■ National Advisory Committee on Rural Health and Human Services 

HIV PREVENTION AND TREATMENT 

CHALLENGES IN RURAL AMERICA 

POLICY BRIEF AND RECOMMENDATIONS TO THE SECRETARY

MAY 2020 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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EDITORIAL NOTE 

During its 87th meeting in Atlanta, Georgia, the Committee examined rural HIV prevention and treatment 

and sought to understand the continuum of HIV care—including prevention, diagnosis, and treatment— 

among rural populations. To this end, the Committee heard from subject matter experts on HIV 

prevention and treatment challenges in rural communities at both the national and state level. The rural 

HIV subcommittee traveled to Anniston, Alabama to visit Health Services Center, Inc., which is a Ryan 

White funded community based organization providing HIV medical care, education and support across 

14 counties in East Alabama (see Appendix A). While there, Committee members heard from providers 

and staff as well as other local HIV service organizations about the challenges and opportunities related 

to improving HIV care in the surrounding communities and the role of the U.S. Department of Health and 

Human Services in providing assistance. 

ACKNOWLEDGEMENTS 

The Committee would like to acknowledge all those whose participation helped make the March 2020 

convening in Atlanta and this policy brief on rural HIV possible. 

The Committee expresses its gratitude to each of the presenters for their contributions to the meeting 

and for their subject matter expertise. These individuals are: Dr. Ken Dominguez, MD, MPH, CAPT USPHS 

(Centers for Disease Control and Prevention); Dr. Mahyar Mofidi, DMD, PhD, CAPT USPHS (HIV/AIDS 

Bureau, Health Resources and Services Administration); Dr. Fayth Parks, PhD, MS (Georgia Southern 

University, Department of Leadership, Technology, and Human Development); Michael Murphree, LCSW 

(Medical Advocacy and Outreach); Eric Paulk, JD (Georgia Equality, Inc.); Gregory Felzien, MD, AAHIVS 

(Georgia Department of Public Health, Division of Health Protection). 

The Committee thanks Dr. Barbara Hanna, Kelly Turner, and the staff at Health Services Center, Inc. for 

hosting the Rural HIV Prevention and Treatment Challenges site visit. 

Special thanks goes to the Committee host and the Rural HIV Prevention and Treatment subcommittee 

chair, Ben Taylor. Additionally, special thanks goes to members who served on this subcommittee: Steve 

Barnett, Bob Blancato, Kari Bruffett, Wayne Deschambeau, Pat Schou, James Werth, and Loretta Wilson. 

Finally, the Committee extends its gratitude to Lamar Greene for coordinating the activities of this 

meeting, summarizing the Committee’s findings, and preparing this policy brief. 

National Advisory Committee on Rural Health and Human Services 
 

 

 

 

 

 

 

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Policy Recommendations 

Recommendation 1: The Committee recommends the Secretary, in modernizing the Ryan White 

HIV/AIDS Treatment Extension Act of 2009, focus on enhancing the ability of the program to meet the 

needs of rural communities. This includes: 

• Increased rural-targeted funding to support pilot programs and capacity building and, when 

issuing Notices of Funding Opportunities, consider having rural as a funding factor and giving 

rural applicants in a designated Health Professional Shortage Area additional consideration 

through the use of Preferences. 

• Expansion of the use of telehealth and telemedicine to increase access to services and reduce 

stigma in rural populations. 

Recommendation 2: The Committee recommends the Secretary, in maximizing the scientific advances 

made in HIV prevention, to increase access to Pre-Exposure Prophylaxis (PrEP) for rural residents 

through the existing statutory authority in Sections 330 and 330A of the Public Health Service Act 

(HRSA's Community Health Centers Program and the Rural Health Care Services Outreach Program, 

respectively). 

Recommendation 3: The Committee recommends the Secretary support a streamlined grant application 

process for resource strapped rural providers, as well as more virtual grant writing technical assistance 

for rural communities to enhance their ability to successfully apply for health and human services funding. 

National Advisory Committee on Rural Health and Human Services 
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National Advisory Committee on Rural Health and Human Services 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION 

The United States has been grappling with the HIV epidemic since the early 1980s. Today, there are 

roughly 1.2 million Americans with HIV, and about 14 percent of them (1 in 7) are not aware they are 

infected.1 The Centers for Disease Control and Prevention (CDC) estimated that 36,000 people became 

newly infected with HIV in 2018.2 Furthermore, the CDC noted that in 2018 men accounted for 81 percent 

and women accounted for 19 percent of new HIV diagnoses.3 Although there is limited data on HIV among 

transgender people, the CDC found that from 2014 to 2018, 3,009 transgender people received an HIV 

diagnosis.3 

After five years of significant declines, the number of new annual HIV infections began to level off in 2013 

to approximately 39,000 new infections per year.2 The decrease in new HIV infections has plateaued 

because effective HIV treatment and prevention services are not adequately reaching the populations 

most disproportionately affected such as people who inject drugs, LGBTQ+ people, Black people, LatinX 

people, and members of Tribal communities. In addition, research shows that HIV cases have been 

increasing among rural communities and that barriers to HIV-related health care need to be addressed.4 

In early 2019, the president announced the “Ending the HIV Epidemic: A Plan for America” initiative, which 

aims to reduce new HIV infections by 75 percent in the next 5 years and by 90 percent in the next 10 

years. The plan points out that, “most infections are now highly concentrated in certain geographic 

hotspots ... and certain rural areas carry a disproportionately high burden of HIV, especially in the South.” 

