High rates of trauma, distrust in rural HIV-positives
Chronic violence and abuse, often stemming from childhood neglect, are pervasive among HIV-positive people living in the rural South, according to two new studies. The findings suggest that clinicians need to address a host of interpersonal issues, ranging from sexual abuse to post-traumatic stress syndrome.
"These are often people who have survived. As one patient puts it, HIV is just icing on the cake of a terrible life,’" says Kathryn Whetten-Goldstein, PhD, MPH, director of the Health Inequalities Program at Duke University in Durham, NC, and author of You’re the First One I’ve told: New Faces of HIV in the South.
Her book chronicles in rich detail the plight of 25 patients, all of whom reported histories of physical or sexual abuse, violence, and stress so chronic that it resembles post-traumatic stress syndrome.
Whetten-Goldstein also is principal investigator of an National Institutes of Health-funded study — Coping with HIV in the Southeast (CHASE) — that has enrolled more than 900 people living with HIV in six Southern states. One goal of the study is to identify unique characteristics of Southern rural life that make it responsible for such high rates of sexually transmitted diseases (STDs), low birth weight, teen pregnancy, and other health indicators. Similar efforts are part of the North Carolina Services Integration Project, which has been collaborating with state medical and social service providers to create a sustainable and replicable model of integrated care for HIV-positive, geographically dispersed residents.1
"What we realized in trying to implement the different demonstration projects was that we really needed to go back to ground zero, and that is when we went back to case study methodology," she says.
While other studies have shown high rates of depression, violence, and suicide in the rural poor, Whetten-Goldstein’s in-depth interviews showed how childhood histories were powerful predictors of behaviors and attitudes. One-third (33%) of the participants reported a history of substance abuse, while 70% reported symptoms of mental illness.
Collectively, more than 160 incidences of abuse were identified among the 25 patients. Stigma and racism, coupled with the South’s strong social hierarchy, has lead to a distrust for the medical profession that still thrives among the rural poor today.
"They don’t trust the system and feel on a basic level they need to figure things out for themselves," Whetten-Goldstein says. The clinical implications of these findings are not insignificant. For example, each of the participants had gone off their HIV medications at one time or another. "If their medications are not working, they are not going to call their providers and say they are feeling sick. They are just going to quit," she says.
The CHASE study now has preliminary results from more than 50% of the participants, half of whom live below the poverty level. The results support findings from her book. They include:
- 100% believed information about AIDS was being withheld from them.
- 50% were not sure if the government had created HIV to kill minorities.
- 50% of women had experienced phobias.
- 43% had witnessed someone seriously injured or killed.
- 25% had been attacked with the intent to kill.
- 17% had a family member killed during a crime.
- 10% had been placed in foster care.
Those factors help explain the fatalism and denial that is driving STD and HIV transmission rates in rural areas of the country. Indeed, a new study of rural HIV-infected patients found that more than half had engaged in unprotected sex — one third of whom reported that their partners were HIV-negative.2
Such findings have even greater implications for the South, particularly in the Bible Belt, where comprehensive sexual health education has been denied to many students. "It’s not just that we have a lot of people in rural areas," Whetten-Goldstein says. "There is something else happening that we need to figure out."
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AIDS Cases by Region and Population Area, 2001 |
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| Region | MSA 500,000 | MSA <500,000 | Nonmetro |
| Northeast | 11,444 | 680 | 298 |
| Midwest | 3,004 | 520 | 361 |
| South | 13,610 | 2,616 | 2,104 |
| West | 5,834 | 447 | 222 |
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Source: Centers for Disease Control and Prevention, Atlanta; 2002. |
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References
1. Nguyen TQ, Whetten K. Is anybody out there? Integrating HIV services in rural regions. Public Health Rep 2003; 118(1):3-9.
2. Heckman T, Silverthorn M, Waltje A, et al. HIV transmission risk practices in rural persons living with HIV disease. Sex Transm Dis 2003; 30:134-136.
Chronic violence and abuse, often stemming from childhood neglect, are pervasive among HIV-positive people living in the rural South, according to two new studies. The findings suggest that clinicians need to address a host of interpersonal issues, ranging from sexual abuse to post-traumatic stress syndrome.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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