Journal of Acquired Immune Deficiency Syndromes (12.01) Vol 28: P 385-392 - Tuesday, December 18, 2001
Susan E Cohn; Mark L Berk; Sandra H Berry; Naihua Duan; Martin R Frankel; Jonathan D Klein; Martha M McKinney; Afshin Rastegar; Stephen Smith; Martin F Shapiro; Samuel Bozzette

The use of rural health services by HIV-infected persons is not well understood. An understanding of the population receiving care for HIV in rural areas, as well as how well medical advances in HIV have been integrated into rural practice, is needed to best plan for future medical and social needs of HIV-infected persons in rural areas of the United States.

This article describes the initial findings from the rural section of the nationally representative HIV Cost and Services Utilization Study (HCSUS). Over-sampling was also done to provide separate information on rural care. Data from HCSUS were obtained from the period of January 5 to June 30, 1996. Geographic areas were defined as rural (non-metropolitan) if they were located outside metropolitan statistical areas or, in the six New England states, New England county metropolitan areas. Based on county and/or local health district AIDS caseload estimates, all 1,853 rural US counties or health districts were grouped in 226 geographic areas. In a three- stage process, interviews were conducted with collaborating medical providers; random samples were taken of 1,820 physicians from the American Medical Association Masterfile; and telephone interviews were conducted of selected physicians. HIV-infected patients who visited participating rural providers were sampled. A total of 632 rural patients were sampled and interviewed.

Adequacy of care processes was evaluated using two measures of medical utilization: taking HAART and taking prophylactic medication against PCP in the 6 months preceding the interview for those with no prior history of PCP and a lowest CD4 cell count of less than 200 cells/mm3.

The authors estimated that 4,800 adults with known HIV infection received medical care in rural areas of the United States in the first six months of 1996. 330,600 adults received HIV care in urban areas during a typical time period in that year. This indicates, according to the authors, the possibility that many rural HIV-infected residents are not getting rural care or that the HCSUS estimates are grossly incorrect.

The rural and urban care groups were similar with respect to age, gender, risk behavior, education, work status, region of care and household income. However, rural care patients were more likely than urban care patients to be non-Hispanic white and less likely to be Hispanic or African-American.

Rural care patients were more likely to see providers with less experience caring for HIV-infected patients than were urban care patients. Thirty-eight percent of patients cared for in rural areas had received care from a provider who had cared for less than 10 HIV-infected patients; only 3 percent of urban care patients received care by a provider seeing less than 10 HIV- infected patients. Women were less likely than men to have CD4 counts <200 cells/mm3 (38% vs. 64%) and were less likely to have been diagnosed with AIDS (26% vs. 46%). Women were more likely to be younger, non-white, less educated and more impoverished and to have Medicaid or no insurance. Similar differences were seen in the urban care group.

In the six months prior to interview, 85 percent of patients in rural care had received antiretroviral therapy: 11 percent with a single drug, 17 percent with combination regimens and 57 percent with combination regimens that contained NNRTIs or PIs. Non-Hispanic whites in rural care were more likely than non- whites to have been treated with HAART (63% vs. 48%).

In a multiple logistic regression model that included patient, disease, and provider variables, the most influential predictors of HAART use among rural care patients were HIV severity and being seen by a known provider. In 1997, only 57 percent of HIV-infected adults in rural care reported having used HAART compared with 73 percent of HIV infected adults in urban care. After adjusting for CD4 count and other covariates, urban care patients had three times higher odds of receiving HAART than patients who received care in rural areas. The strongest predictors of use of PCP prophylactic therapy in rural patients were lowest ever CD4 count and being non-Hispanic white versus non-white. There was a trend toward women in rural areas receiving less prophylaxis than men.

In their conclusion, the authors stressed that "although efforts should be made to improve the distribution of current HIV/AIDS treatment information to rural physicians, information alone is unlikely to change behavior or outcomes. Rather, appropriate interventions are likely needed to support change in the models of care by channeling patients to higher volume local providers, providing transportation to regional experts, and/or increasing co-management or telemedicine consulting between rural clinicians and HIV experts."
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