The plan is structured around providing the geographic locations most affected by HIV (including rural 

areas) with the additional expertise, technology, and resources required to address the epidemic in their 

communities. The initiative will focus on four key strategies while working to end the HIV epidemic: 

Diagnose, Treat, Prevent, and Respond. More detailed information about the Ending the HIV Epidemic 

initiative can be found in the “Federal Programs” section of this policy brief. 

BACKGROUND 

Rural HIV 

There are regional and geographic differences regarding the prevalence of HIV and access to HIV 

treatment and prevention services. Historic factors have contributed to HIV disparities based on 

geography. The HIV epidemic was first widely centralized in major cities, which meant that resources and 

research attention were heavily concentrated in urban areas despite rural areas potentially also being 

impacted.5 In addition, incidence of HIV in rural communities may appear to be low because data are 

collected from where patients receive care, not where they live.6 Stigma also plays a role in increasing 

the possibility of rural residents getting treated in urban areas or providing a false address to testing 

facilities out of fear that others in their community might learn about their HIV status.6 

Some of these factors account for the limited amount of data on HIV in rural America. In 2010, the two 

counties with the highest HIV prevalence rates were rural counties, and 16 percent of the 50 counties 

with the highest HIV prevalence rates were rural.6 Racial disparities were also apparent. In seven of eight 

high-prevalence rural counties, the proportion of Black American, LatinX, Tribal, and other minority 

populations exceeded the national average.7,8 In 2015, the American Psychological Association reported 

that rural communities have HIV prevalence rates approaching those of urban areas.9 Most recently, rural 

communities have been experiencing notable increases in recognized new HIV cases, at least in part 

because of the opioid epidemic, and especially in the southern regions of the country. It is reasonable to 

4 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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assume that more research on rural HIV will be published in the future. The recent increases of HIV cases 

in rural areas led the National Advisory Committee on Rural Health and Human Services (NACRHHS) to 

focus on the issue during its March 2020 convening in Atlanta. 

Among all regions of the 

country, the South has the 

greatest number of new HIV 

infections (see Figure 1), 

with Southern states 

accounting for 52 percent 

of new HIV diagnoses in 

2018.3 HIV rates for 

suburban and rural areas 

are higher in the South and 

Midwest compared to the 

Northeast and West. In the 

South, 23 percent of new 

HIV diagnoses occurred in 

suburban and rural areas, 

whereas in the Midwest, 21 

percent were suburban 

and rural.

3 Gaps in access 

to HIV treatment and 

prevention services are especially problematic in rural areas for LGBTQ+ people and people who inject 

drugs.10 

Barriers to Accessing Health Care 

Social factors, HIV criminalization laws, and the lack of public health infrastructure investment lead to 

barriers and challenges complicating access to HIV prevention and treatment efforts in rural 

communities. In addition, compared to their urban counterparts, rural residents have higher rates of 

poverty, less access to health care and transportation, and are less likely to have health insurance.4 The 

lack of available services is another barrier for health care access in rural areas. In fact, most rural 

counties have been deemed “Health Professional Shortage Areas” (HPSA) by the Department of Health 

and Human Services (HHS) because they have insufficient providers for primary, dental, and/or mental 

health care.4 In addition, most rural communities will lack health care providers who specialize in 

providing care to persons with HIV disease.6 

Further, many rural communities lack drug rehabilitation and syringe services programs (SSPs). Increasing 

rates of injection drug use in rural communitiesi

, driven by the opioid epidemic, has led to an increase in 

rates of HIV, Hepatitis C, and other infectious diseases in rural areas.11 SSPs have been proven to decrease 

the spread of infectious diseases amongst people who inject drugs; however, these programs are 

uncommon, especially in rural areas.12 Those SSPs that do exist are underfunded, partially because federal 

funding cannot be used for clean syringes. As of 2017, furthermore, a number of states had deemed SSPs 

illegal, with 15 states requiring legislative action to permit the operation of SSPs (see Figure 2). 

i Click here to learn more about increasing rates of injection drug use in rural areas 

Figure 1: Rates of Diagnoses of HIV Infection among Adults and Adolescents, 2018. Source: 

CDC. Diagnoses of HIV infection in the United States and dependent areas, 2017. HIV

