In this study, persons living with HIV/AIDS in rural and peri-urban areas who received care in urban areas experienced high levels of appropriate OI prophylaxis and favorable HIV outcomes (i.e., virologic suppression, incidence of ADIs), comparable to those living in urban areas. Unexpectedly, the unadjusted proportion of eligible patients receiving HAART was actually somewhat higher for non-urban patients than for urban patients. Also, outpatient utilization was lower among HIV-infected rural patients, compared to urban patients. Finally, HIV-infected patients from non-urban areas followed in this observational cohort are less likely to be Black or Hispanic than HIV-infected urban patients, but were otherwise demographically similar.
Rural and peri-urban patients in this study had high rates of HAART utilization and opportunistic illness prophylaxis that were consistent with national guidelines (Yeni et al., 2004
). Most rural and peri-urban patients in this population traveled to urban tertiary centers to receive care. In addition, previous work has demonstrated that when providers from urban centers travel to deliver care in rural areas, high quality HIV care can also be achieved (Wilson L et al., 2006
). Thus, elimination of access barriers may contribute to an improvement in quality of care for rural HIV residents. In contrast, studies from the pre-HAART era that reported sub-standard HIV care for rural patients (Calonge et al., 1993
; Miller et al., 1995
; Whyte & Carr, 1992
) primarily dealt with HIV patients who received care in rural areas. Future studies will need to examine whether patients who receive their care at local, rural or peri-urban settings have different outcomes than those who travel to urban high volume HIV care centers.
Rural and peri-urban patients had less frequent outpatient utilization than urban patients overall, as well as among those on HAART therapy. This raises concern about quality of HIV monitoring in non-urban patients on HAART. However, rural and peri-urban patients on HAART still met International AIDS Society HIV-USA Panel treatment guidelines (Yeni et al., 2002) by having at least quarterly visits with their providers and were as likely to achieve virologic suppression. Interestingly, rural and peri-urban patients also had lower inpatient utilization rates than urban patients, although these rates were not different if patients were taking HAART. While observed geographic differences may be due to patients’ seeking care outside of the HIV Research Network, all sites make an effort to comprehensively record inpatient utilization by patients at both their sites and outside medical facilities.
Consistent with previous literature demonstrating that patients affected by HIV in rural areas differ from those in urban areas (Cohn et al., 2001
; Wasser et al., 1993
; Young et al., 1992
; Rural Center of AIDS/STD Prevention, 6 A.D.
; Ellerbrock et al., 1992
), we found that non-urban patients were more likely to be White than urban patients; however, unlike previous studies, we found no differences in the prevalence of IDU by geographic distribution. Otherwise, in this multisite, multistate cohort, there were few demographic differences between rural and urban patients, other than increased MSM HIV risk factor among peri-urban patients.
Like previous studies, our results demonstrate that IDU’s were less likely to revieve HAART than non-IDUs, and those engaged in longitudinal care (≥ 4 visits per year) were more likely to receive HAART than those who were not in care. Of note, those with private insurance were less likely to receive HAART than those with governmental assistance or no insurance. This may reflect the utilization of AIDS Drug Assistance Programs (ADAP) which provide access to medications for HIV infected patients. Rules for eligibility for these programs and drugs covered vary state to state. Future studies will need to evaluate changes in HAART utilization with changes in our health care delivery system.
There are several potential study limitations. Our study population is not nationally representative and may not generalize to all HIV-infected Americans. However, sites from which patients were sampled do encompass a broad geographic distribution, and multi-site studies afford greater generalizability than single-site studies. In addition, providers at these sites are highly experienced in HIV care with high rates of HAART usage (Gebo et al., 2005
) and OI prophylaxis (Gebo KA et al., 2005
) among their patients. Therefore, our results may not generalize to patients receiving care from providers with less HIV experience, as may be typical in a rural/peri-urban clinic with lower HIV patient volume. As the data collected were on patients actively engaged in primary care, we were unable to capture individuals not engaged in primary HIV care, incarcerated, or unaware of their HIV diagnosis. HIV-infected patients who are not in primary care may be significantly different than those who engage in HIV care. Also, it must be acknowledged that “rural” and “peri-urban” do not depict uniform demographic or geographic entities, but rather many unique regions within the United States with lower population density. Additionally, we were unable to analyze the distance traveled by each patient to determine whether quality of HIV care was related to distance traveled, as de-identified data made it impossible to match geographic location with HIV care site. HIV patients who reside in non-urban areas but receive care in urban areas may not be representative of the full population of non-urban patients with HIV infection. They may have more economic or social resources, or they may have more motivation to seek high-quality care than other non-urban dwellers. Such factors might explain why non-urban residents in this study had higher odds of receiving HAART than urban dwellers. As we did not have access to a large number of rural HIV patients accessing HIV care in rural locations, future studies will need to assess this topic further.
In summary, this study demonstrates that, despite demographic and geographic differences between urban, rural and peri-urban HIV patients followed in the HIV Research Network, it is possible to provide high quality HIV care to non-urban residents. With care from providers with extensive HIV clinical expertise, these patients had high rates of opportunistic illness prophylaxis and HAART usage. Given the increasing prevalence of HIV in non-urban areas in the United States, future studies will need to examine care provided by providers located in non-urban settings to confirm the results of this study.