HIV in the Rural Setting:

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• HIV in the Rural Setting
• Obstacles and Opportunities
• Polly E. Ross, MD
• Medical Director
• WNC Community Health Services
• Asheville, N.C.

Erin Chambers, CQI Coordinator, Partnership
Health Center, Missoula, MT
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Barriers to Care HIV in Rural America

• THE THREE Ds

DENIAL
DEVIL
DRUGS
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First D DENIALWho is in Denial?

• Community at large
• Providers
• Patients

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Community Denial
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First D - DENIAL

• Community Denial
• - HIV is not a problem out here.
• - HIV is not in my small town.
• - bring more of those people here.

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Living
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HIV in Montana
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WNC Community Health Services HIV
Service Area
Total Population 524,710 U.S.Census -2000
Avery, Buncombe,Cherokee, Clay, Graham, Haywood,
Henderson, Jackson, Madison, Macon, McDowell,
Mitchell, Polk, Rutherford, Swain, Transylvania
and Yancey.
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WNC Community Health Services New HIV
Disease Cases

Year New New R. I WNCCHS

• 2002 56
• 2003 46
• - 42
• - 53

105
119
90
129
Data Sources NC DHHS HIV/STD Surveillance
Report WNCCHS CADR
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First D - DENIAL
Providers

• Providers in the Medical Community
• HIV is not a disease that I will see in my
  practice.
• HIV must be the reason for this.

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HIV Providers Community Educators

• ER staff, Correctional staff, local health dept.,
  peers.

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D Denial Patient Denial
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D Denial Patient Denial

• HIV cannot happen to me
• HIV is something that only gay people get.

others

• HIV happens only in the big cities.

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D Denial Patient Denial
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The Second DDevil
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The Second D DEVIL

• aka - self doubt
• - low self esteem
• - compounding mental health issues

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Second D dDEVIL

• Oh honey- you DESERVE this HIV ! If you just
  hadnt a ..

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Case Study James

• 38-year old white male
• Suffering from schizophrenia
• Extremely isolated has had to travel hundreds of
  miles to receive care
• Transient to some degree has moved away and come
  back several times

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Rural Female Statistics

• 1 in 3 women in the US live in a rural area.
• Nearly 25 of rural women do not have a high
  school diploma.
• 41 of rural women, compared with 13-20 of urban
  women, are depressed or anxious.
• Rural women suffer more chronic illness.
• Suicide rates are 3 times higher than in urban
  areas.

APA Report Executive Summary of The Behavioral
Health Care Needs of Rural Women, 2002
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Case Study Qiana

• 26-year old white female
• Mother of 2
• At time of diagnosis, faced stigma so extreme she
  felt the need to relocate
• Supports family by working at Wal-Mart

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Why is DOUBT and/or DESPAIR such a factor in
Rural areas?
Reason 1 Persistent poverty
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Why is DOUBT and/or DESPAIR such a factor in
Rural areas?
HIV in the South -Kathryn Whetten PhD,MPH

• As children
• 21 didnt have enough to eat
• 34 had parents who were problem drinkers
• 12 had parents too drunk or high to care for them

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HIV in the South Kathryn Whetten, PhD,MPH

• As children
• 21 didnt have enough to eat
• 34 had parents who were problem drinkers
• 12 had parents too drunk or high to care for
  them

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HIV in the South Kathryn Whetten, PhD,MPH

• Before the age of 13
• One quarter were sexually abused
• 14 had intercourse with someone 5 years or more
  older by using force or threats
• 54 of these forced encounters were with parents,
  guardians, partners of parents, brother or other
  family member

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HIV in the South

• 22 had parents who were depressed or mentally
  ill (34 non-minority 15 minority)
• 6 had parents who tried to commit suicide with
  3 being successful
• 17 had a family member killed in a crime
• 43 had seen someone seriously injured or
  violently killed

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Why is DOUBT and/or DESPAIR such a factor in
Rural areas?

• Reason 2 A religious culture of demoralization

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Why is DOUBT and/or DESPAIR such a factor in
Rural areas?

• Reason 3 Generational mistrust

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HIV in the South - Trust Kathryn Whetten,
PhD,MPH

• More than 50 believed that it is possible that
  the govt created AIDS
• 25 believe that God created AIDS as punishment
• 25 believed that their doctors were not giving
  them the best care possible

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The Third D Drugs
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Third D Drugs
DRUGS

• DENIAL DEVIL

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Overcoming the Barriers to HIV care in Rural
Areas

• THE THREE Ds
• DENIAL
• DEVIL
• DRUGS

Education
Trust
Mental Health
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Overcoming Barriers to Care MT Strategies

• Consolidating HIV care in one place has helped
  care become more coordinated in Missoula
• Providing non-cash incentives and assistance to
  clients for participating in group process,
  attending CAB meetings, traveling to medical
  appointments
• Implementing Quality Management plan designed to
  monitor and improve care throughout the region
• Offering courses in Chronic Disease Self
  Management.