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SSP ■ are illegal 

Statewide legislation l•gahz•ng SSP operation 

SSPs locally p1Drmltted or no law exists addrHsing SSPs 

Because of the lack of availability of services, rural residents often must travel long distances to find a 

provider, which can be 

problematic because many 

rural communities have poor 

transportation infrastructure 

or lack public transportation 

systems.12 

A systematic review of HIV 

care for people in rural areas 

noted that, nine of the 11 

studies examined found 

transportation to be a 

significant, and perhaps the 

most problematic, barrier to 

people keeping their medical 

appointments and receiving 

HIV-related care.12 

Lack of local health care 

providers and lack of 

transportation services to 

larger communities can make 

it difficult for rural residents Figure 2: Syringe Services Programs and the Opioid Epidemic, 2017. Source:

to find out they are HIV https://www.amfar.org/ssp-opioid-epidemic/

positive, maintain preexposure prophylaxis (PrEP)ii regimens, engage in regular HIV care, and adhere to antiretroviral therapies 

(ART)iii as part of a comprehensive approach to HIV treatment.12 Telemedicine offers promise for 

addressing the lack of providers and transportation issues in rural areas. Telemedicine can connect rural 

clinics to HIV specialty physicians in urban areas to rural clinics without the patient having to travel a great 

distance. The Committee has heard that clinics are beginning to use this HIV care delivery model and 

programs aimed at addressing provider and patient acceptance. On the other hand, billing for 

telemedicine presents some restrictions for site locations, and lack of high-speed internet is a significant 

obstacle to the use of telemedicine in some rural areas. 

Another barrier to accessing HIV-related health care services in rural areas is the cost of care. Because 

residents of rural communities frequently struggle with persistent poverty, rural individuals may require 

financial assistance for treatment and medications, particularly if they are uninsured or do not qualify for 

Medicaid.12 A study of rural women with HIV, for example, found that 17 percent of participants viewed 

affordability as “sometimes” or “always” a barrier to care and 15 percent reported that lack of insurance 

was “sometimes” or “always” a barrier to care.13 

ii HHS defines PrEP as an HIV prevention method in which people who do not have HIV take medicine daily to 

reduce their risk of contracting the virus if they are exposed. When used correctly, PrEP is more than 90 percent 

effective. Patients must meet with their provider every 3 months for repeat STI testing, prescription refills, and 

follow up. 

iii According to NIH, ART is the use of daily HIV medicines to treat HIV infection. ART cannot cure HIV, but HIV 

medicines help people with HIV live longer, healthier lives. ART also reduces the risk of HIV transmission. 

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Furthermore, because rural areas have a lower population density, and consequently a lower density of 

HIV-positive individuals, HIV programs in rural areas have a higher operating cost per person compared 

to programs in urban areas.12 The higher operating cost per person feeds into the lack of availability of 

HIV-related health services and affordability concerns for both rural providers and residents. For people 

with HIV who lack insurance and needed financial resources, the Ryan White HIV/AIDS Program (RWHAP)iv 

serves as a safety net to help manage their HIV treatment. Most program funds for critical medical and 

support services are targeted toward eligible areas reporting 500 to 999 cumulative HIV cases in the most 

recent 5 years. However, because of the lower population density, rural counties often do not reach this 

threshold even with high case rates.4 Research has found that 31 percent of urban counties had at least 

one RWHAP provider compared with 5 percent of rural counties, even after controlling for HIV prevalence 

rates.14 

HIV-related stigma, negative beliefs, feelings, and attitudes towards people living with HIV, groups 

associated with people living with HIV, and other key populations at higher risk of HIV infection, is another 

obstacle that inhibits people in rural areas from accessing HIV-related health services and contributes to 

the social isolation of people with HIV in rural communities.11,15 Rural communities are often made up 

of small, close-knit social networks, which can make it difficult for individuals to privately seek HIV-related 

care. People may be concerned that their neighbors or co-workers may see them accessing HIV-related 

services.6 Stigma may make people less willing to engage in HIV testing, PrEP, and HIV treatment.6 Stigma 

can be especially problematic for vulnerable populations in rural areas that are disproportionately 

affected by HIV, particularly LGBTQ+ people, and people who inject drugs.6 

During the Committee’s site visit to Health Services Center, Inc. in Alabama (see Appendix A), leaders of 

HIV services organizations across the state identified stigma as a significant problem. Most of the 

organizations represented had removed “HIV” or ”AIDS” from their organization’s or program names in 

order to reduce the impact of stigma and increase utilization of their services. One organization even 

noted how they worked with a local Critical Access hospital to create a destigmatized HIV treatment 

program, but no patients attended out of fear. 

HIV stigma is also present in the health care system. People with HIV have experienced health care 

provider-related stigma and discrimination, which pose significant barriers to medical care. One study 

focused in the rural Southeast found that 11 percent of the sample had been turned away from a physician 

in the previous year, which not only leads to patients not being accepted into care but also increases the 

possibility that these individuals will not be inclined to return to care.16 Other research has shown that 

patients were hesitant to talk openly with medical providers because of perceptions that the providers 

were uncomfortable with their sexual orientation and sexual behaviors.17 This lack of trust in the patientprovider relationship can negatively affect patient engagement and retention in care. 

