announced on Nov. 22, reporting that the largest city in the United States had fewer new diagnoses of H.I.V. in 2018 than during any year since statistics were first kept in 2001. This was just a few weeks after Philadelphia’s Department of Public Health reported a 14 percent drop in the number of newly diagnosed H.I.V. infections overall, and a drop of more than one-third among black men who have sex with men — an especially vulnerable population.
San Francisco and Chicago have also seen their rates of new H.I.V. infections falling.
But while robust municipal health campaigns are creating downward H.I.V. trends in some of America’s largest cities, in much of rural America, an opposite trend is emerging. There have of course always been cases of H.I.V. in sparsely populated parts of the country, butin these places far from cities, the conditions that lead to H.I.V. transmission are now intensifying — and rural America is not ready for the coming crisis.
Indeed, in Appalachian West Virginia, the crisis has already arrived. A cluster of 80 new H.I.V. infections has been diagnosed since early last year in Cabell County.
As A. Toni Young, an AIDS activist, puts it, the “epidemic of opioid addiction — fueled by drug companies’ promotion of pain medications beginning in the 1990s — is a crisis for rural regions in part because these regions are completely unprepared to deal with the magnitude of the problem.” Ms. Young founded what is now called the Community Education Group in Washington, D.C., in 1993, originally to address H.I.V. and AIDS in women. An African-American lesbian, she has spent most of the past 30 years working to help members of the black, gay and urban communities it affects.
But since her recent move to West Virginia, near the Appalachian coal fields,she’s seen the crisis take a different shape. Unlike large urban areas that have dealt with similar health and substance crises in the past, and that have networks of service providers and consumers in place, small rural health jurisdictions often lack the infrastructure to confront the crisis and have little history of dealing with comparable health issues, she explained.
And it’s quite a crisis. Between 2006 and 2016, The Charleston Gazette-Mail reported, nearly 21 million opioid pills were sent to a single West Virginia town of 2,900 people. For years, according to the Centers for Disease Control and Prevention, West Virginia has had the highest rate of drug overdose deaths of any state in the country. By 2017 in Jefferson County, one in four people had a controlled-substance prescription. And when prescription highs can’t be sustained, people often turn to using — and sharing — needles to inject heroin and then fentanyl, leading to hepatitis C and H.I.V. This avoidable crisis has been exacerbated by unemployment, declining coal mining production and economic pressures on regional press to act as effectively as a watchdog.
At the same time, health care is relatively inaccessible. “It’s not so easy to get to the nearest town to see a doctor,” Dr. Judith Feinberg, professor of medicine at West Virginia University, explained, pointing to a lack of transportation and stigma as the biggest barriers to testing and care. People living with H.I.V. are stigmatized everywhere, but those who live in large cities can get tested while feeling relatively anonymous in a clinic in ways rural dwellers cannot.
What’s happening in West Virginia shouldn’t be a surprise. After a hepatitis C and H.I.V. outbreak in Scott County, Ind., in 2014 and 2015 that was fueled by deindustrialization and opioids, the C.D.C. released a list of 220 counties similarly vulnerable to such outbreaks among people who use intravenous drugs. The densest concentration of those counties is along the Appalachian Trail, with 28 of them in West Virginia — more than half of the state’s 55 counties.
“There is no way that doesn’t wind up as an H.I.V. outbreak in the state,” Ms. Young says. Yet unlike in places like New York — with its comprehensive sex education; efforts at queer- and trans-specific public health; embrace of public syringe exchanges; and what its health commissioner, Oxiris Barbot, describes as a “sex positive approach” — when it comes to confronting its H.I.V. epidemic, rural America is ill-prepared at best and antagonistic at worst.
For instance, despite research showing that syringe programs are effective at limiting transmission of H.I.V. and encouraging people to enter drug treatment, two cities in West Virginia — Clarksburg and Charleston — have recently moved to close or limit their needle-exchange programs. Negative press, business worries and conservative approaches are among the reasons the programs have been reduced when they urgently need to be expanded (along with statewide testing and education about preventive H.I.V. medication).
I have seen such tragic, avoidable public health policies unfold in a suburban setting in my own research in America’s heartland. Since 2014, I have been reporting and researching in St. Charles County, Mo., a “white flight” suburb to the west of St. Louis, where the local prosecuting attorney charged Michael L. Johnsonwith multiple felonies for transmitting H.I.V. (Mr. Johnson’s conviction was overturned on appeal in 2016.). Even though criminalizing H.I.V. is not effective in decreasing rates of H.I.V., one of the reasons the county wanted to prosecute and imprison Mr. Johnson was likely to prevent him from transmitting the virus to others in order to protect the public health. Yet in 2017, St. Charles County closed its only clinic for sexually transmitted infections, which provided nearly 1,000 exams a year. With fewer people getting tested — and with fewer people living with the virus taking medication that can prevent transmission to others — more people in this area could become H.I.V. positive.
While it’s true that people who are black, queer, transgender, homeless, incarcerated or poor, or who use injection drugs, are disproportionately affected by H.I.V. and AIDS, the misguided impression that members of these groups are the onlyones affected has unfortunately contributed to the media’s choice to deprioritize coverage of H.I.V. and AIDS in recent years.
Meanwhile, the rural, heterosexual white Americans who have been the subject of countless national profiles because they’re imagined — incorrectly — to represent all of President Trump’s supporters, are more at risk all the time. But while we’re bombarded by analyses of many aspects of their plight, we don’t hear about this crisis facing them.
It’s time for that to change, and for policymakers to address the root conditions that allow H.I.V. and AIDS to flourish in rural communities. In West Virginia this includes increasing access to health care, supporting all workers hurt by deindustrialization and undoing the stigma tied to sex and drug use.
These changes will, of course, provide much-needed help for the people in urban cities where H.I.V. rates are dropping as well. But the new major terrain of the crisis right now is in rural America, and it can’t be ignored any longer.
Steven W. Thrasher (@thrasherxy) is an assistant professor at Northwestern University’s Medill School of Journalism and is on the faculty of the Institute of Sexual and Gender Minority Health and Wellbeing at Northwestern University.
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