Report highlights challenges of HIV care in rural deep South
In Louisiana, which has the highest rate of new HIV infections of any U.S. state, young people in rural parishes are more likely to test positive for HIV than those living in the state’s biggest two cities, and rural residents of all ages are more likely to be diagnosed with AIDS, according to a recent report.
In rural areas, fewer HIV/AIDS services and a compromised continuum of care mean patients are less likely to achieve viral suppression than those living in New Orleans or Baton Rouge, explained Monica Johnson, director and founder of the nonprofit group HEROES. Meanwhile, the rate of HIV-related deaths has plateaued in rural areas of Louisiana while decreasing in metropolitan regions of the state.
Johnson and colleagues used data from the Louisiana Department of Health and other sources to compare risk factors that influence the HIV/AIDS epidemic in nonmetropolitan areas of the state. Johnson said their findings have larger implications for HIV care across the South, which accounts for around half of all new HIV and AIDS diagnoses in the United States while making up just 38% of the population, but trails other regions in most HIV prevention and care indicators, according to the CDC. Blacks account for 54% of new HIV diagnoses in the South, and more than 60% of black MSM diagnosed with HIV nationally in 2014 were living in the South.
“While the deep South is finally receiving much needed attention, resources and funding, none of this help has been targeted specifically for rural areas,” Johnson told Infectious Disease News.
Differences in care
In the 12 parishes located in the rural northeast region of Louisiana where Johnson and colleagues focused their research, residents are exposed to more risk factors for HIV, including higher rates of persistent poverty, STD infection in blacks, and incarceration, and a significantly lower percentage of adults with bachelor’s degrees. Yet the report found that rural residents have fewer HIV/AIDS-specific resources.
For example, there is one HIV testing site per 640 square miles compared with every 90.1 square miles in the metropolitan area of New Orleans. Pre-exposure prophylaxis (PrEP) services are even rarer, occurring every 7,043 square miles. In the New Orleans area, there is a PrEP facility every 147.5 square miles.
“I haven’t seen any signs of funding specifically targeting rural areas,” Nicholas Van Sickels, MD, assistant professor of clinical medicine at the Tulane University School of Medicine, told Infectious Disease News.
Van Sickels is both the medical director of Tulane’s HIV clinic in Alexandria, Louisiana, and the director of a large federally qualified health center in New Orleans.
At the New Orleans facility, a point person with access to CDC funds can use a ride-sharing app or physically walk patients to the clinic, according to Van Sickels. Patients are seen the day of their diagnoses, started on medication and are linked to case management and support services. Patients lost to care are brought back by a re-engagement project run by the city. Van Sickels said the center has numerous providers who can see and treat patients with HIV any day of the week, during the evening 2 nights a week and on Saturday mornings.
“One of the things we do best in New Orleans is we test like crazy,” he said.
By comparison, the clinic in Alexandria has a linkage coordinator and a nurse practitioner who works 40 hours per week. Van Sickels said he makes the 3 1/2-hour trip twice a month, and there is an additional physician who treats patients with HIV 4 hours per week. Once patients are in care, they do well, he said. The trouble is in navigating more patients to the clinic.
According to Van Sickels, the nonprofit that is responsible for the bulk of patient referrals at the Alexandria facility cannot penetrate all the rural communities in the area. It is also more difficult to provide specialty care for uninsured patients or those with Medicaid. For example, dental services for people with HIV have not been available in Alexandria for almost 2 years, so a dental clinic was set up by stretching existing funds, Van Sickels said.
“The bottom line is [we] do a lot of management of conditions that I don’t have to do in New Orleans,” he said. “In New Orleans, I can more easily engage with specialists, expert opinions and support services to optimize patient care. I have a full suite of case managers and eligibility specialists, who are stretched thin in New Orleans, but they are at least there.”
Van Sickels said parish jails do not test people for HIV unless they are very ill. He said hospitals and community clinics do better, but it is not common for these facilities to test all patients for HIV, especially in the rural parishes.
“Often, many people get to us after they’ve been seen several times by multiple providers for various acute illnesses, and only when they are hospitalized and truly ill, is an HIV test done,” Van Sickels said.
According to the HEROES report, rural northeast parishes had a higher proportion of people with HIV/AIDS without any health care. In these parishes, 51% of patients with HIV have achieved viral suppression compared with 59% in New Orleans and 58% in Baton Rouge.
“This report should be a wake-up call to action for our policy- and decision-makers,” Johnson said.
The recent United States Conference on AIDS in Washington, D.C, hosted several workshops and presentations that touched on aspects of the HIV/AIDS epidemic in the South. Johnson said the goal of ending the HIV/AIDS epidemic in the U.S. is not attainable without making progress in rural areas of deep South states like Louisiana. She hopes the HEROES report will give clinicians an even better understanding about HIV/AIDS in rural areas of the deep South so that they can help modify the course of care in these settings.
“For example, if we can increase the number of staff and focus on the HIV continuum we could streamline protocols for getting newly infected folks into treatment,” she said.
Johnson said there should be a continuum coordinator at every HIV testing site so that once a patient tests positive, they can make their first appointment for treatment.
“We know that if you have someone to help you get care on the day you test HIV positive, and you get medication on your first treatment visit, then you have a much better chance of staying in care and achieving and maintaining virologic suppression — the critical steps necessary to extend life and prevent new infections,” she said. – by Gerard Gallagher
CDC. HIV in the United States by geographic distribution. https://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html. Accessed September 28, 2017.
HEROES. HIV/AIDS in metropolitan vs. rural Louisiana. 2017. http://www.heroesla.org/uploads/2/6/3/3/26339281/heroes_report__1_.pdf. Accessed September 28, 2017.
Disclosures: Johnson is the founder and director of HEROES. Van Sickels reports no relevant financial disclosures.