In addition to having negative biases toward people with HIV, medical staff may not be equipped to 

address HIV prevention and treatment needs. According to the CDC, as of 2015 one in three primary care 

physicians and nurses across the country have not heard of PrEP, which may have been stifling HIV 

prevention efforts.18 Beyond PrEP, research demonstrates that rural medical staff often are inadequately 

trained in providing comprehensive HIV care, especially in the context of a patient having multiple chronic 

conditions. Further, clinicians may defer starting antiretroviral therapies for people with HIV who also 

inject drugs. The widespread substance use disorder crisis has made treating HIV among people who also 

iv See the Federal Programs section for more information about the Ryan White Program 

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use drugs even more complicated. Providers also may be less confident in identifying and treating 

depression, substance use disorder, and chronic non-malignant pain in HIV patients.4 Exacerbating these 

difficulties, rural medical staff often lack knowledge about federal and state resources available to assist 

people with HIV.19,20 

HIV-related stigma extends to the policy and legal environments as well. In 1990, the Ryan White 

Comprehensive AIDS Resources and Emergency Act, which provided funding to assist vulnerable 

communities in accessing HIV treatment services, required states to certify that they had adequate 

criminal laws in place to prosecute individuals who knowingly exposed another person to HIV.21 This 

requirement was excluded from the Act’s reauthorization of 2000. Despite the removal, more than half 

of the statesv currently have one or more HIV-specific criminal laws and the remaining states have, 

historically, used other laws to criminalize HIV and meet the requirements set forth by the Ryan White 

Act.

21 Most HIV-specific criminal laws require people with HIV to disclose their status before engaging in 

sexual penetration, sharing injection drug paraphernalia, and/or donating blood.22 A majority of these 

HIV-specific laws criminalize non-disclosure, regardless of intent to transmit HIV or whether HIV is 

transmitted or not, and some states such as Georgiavi punish people with HIV for behaviors that are 

virtually impossible for transmitting the virus such as spitting or biting.22 

A number of research studies that have shown HIV criminalization laws to be ineffective and have found 

no associations between these laws and safer sex practices such as abstinence, decreased number of 

sexual partners, condom use, or HIV status disclosure.23, 24, 25, 26, 27 Legal and public health researchers 

generally oppose HIV criminalization laws because they may increase HIV-related stigma and 

discrimination, and because the laws do not take into account the development of transmission reducing 

treatments such as PrEP, sexual partner PrEP usage, and antiretroviral therapies.

22 More rural-specific 

research is needed in the area of HIV criminalization. 

FEDERAL PROGRAMS 

The U.S. Department of Health and Human Services (HHS) administers programs that support and 

enhance HIV prevention and treatment efforts in rural areas. Several agencies work to address the HIV 

epidemic through grant distribution, service delivery, capacity building, and program evaluation. While 

there may be other agencies and programs within HHS that address HIV prevention and treatment, this 

brief will cover the ones that the Committee identified as key: the National Institutes of Health (NIH), 

the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health 

Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), the Centers 

for Medicare and Medicaid Services (CMS), and the Indian Health Service (IHS). 

HHS – Ending the HIV Epidemic: A Plan for Americavii 

The Department of Health and Human Services began a 10-year initiative in FY 2020 with the goal of 

reducing new HIV infections to less than 3,000 per year by 2030. According to the National Plan to End 

HIV, reducing new infections to this level would essentially mean that HIV transmissions would be rare 

and meet the definition of ending the epidemic. The initiativeviii will focus efforts in 48 counties, 

v Click this link to see which states have criminal laws for HIV vi Visit this link to learn more about HIV-specific criminal laws in Georgia vii Click here to learn more about the goals and strategies for the Ending the HIV Epidemic Initiative viii Click here to view the list of counties, territories, and states that will have an added focus during the initiative 

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Washington, DC, San Juan (PR), where >50 percent of HIV diagnoses occurred in 2016 and 2017, and an 

additional seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South 

Carolina) with a substantial number of HIV diagnoses in rural areas (see Figure 3). There are four key 

strategies in the initiative to end the HIV epidemic in the United States: 

1. Diagnose all people with HIV as early as possible after transmission.

Approximately 161,800 Americans are with HIV but do not know they have it.2 Early detection is

critical and can lead to quicker results in treatment and prevent transmission to others. Using

the latest diagnostics and advanced automation systems, we will make HIV testing simple,

accessible, and routine we will connect people with HIV immediately to care.

2. Treat HIV rapidly and effectively to

achieve sustained viral suppression.

People with HIV who take medication as

prescribed and stay virally suppressed

can live long, healthy lives and have

effectively no risk of sexually transmitting

HIV to a partner. Eighty percent of annual 

new infections are transmitted by those

with HIV who are not receiving HIV care

and treatment. We will establish and

expand programs to follow up with

people with HIV no longer receiving 

care—and provide the resources needed 

to re-engage them in effective HIV care 

and treatment. The Ryan White HIV/AIDS 

Program has achieved a viral suppression 

rate of nearly 86 percent. We aim to leverage the program’s comprehensive system of care and 

treatment to increase viral suppression around the country to 90 percent. 

