STI epidemiology and care in rural areas: a narrative review

Abstract

Background

Though rural areas contain approximately 19% of the US population, little research has explored sexually transmitted infection (STI) risk and how urban-developed interventions may be suitable in more population-thin areas. While STI rates vary across rural areas, these areas share diminishing access to screening and limited rural-specific testing of STI interventions.

Methods

This narrative review utilizes a political ecology model of health, and explores four domains influencing STI risk and screening: epidemiology; health services; political and economic; and social. Articles describing aspects of rural STI epidemiology, screening access and use, and intervention utility within these domains were found by a search of PubMed.

Results

Epidemiology contributes to risk via multiple means, such as the presence of increased-risk populations and the at-times disproportionate impact of the opioid /drug use epidemic. Rural health services are diminishing in quantity, often have lesser accessibility, and may be stigmatizing to those needing services. Local political and economic influences include funding decisions, variable enforcement of laws/statutes, and systemic prevention of harm reduction services. Social norms such as stigma and discrimination can prevent individuals from seeking appropriate care, and also lessen individual self-efficacy to reduce personal risk.

Conclusion

STI in rural areas is significant in scope, and facing diminished prevention opportunities and resources. While many STI interventions have been developed and piloted, few have been tested to scale or operationalized in rural areas. By considering rural STI risk reduction within a holistic model, purposeful exploration of interventions tailored to rural environments may be explored.

SUMMARY

Rural areas often experience increased STI risk, but urban-developed interventions should not be expected to be equally effective in rural areas, and alternatives need to be devised and tested.

INTRODUCTION

Even before the SARS-CoV-2 pandemic necessitated changes in the provision of clinical services, and altered personal behaviors in ways yet to be quantified, sexually transmitted infection (STI) epidemiology, intervention and control was the nexus of multiple large-scale public health concerns. First, there is the trajectory of increasing rates of bacterial STI during the 21^st century.¹ Second is the adoption of the national Ending the HIV Epidemic: A Plan for America (EHE), and the awarding by the Centers for Disease Control and Prevention (CDC) of $109 million to the 57 EHE Phase I jurisdictions.² This brings considerable resources and attention to aspects of HIV control and prevention, and how rural HIV and STI screening and prevention are important to national strategies and outcomes.³ Third, there is the increasingly examined epidemic of opioid and other drug abuse.⁴ As the number of people who use drugs (PWUD) increases, so too do the associated adverse behaviors (e.g. unprotected sex; transactional sex) and health outcomes (e.g. STI; overdose). Indeed, the increase in drug use is possibly associated with the increase in primary/secondary syphilis reported among heterosexual females.⁵

One commonality among all three concerns is the unique burden among rural populations. While metropolitan and urban areas most often experience the greatest burden of STI or drug use in terms of numbers of individuals impacted (cases), as we will discuss, the actual proportion of population impacted (rates) are at times significantly higher in rural areas. This factor is critically important in the design, implementation, and effectiveness of STI control programs. Rural communities are not simply small metropolitan areas, but have distinct differences in risk, services, and access. The majority of STI interventions and programs are developed in urban areas, and their translation to rural settings is not necessarily obvious or equally effective.

In thinking about STI screening, and especially how programs may be developed and implemented to affect positive change, it is useful to consider the context within which screening occurs. It is not simply a case of ‘build it and they will come’. There are numerous contextual factors influencing many aspects of screening, from outright facility access and availability, to the local prevalence of STI and associated risk factors, to community-level influences such as social norms and policing practices. It is therefore useful to consider rural STI risk and screening within a theoretical construct. A political ecology model of health posits that health outcomes can be understood as being influenced by social, economic, and political domains.⁶ Specific contextual factors in each of these domains are understood to shape the social and health-related structures, conditions, and events in a given setting that together produce epidemiological outcomes. By applying this theoretical framework, we can thus conceive of STI outcomes in rural settings as being a function of characteristics falling into distinct domains.

