HIV, STI Testing Uptake Among Rural vs Nonrural Men

Jeb Jones, PhD, MPH, MS, assistant professor, Department of Epidemiology, Emory University, reviews new findings on how various definitions of rurality impact estimates of HIV testing among men who have sex with men (MSM) in the United States, especially when determining disparities for rural vs nonrural MSM.

What existing data led you and your coinvestigators to conduct this research? 

We have long known that uptake of HIV and STI testing was lower among men who have sex with men (MSM) in rural areas of the United States, despite evidence suggesting that sexual behavior is relatively consistent across levels of rurality.

However, studies have used different methods to define which areas are rural and which are not. Additionally, the Ending the HIV Epidemic (EHE) initiative has identified priority jurisdictions for targeting of HIV prevention services, including 7 states in which a substantial proportion of new HIV diagnoses occur in rural areas. Notably, those 7 states were selected because of the rural burden of new HIV diagnoses and the fact that they did not also contain a priority county. Using data from AIDSVu.org, it is apparent that some states with EHE-priority counties also have a high burden of cases of HIV in rural areas.

Various definitions of rurality and the emphasis placed on rural areas by the EHE initiative led us to ask how the definition of rurality affects our understanding of outcomes. Do different definitions of what constitutes a rural area result in different outcomes when comparing HIV and STI testing uptake among rural vs nonrural MSM?

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

We used data from the American Men’s Internet Survey (AMIS), an annual, cross-sectional survey of approximately 10,000 MSM aged 15 years and older in the United States. We classified MSM as living in rural or nonrural areas using 3 different methods of determining rurality: the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties, the United States Department of Agriculture’s Rural-Urban Commuting Area Codes (RUCA), and the Index of Relative Rurality (IRR).

Using each of these classifications, we compared the prevalence of testing for HIV and STIs, including extragenital (ie pharyngeal, rectal) STI testing. We also compared sexual behavior, including condom use, and pre-exposure prophylaxis (PrEP) eligibility by rural status.

The 3 different methods of defining rurality resulted in different proportions of MSM being classified as living in a rural area. Using the NCHS and RUCA measurements, approximately 10% of MSM in the AMIS sample lived in a rural area; using the IRR, approximately 30% were considered to live in a rural area.

Despite this, the rural populations were very similar across definitions. As expected based on previous studies, sexual behavior was very consistent across levels of rurality. In fact, approximately 71% of rural and nonrural respondents had indications for PrEP regardless of which rural definition was used. This indicates that the sexual health needs of MSM are similar regardless of their rural status. However, we observed marked differences in HIV and STI testing, which indicates a substantial unmet need.

In general, rural MSM were about 10%-15% less likely to have ever been tested for HIV or to have been tested for HIV in the past 12 months. The disparities were even more pronounced for STI testing. Rural MSM were 30%-40% less likely to have been tested for any STIs or to have undergone any extragenital STI testing in the past 12 months. Although the disparity in receiving any STI test was attenuated when controlling for suspected confounding variables, the disparity in extragenital testing remained very strong even after adjustment.

Given the role STIs can play in HIV transmission and the tendency for rectal gonococcal and chlamydial infections to be asymptomatic, this reduced screening represents an important missed opportunity for STI treatment and HIV prevention.

What are the possible real-world applications of these findings in clinical practice?

These findings support previous results that have identified disparities in HIV and STI testing among rural MSM. Interventions are needed to overcome additional barriers that many rural MSM face compared to their nonrural counterparts.

Our results suggest many definitions of rural areas might be too restrictive when used to identify MSM in need of these interventions. The IRR definition we used classified 3 times as many respondents as rural compared to the NCHS and RUCA methods, but the disparities we observed were similar. Health departments and other funding agencies can use these data to inform where to implement programs supporting rural MSM.

Do you and your coinvestigators intend to expand upon this research?

Future work will continue to focus on the disparities in HIV and STI prevention in rural compared to nonrural areas. Achieving the goals of EHE will require increased availability and uptake of culturally appropriate services for MSM living in rural areas, broadly defined.

We will explore surveillance data that might allow us to further characterize HIV and STI testing and PrEP use among rural MSM. We are also actively developing mobile health interventions that will hopefully overcome some of the barriers that rural MSM face by allowing them to privately access information about HIV and STIs, order at-home HIV and STI test kits, and identify telehealth providers.

About Dr Jones

Jeb Jones is an assistant professor in the Department of Epidemiology at Emory University. His research focus is on HIV prevention among MSM and gender minority populations in the United States, particularly in the US South where the epidemic is concentrated. He studies technology-based methods (eg, smartphone apps) for increasing uptake of HIV prevention strategies and methods for assessing PrEP uptake and use.