3. Prevent HIV transmission among people at highest risk with Pre-Exposure Prophylaxis (PrEP) and

prevention education.

Of the estimated 1 million Americans at substantial risk for HIV, and who could benefit from

PrEP, less than 1 in 4 are actually using this medication. In May 2019, HHS and Gilead

Sciences announced that the pharmaceutical company has agreed to donate PrEP medication

for up to 200,000 individuals each year for up to 11 years. In December 2019, HHS launched

Ready, Set, PrEP, a nationwide program that provides PrEP medications at no cost to thousands

of individuals who qualify. In addition, SSPs are an effective component of a comprehensive,

integrated approach to HIV prevention among people who inject drugs. Nearly 30 years of

research has shown that comprehensive SSPs are safe, effective, cost-saving, do not increase

illegal drug use or crime, and play an important role in reducing the transmission of viral

hepatitis, HIV, and other infections.

4. Respond rapidly to detect and respond to HIV clusters and prevent new HIV infections.

New laboratory methods and epidemiological techniques allow us to see where HIV may be

spreading most rapidly, thereby allowing CDC and other partners to quickly develop and

Figure 2: Geographic Hotspots - The 48 counties, plus 

Washington, DC, and San Juan, PR, where >50 percent of HIV 

diagnoses occurred in 2016 and 2017, and an additional seven 

states with a substantial number of HIV diagnoses in rural areas. 

Source: https://www.hiv.gov/ 

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implement strategies to stop ongoing transmission. We will work with impacted communities to 

ensure they have the technology, personnel, and prevention resources to follow up on all HIV 

cases and to intervene to stop chains of transmission, and to get those impacted into 

appropriate care and treatment. 

Centers for Disease Control and Preventionix 

CDC provides clinicians with tools and guidelines, continuing education resources, and patient materials 

on HIV screening, prevention, treatment and care. CDC’s largest single investment in HIV surveillance 

and prevention efforts are led by health departments in states, territories, and select cities. Health 

departments use this funding to implement high-impact HIV prevention activities that take full 

advantage of recent advances in surveillance data collection and HIV prevention and maximize the 

impact of every federal dollar. For its role in the national Ending the HIV Epidemic Initiative, the CDC will 

work with communities and other agencies to: 

• Use the latest systems and technology to make HIV testing simple, accessible, and truly routine 

in healthcare and non-healthcare settings. 

• Carry out focused approaches that encourage more people who are at substantial risk for HIV to 

be tested for HIV at least annually. 

• Further collaboration to identify and implement innovative technologies and programs, such as 

self-testing, to make testing more accessible. 

• Help partners expand local programs that identify and follow up with people who have stopped 

receiving HIV care and treatment. Data-to-Care tools and approaches will encourage them to get 

back in HIV care and treatment. 

• Continue updating clinical guidelines for prescribing PrEP, and add more public and private 

providers who offer PrEP to its PrEP Locator. 

• Continue providing education campaigns for both the public and healthcare providers to combat 

stigma associated with PrEP use, as well as the stigma associated with HIV. 

• Assess and address gaps in staffing, expertise, and data management systems that prevent 

states and local areas from being able to fully investigate and respond to increases in HIV 

transmission and outbreaks. 

HRSA’s HIV/AIDS Bureau (HAB) – Ryan White HIV/AIDS Programx 

The program provides a comprehensive system of HIV primary medical care (includes HIV medical 

services; also mental health, substance abuse, nutrition and oral health, medical case management, 

etc.), essential support services, and medications for low-income people with HIV who are uninsured 

and underserved. The Program funds grants to states, cities/counties, and local community-based 

organizations to provide care and treatment services to people with HIV to improve health outcomes 

and reduce HIV transmission among hard-to-reach populations. 

• Part A: funds medical and support services to Eligible Metropolitan Areas (EMAs) and 

Transitional Grant Areas (TGAs). EMAs and TGAs are counties/cities that are the most severely 

affected by the HIV epidemic. 

ix Visit this link to learn more about the CDC’s HIV programs x Visit this link to learn more about the Ryan White HIV/AIDS Program 

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• Part B: administers funds for states and territories to improve the quality, availability, and

organization of HIV health care and support services. In addition, Part B also includes grants for

the AIDS Drug Assistance Program (ADAP).

• Part C: administers funds for local community-based organizations to provide comprehensive

primary health care and support services in an outpatient setting for people with HIV through

Early Intervention Services program grants. Part C also funds Capacity Development grants to

strengthen organizational infrastructure and increase access to high quality HIV primary health

care services.

• Part D: administers funds for local, community-based organizations to provide outpatient,

ambulatory, family-centered primary and specialty medical care for women, infants, children

and youth with HIV. Part D funding may also be used to provide support services to people with

HIV and their affected family members.

