allocation propor-
tional to the affected populations.
Knowing where HIV is prevalent allows more ac-
curate planning of resource needs, including medical
and social services, specialized training for care pro-
viders, and prevention services. The use of antiretro-
17 Winter 2oW
viral therapies early in the course of HIV infection
can reduce inpatient hospitalizations and increase the
quality of life for those infected (Ramon and Barr,
1997;Revicki and Swartz, 1997).Since the advent of
effective treatments, HIV incidence can no longer be
inferred from AIDS. Although the distribution of
AIDS cases provides information to direct limited re-
sources for patient services, because therapies in-
crease survival time,data on HlV and AIDS inci-
dence are important in urban and rural areas. Early
recognition of changes in the prevalence of HTV in an
area, and possibly in a subpopulation, can help a
community assess where efforts should be concen-
trated or where prevention may be working well. Ide-
ally, knowledge of HIV prevalence, including AIDS,
will allow time for action before more people are
infected.
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