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WNC Community Health ServicesAsheville, N.C.

• Our mission is
• to promote the health and well-being of the
  individuals, families, and communities that we
  serve.

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WNC Community Health Services the Early Years
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WNC Community Health Services HIV
Service Area
Total Population 524,710 U.S.Census -2000
Avery, Buncombe,Cherokee, Clay, Graham, Haywood,
Henderson, Jackson, Madison, Macon, McDowell,
Mitchell, Polk, Rutherford, Swain, Transylvania
and Yancey.
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WNC Community Health Services HIV
Service Area
Total Population 524,710 U.S.Census -2000
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WNC Community Health Services HIV Area
of Service
Total Population 524,710 U.S.Census -2000

• 3900 square miles
• Asheville/Buncombe Cty Urban 21

79 Rural
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WNC Community Health Services HIV
Service Area
Total Population 524,710 U.S.Census -2000

• 12 of Service Population is at or below the
  Federal Poverty level

At any one time, one third of the population
does not have health insurance.
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WNC Community Health ServicesIntegrated Approach
Comprehensive Care

• HIV/STD Counseling, testing, treatment and
  referral
• Primary Medical care
• HIV Specialty Care
• Dental Care
• On-Site Pharmacy with adherence support
• On-site Laboratory collection and processing

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WNC Community Health ServicesIntegrated Approach
Comprehensive Care

• Transportation
• Outpatient Mental Health ( w/ Psychiatric
  Services)
• Outpatient Substance Abuse Services
• Family Centered Case Management

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Clinic Overview Partnership

• Partnership Health Center oversees Title II III
  funds
• CHC model
• ambulatory medical/dental services with onsite
  pharmacy.
• Services offered
• medical, dental, pharmacy (non-ADAP), limited
  onsite mental health

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Program Overview

• Staffing
• -Temporary dedicated Continuous Quality
  Improvement (CQI) coordinator, program
  coordinator, part-time permanent program
  assistant
• Funding
• -Title II and III funds, Capacity Grant for CQI
  (temporary funding only).
• -ADAP funds administered by State ADAP
  Coordinator waitlist of approximately 25

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Client Population Overview

• 141 RW patients in the 16 counties of the western
  region
• Demographics
• 83 MSM, 14 women 3 heterosexual men,
• 84 Caucasian, 6 Native American, 1 African
  American, 4 Latino, 4 were more than one race,
  1 unknown.

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Barriers to Care
Transportation
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Barriers to Care - Transportation
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Barriers to Care -
Confidentiality
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Barriers to Care- Confidentiality

• Inquire about support systems and who knows.
• Train staff on confidentiality and remind them
  frequently.
• Practice what you preach.

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Barriers to Care - Isolation
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Case Study Paul

• 36-year old Native American man
• Dealing with substance abuse issues
• Reluctant to engage in care or case management
• In denial about status
• Pain management used as a method of maintaining
  engagement

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Barriers to Care - Isolation
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WNC Community Health ServicesIntegrated Approach
Comprehensive Care

• Adult Day Health Care for PWLA
• Supervised Group Home for dually diagnosed
• Shelter Care ( rental assistance)
• SS Representative Payee Services
• Emergency Food Pantry

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Barriers to Care - Isolation

• Be a resource of other AIDS service groups in
  your area.
• Explore the symptoms of depression.
• Dont forget the power of touch.

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Barriers to Care - Isolation
-Providers

• Find a empathic ear
• Try to rejuvenate
• clinically at least once a year.
• Take care of yourself

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Tips from the Experts
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Tips from the Experts

• Take time with me dont rush.
• Dont make me tell my story so many times.
• Listen to my needs.

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In the long run .
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Benefits of the Rural Setting

• Less likely to lose clients to care, since they
  are easier to track.
• A closely-knit provider network means that all
  providers are better informed about individual
  client needs
• Collaboration and teamwork are necessary in order
  to ensure quality care

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WNC Community Health ServiceOutcomes HIV-1
Viral Load( with lt 400 cop/ml)
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WNC Community Health Services Morbidity - New
AIDS Cases
WNCCHS Patients 2002- 6 (1.2) 2003 11
(2.0) 2004 7 (1.3) 2005 3 (0.9)

Data Source WNCCHS CQI
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WNC Community Health Services Mortality
WNCCHS HIV/AIDS Deaths 2002 - 6
(1.0) 2003 10 (1.8) 2004 5 (0.9) 2005
7 (1.2 )

WNCCHS CADR 2002-2005
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