• Part F: funds support clinician training, technical assistance, and the development of innovative

models of care to improve health outcomes and reduce HIV transmission. These programs

include the Special Projects of National Significance Program, the AIDS Education and Training

Centers Program, the Dental Programs, and the Minority AIDS Initiative.

HRSA’s Bureau of Primary Health Care (BPHC) – Primary Care HIV Prevention (PCHP)xi 

Fiscal year (FY) 2020 Ending the HIV Epidemic—Primary Care HIV Prevention (PCHP) funding will 

supplement identified health centers’ current Health Center Program operational grant (H80) award. 

Health centers will use PCHP funding to expand HIV prevention services that decrease the risk of HIV 

transmission in geographic locations (PDF - 76 KB) identified by Ending the HIV Epidemic: A Plan for 

America, focusing on supporting access to and use of pre-exposure prophylaxis (PrEP). HRSA identified 

eligible health centers based on service delivery site location, and either existing Ryan White HIV/AIDS 

Program (RWHAP) funding or proximity to a RWHAP-funded organization. The objectives of the funding 

program is to increase outreach, HIV testing, partnerships, and personnel. Nearly 10 percent of the grant 

recipients are primary care providers in rural areas; however, with other awardees likely having service 

sites in rural areas, the rural footprint it presumably larger than just the direct awardees. 

HRSA’s Federal Office of Rural Health Policy (FORHP) – Rural Health Network Development 

Programxii 

The purpose of this program is to support integrated rural health care networks that have combined the 

functions of the entities participating in the network, including skilled and experienced staff and a high 

functioning network board, in order to address the health care needs of the targeted rural community. 

Recipients will combine the functions of the entities participating in the network to address the 

following legislative aims: (i) achieve efficiencies; (ii) expand access, coordinate, and improve the quality 

of essential health care services; and (iii) strengthen the rural health care system as a whole. The RHND 

Program encourages innovative solutions to local health care needs identified by local communities and 

supports rural communities in preparing for changes within the health care environment. Furthermore, 

the program creates an opportunity for rural health networks to collaboratively address the key 

priorities of HHS: mental health, substance use disorder, and value-based care. 

xi Click here to learn more about the Primary Healthcare Prevention Funding xii Click here to learn more about the Rural Health Network Development Program 

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HRSA’s National Health Service Corps (NHSC)xiii 

Since 1972, the National Health Service Corps has been in place to strengthen and develop the primary 

care workforce. NHSC awards scholarships and loan repayment to primary care providers in eligible 

disciplines. Since the NHSC began, more than 50,000 primary care medical, dental, and mental and 

behavioral health professionals have served. By addressing the primary care shortage, the NHSC ensures 

access to healthcare for everyone (regardless of their ability to pay), prevents disease and illness, and 

cares for the most vulnerable people who may otherwise go without it. 

NIH – Research for the National Plan to End HIVxiv 

The NIH will make awards of up to $500,000 for research on effective approaches to screen and treat 

substance use or mental health disorders in the Health Resources and Services Administration’s Ryan 

White HIV/AIDS Program. Research sites should be located within the National Ending the HIV Epidemic 

Plan, including the top 48 counties; Washington, DC; San Juan, Puerto Rico; and the 7 states with a 

disproportionate occurrence of HIV in rural areas. 

SAMHSA – Substance Abuse & HIV Prevention Navigator Program for Racial/Ethnic 

Minoritiesxv 

SAMHSA will make 82 awards from a total investment of $16.5 million for a five-year program providing 

services to racial/ethnic minorities at highest risk for HIV and substance use disorders. SAMHSA will also 

conduct outreach to vulnerable populations so they know what PrEP is and how to access it. Eligible 

applicants are community-based domestic public and private nonprofit entities, federally recognized 

American Indian/Alaska Native Tribes, and other Tribal organizations. 

Division for At-Risk Individuals, Behavioral Health, and Community Resilience (ABC)xvi 

The Division for At-Risk Individuals, Behavioral Health & Community Resilience (ABC) provides policy 

leadership, subject matter expertise, and coordination to internal and external partners to ensure that 

the access and functional needs of at-risk individuals, behavioral health, and community resilience are 

integrated in the public health and medical emergency preparedness, response, and recovery activities 

of the nation. 

