Rural areas in the United States have limited access to screening and testing of sexually transmitted infections (STIs). Tailored interventions for these populations are important.1
“STI rates can be quite high in some rural areas,” says Wiley D. Jenkins, PhD, MPH, FACE, research professor and chief of epidemiology and biostatistics at Southern Illinois University School of Medicine.
Reproductive health providers often think about STIs, such as gonorrhea and chlamydia, as a metropolitan problem, Jenkins notes. Not only are the STI rates in rural areas high, but the same phenomenon can be seen with HIV.
“The rates of HIV, especially in the rural South, are notoriously high,” Jenkins says. “STI rates are important. If we want to have control of sexually transmitted infections, we can’t just ignore rural areas.”
Although many rural areas are predominately white, there is a lot of diversity in some places, he notes. For instance, one rural county in Illinois reported about 33% Black residents at the last census.
“Especially in the deep South, the number of racial minorities can be much higher,” he says.
There also are sexual gender minorities, as well as people with substance use issues. “[Rural residents] all have their own distinct risk profiles, and there are a lot more of these individuals in rural populations than people tend to surmise,” Jenkins says. “It is not all the white race; it is highly variable.”
Several factors might lead public health officials and providers to underestimate STI risk in rural areas. One factor is that rural populations tend to be older. Relatively few people live in these counties, and it can be harder to obtain data on their risk behaviors.
“But STIs seem to be an increasing risk among geriatric populations,” Jenkins says. “Probably, the increased rates of drug use — even among older people — may be contributing to those STI problems.”
There is not yet enough information on this trend. “Overall, the data show that a large proportion of STIs are diagnosed in clinical environments, such as primary care providers and hospitals, and they are not done at STI clinics,” Jenkins says. “What we’re finding is that many of these clinical environments in rural areas are closing, and there is a retraction of clinical services.”
This trend creates challenges for designing interventions to reduce STIs in rural communities.
“In my personal opinion, we cannot create the same types of interventions in rural areas that work in metropolitan areas,” Jenkins says. “I think the city of Chicago has nine or 11 standalone STI clinics. You just cannot support that in rural areas.”
STI prevention and treatment methods for rural areas should focus first on strengthening and funding the few existing resources to make them more efficient and accessible, he explains. For example, the federal government could add funding to federally qualified health centers (FQHCs) to enable them to open for longer operating hours, including weekends.
“Our research found that in rural areas, the open hours [of FQHCs] were less than in metropolitan areas,” Jenkins says.
Also, local health departments exist in almost every county in the United States, but the ones in rural counties operate with tight budgets.
“Funding could be directed to health departments to increase STI screening and to expand hours,” Jenkins says. “There are some rural areas where STI clinics may be open only two half-days a week.”
STI prevention and screening can be made both more accessible and efficient. “We also need to invest in things that work better in rural areas and don’t require an economy of scale,” Jenkins explains.
For example, reproductive health clinics could offer patients mail-in STI kits for chlamydia and gonorrhea, he notes. Internet-based companies offer home test kits for those STIs. Patients can self-collect a specimen and mail it back to the company for testing.
“If the results are positive, then the company will report that to a public health authority,” Jenkins explains.
Although these types of companies charge people for the kits, it is possible that a government agency could offer the same service at no charge — depending on its source of funding.
“I think this [option] might be disproportionately useful in rural areas because there are so few alternatives,” he says. “Having an option to be able to do this online would be huge [in a rural area].”
One obstacle to providing an online STI testing service is the challenge of capturing people’s attention. “You have to have some mechanism to engage people and to get them to return the testing kit,” he notes.
The return rate for online STI testing kits is very low, but the positivity rate is very high, Jenkins says. One tactic that may work in a rural area is to market online STI testing through school systems or organizations with the potential to reach the target audience.
“There needs to be engagement,” Jenkins says. “But, it obviously will not reach everyone.”
Another method of STI outreach in rural areas is to build on existing community-based organizations (CBOs). Local CBOs have tried different types of outreach, but they do not always receive research funding, which can be a problem.
For instance, a small CBO that targets a rural community could be a sexual risk reduction provider as well as a syringe service provider for people who use injectable drugs. The CBO might provide screenings, condoms, and referrals for drug treatment through a combination of novel state, research, and philanthropy funding, Jenkins explains. Such a CBO could fill a gap in a rural area and become a trusted partner for populations of drug users and sexual gender minorities.
People who are sexual gender minorities often experience stigma, so they do not disclose their sexuality. “In my mind, rather than trying to build a new clinical venue, investing in an already existing resource, like a CBO, may make much more sense,” he says.
Building new infrastructure to deliver STI services is not going to be feasible, but it also is not effective to duplicate what works in a metropolitan area to a rural area.
“If we want to change things, we have to invest in the organizations that already exist, making them more accessible with longer hours, more funding, and increased personnel,” he says.
There has never been a national strategy to invest in and explore new types of STI screening that target specific populations and areas, including rural communities, Jenkins says.
- Jenkins WD, Williams L, Pearson WS. STI epidemiology and care in rural areas: A narrative review. Sex Transm Dis 2021 Jul 15. doi: 10.1097/OLQ.0000000000001512. [Online ahead of print].