IHS – National HIV/AIDS Programxvii 

The program coordinates and promotes HIV/AIDS prevention and treatment activities specific to Indians 

as part of a comprehensive public health approach. In addition to providing medical care to eligible 

beneficiaries, the IHS also serves as a public health system. The goals of the HIV/AIDS Program are to 

prevent further spread of HIV and improve health outcomes for those already with HIV and AIDS. Some 

of the manners in which these goals are supported include developing HIV prevention and care standards 

and performance measures, increasing routine HIV testing, increasing access to care, improving health 

outcomes for people with HIV/AIDS, and providing technical assistance to Native Tribes. 

xiii Visit the link to learn more about the National Health Service Corps xiv Click here to learn more about research awards the NIH has coordinated as part of the National Plan to End HIV xv Visit this link to learn more about SAMHSA grants for the Prevention Navigator Program xvi Visit this link to learn more about the ABC Division xvii Visit this link to learn more about IHS’ National HIV/AIDS Program 

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POLICY RECOMMENDATIONS & CONSIDERATIONS 

There are a broad range of challenges in the provision of HIV services in rural communities as well as in 

prevention and screening. Some of these challenges include stigma, transportation issues, costs, and 

workforce shortages. Rural providers have noted that they simply do not have enough time to manage 

grant applications and management responsibilities in addition to providing clinical care. The Committee 

acknowledges that comprehensive social, behavioral, and biomedical approaches are necessary to 

address these intersecting barriers that limit rural patients from accessing and engaging in the full 

continuum of HIV care, including prevention and treatment. In an attempt to address these barriers and 

to ultimately reduce rural HIV disparities and end the epidemic, the Committee presents its 

recommendations. The focus of the recommendations is on enhancing federal funding to increase and 

improve capacity building for rural HIV services (including telehealth and PrEP) in addition to providing 

more technical assistance for community-based organizations around grant writing. 

These recommendations were informed by subject matter experts and stakeholders during the 

Committee’s March 2020 meeting in Atlanta and the subcommittee’s site visit to Health Services Center 

in Anniston, Alabama (see Appendix A). During those presentations, the subcommittee heard 

stakeholders speak to a need for better infrastructure for HIV prevention services, additional attention to 

the importance of social and behavioral services, and common barriers that come up in their work. The 

subcommittee also heard about successful efforts regarding HIV prevention and treatment in rural areas. 

Recommendation 1: The Committee recommends the Secretary, in modernizing the Ryan White 

HIV/AIDS Treatment Extension Act of 2009, focus on enhancing the ability of the program to meet the 

needs of rural communities. This includes: 

• Increased rural-targeted funding to support pilot programs and capacity building and, when 

issuing Notices of Funding Opportunities, consider having rural as a funding factor and giving 

rural applicants in a designated Health Professional Shortage Area additional consideration 

using Preferences. 

• Expansion of the use of telehealth and telemedicine to increase access to services and reduce 

stigma in rural populations. 

Recommendation 2: The Committee recommends the Secretary, in maximizing the scientific advances 

made in HIV prevention, to increase access to Pre-Exposure Prophylaxis (PrEP) for rural residents 

through the existing statutory authority in Sections 330 and 330A of the Public Health Service Act 

(HRSA's Community Health Centers Program and the Rural Health Care Services Outreach Program, 

respectively). 

Recommendation 3: The Committee recommends the Secretary support a streamlined grant application 

process for resource strapped rural providers, as well as more virtual grant writing technical assistance 

for rural communities to enhance their ability to successfully apply for health and human services funding. 

In addition to the policy recommendations listed above, the Committee also sets forth a number of 

policy considerations to address rural HIV disparities and improve rural HIV prevention and treatment 

efforts. Policy considerations consist of actions the committee thinks should be taken that may involve 

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work across multiple departments or be outside of the jurisdiction for HHS. The considerations are also 

informed by the subject matter experts and site visit stakeholders that the committee heard from. 

Consideration 1: The Committee believes HHS would benefit from a more targeted focus on harm 

reduction, which can further reduce the likelihood of outbreaks and significantly reduce their 

scope. Recent outbreaks of HIV and Hepatitis C, driven by the opioid epidemic, in rural areas such 

as Indiana and West Virginia show that lack of harm reduction efforts (e.g., needle exchange) can 

lead to a significant burden in rural areas. 

Consideration 2: The Committee heard from several speakers who expressed concerns about the 

implications of criminalization of those with HIV and that research indicates such laws are more 

likely to be enforced in rural communities. 

Consideration 3: The Committee urges CMS to provide guidance to states regarding Medicaid 

telehealth coverage policies that can better serve rural residents with HIV. 

Consideration 4: While HRSA supports a range of efforts to provide rural training experiences for 

health profession students in rural areas, it is not clear that those clinical opportunities include the 

chance to treat people with HIV. The Committee encourages HRSA to expand the number of rural 

HIV training experiences so that future doctors, nurses, dentists and behavioral health providers will 

have been exposed to caring for this population. That familiarity could lead to increased numbers 

of these students choosing to practice in rural areas and in providing clinical services to those with 

HIV. The AIDS Education and Training Center Program’s (AETC) National HIV Curriculum can play a 

role in educating future rural providers. 

Consideration 5: Address stigma, especially as it pertains to LGBTQ people and people who inject 

drugs, in relation to provider attitudes/bias/cultural competency issues that serve as barriers to 

people with HIV being linked to and retained in HIV care. The Committee notes that HHS should 

consider whether existing efforts on stigma reduction are as effective in rural communities and if 

not what additional educational campaigns could be used to address this issue. 

Consideration 6: HHS could play a key role in better understanding how to help CHW initiatives 

achieve sustainability. The Committee is aware of calls to develop broader credentialing and 

uniform training of CHWs. 

Consideration 7: The Committee notes that Medicaid is a primary coverage mechanism for many 

people with HIV, particularly in the Southeast. Given the important role Medicaid plays in 

supporting this population, the Committee believes HHS should provide states with maximum 

flexibility to support innovative approaches that enhance care options for rural Medicaid patients 

with HIV. 

Consideration 8: The Committee also heard from speakers and stakeholders that one of the most 

challenging issues they face in providing HIV services is the lack of transportation. While this issue is 

beyond HHS’ jurisdiction, the Committee believes HHS should work more closely with its Federal 

partners to address these concerns. 

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CONCLUSION 

The United States has grappled with the HIV epidemic for several decades, and HIV-related programs and 

health care costs the country billions of dollars every year.xviii There have been notable increases in new 

HIV infections in rural communities, with the opioid crisis being one of many drivers behind this. According 

to HHS, 1 in 10 new HIV infections occur among people who inject drugs. In addition to people who inject 

drugs, other communities disproportionately affected by HIV in rural areas include racial minorities, 

members of Tribal communities, and LGBTQ+ people. Barriers such as transportation challenges, lack of 

broadband, persistent poverty, workforce shortages, and stigma have made HIV prevention and 

treatment work in rural areas more difficult. Given the scale and scope of this issue, through its policy 

recommendations and considerations, the Committee emphasizes the importance of focusing on 

comprehensive, multifaceted solutions to address rural HIV disparities, continue reducing the disease 

burden nationally, and ultimately end the epidemic. 

xviii Overview of costs for U.S. government investment in domestic HIV response, noting an increase to more than 

$28 billion per year. 

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APPENDIX A – SITE VISIT PROFILE 

Established in December 1990, Health Services Center (HSC) Inc. is a 501 c3 registered non-profit, 

Community Based Organization (CBO), and medical clinic providing HIV medical care, education and 

support to a 14 county area of East Alabama. The organization is a recipient of funding from the HIV/AIDS 

Bureau’s “Ryan White Program.” HSC’s mission is the provision of quality, comprehensive HIV services 

to all HIV infected and affected persons in their service area. HSC provides comprehensive HIV health 

care across East Alabama with services including free HIV testing and counseling; HIV-specific medical 

care; HIV medication assistance; housing assistance for persons with HIV; mental health care for PLWH; 

substance abuse treatment for HIV positive and negative individuals; case management services; 

education, outreach and prevention programs; and convenient medical transportation services. 

HIV Disparities in Rural Alabama 

Compared to their urban counterparts, rural 

communities in Alabama have been 

disproportionately affected by the burden of 

new HIV cases affecting the state. Alabama is 

one of the 7 states identified by the “Ending the 

HIV Epidemic” initiative with a substantial 

number of HIV diagnoses in rural areas. At the 

end of last year, the Alabama Department of 

Public Health (ADPH) released HIV reports for 

the period of January 1 through September 30, 

2019, noting that there were 390 confirmed new 

HIV diagnoses across the state. Assessments of 

the ADPH data revealed that 48 isolated 

counties in Alabama needed additional focus for 

containing HIV infection. Some of the most 

pressing challenges contributing to the high 

rates of HIV in Alabama include severe poverty 

and health provider shortages. According to 

Medical Advocacy and Outreach, 46 of 

Alabama’s 67 counties have poverty rates higher 

than the national average. Sixty-two of 

Alabama’s 67 counties are either partially or 

whole Health Professional Shortage Areas. 

One of the ways that HSC engages in HIV prevention 

and educations among the rural communities that it 

serves is through their drop in center, which has 

recently been moved to the main office. The goal of 

the drop in center is to provide no cost testing and 

education prevention services to the residents of 

Northeast Alabama, especially people of color. 

There is an additional focus on young adult women 

of color (19 to 24 years) and their partners, who may 

be at higher risk for substance abuse and HIV 

infection. 

Furthermore, HSC provides high quality specialized 

HIV health care services throughout their 14-county 

service area, regardless of ability to pay. Services are 

provided by three board certified infectious disease 

physicians and two experienced nurse practitioners 

across their primary site and four satellite locations. 

A contract psychiatrist and one or more mental 

health counselors attend each clinic to provide 

comprehensive mental health services. An annual 

oral health examination and referral to a local 

dental provider is made for all patients. Medication 

access, nutritional support services, and substance 

abuse treatment services are available as 

needed. Support is also provided for patients requiring housing assistance. 

Given the increased rate of new HIV infections in rural areas, organizations providing comprehensive 

HIV health care services to rural communities is needed now more than ever. The Committee commends 

the work of HSC and all the health departments and HIV services organizations that they heard from 

during the site visit. Their insight was crucial for the development of policy recommendations and 

considerations. 

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