Epidemiological characteristics

There are multiple epidemiological factors that influence risk of STI acquisition. For example, since substance use is associated with a higher likelihood of engaging in sexual activities where disease transmission is more likely (e.g., condomless and/or transactional sex), reducing rates of substance use may reduce STI transmission.^7,8 Local STI/HIV prevalence is also an obvious influence.

Health services characteristics

The availability, accessibility, and quality of healthcare services related to STI prevention, screening and treatment (and other related behaviors and conditions) are directly related to overall risk of personal infection and local prevalence. Inequities in healthcare access, which may be particularly pronounced in rural communities, are thus also important predictors of STI risk and of variation in risk among different subpopulations.

Political and economic characteristics

Though broad in scope, some policy and economic factors have important implications for STI risk reduction and treatment. Funding decisions, for example, directly influence healthcare availability. Of particular concern is the promulgation and enforcement of laws and statutes which may limit preventive services (such a syringe service and harm reduction programs) and cause individuals engaged in illicit activities (such as sex work) to avoid seeking care.^9,10

Social characteristics

Social norms can directly influence individual willingness to engage with available services and programs. Stigma and discrimination by healthcare workers against populations with higher STI prevalence, and also against PWUD, can prevent members from engaging with prevention, screening, and treatment services.¹¹ Stigmatizing norms (e.g., racism and homophobia) have also been found to be directly related to sexual behaviors which increase transmission risk.^12,13 Community-level norms around religious and political belief can influence stigma and discrimination severity and pervasiveness.^14,15

In this narrative review we explore the epidemiology of rural bacterial STI risk, the current landscape for screening (and treatment), and proposed actions and needed research. We’ll explore each within the context of the four political ecology domains, but will quickly discover that a) these are not necessarily mutually independent, and b) much more is known about some domains that others. Still, this overview will serve to describe the extent of what is known about rural STI risk, what may be the most feasible paths forward to reduce risk and disease burden, and how exploring rural STI risk in the context of domains allows for outside-the-box thinking – especially in proposed areas of research needed.

THE CURRENT LANDSCAPE

Rural STI risk and epidemiology

Multiple epidemiological studies report that some rural communities have higher STI rates than their urban peers. Among the eight Delta Regional Authority states, rural county rates are increased for Chlamydia trachomatis (CT; 578/100,000 vs 330), Neisseria gonorrhea (GC; 143 vs 62) and Treponema pallidum (TP; 3.6 vs 1.7) in total and by individual state.¹⁶ Pennsylvania CT and GC rates were found to be higher in rural communities (2004-2017).¹⁷ STI rates across the ‘8 Americas’ were increased among Black populations in the ‘Middle’ and rural South (and others).¹⁸ Geospatial STI core analysis of GC cases in North Carolina found that while some rural areas had high rates, there were no defined core areas.¹⁹ Though rural STI epidemiology has been the subject of relatively little research, high rural rates may be facilitated by interconnectedness with more urban areas, and large spatial sexual networks.²⁰ However, the studies of increased rates among rural areas should not be taken to assume a uniform experience across all states (e.g. a report from Georgia finds STI more of an urban burden).²¹

Concomitant with increased STI rates in many rural communities is the opioid (and other drug use) epidemic and associated behaviors. Compared to more metropolitan areas, many rural areas have similar, if not increased, rates of substance abuse.²² Drug use in general is a risk factor for STI acquisition, and perhaps more so for those using illicit stimulants such as methamphetamine (disproportionately reported in rural areas).²³ Frequently found in association with drug use, transactional sex is also a STI risk factor, and may be especially high among rural people who use drugs (PWUD) (e.g. 18.3% in West Virginia).²⁴ Homelessness is also associated with drug use, and is high among rural PWUD.²⁵ Finally, these behaviors are often congregated, as transactional sex is commonly reported among both PWUD and homeless individuals.^26–28

Its estimated that 2.9-3.8% of rural residents identify as sexual and gender minorities (SGM) and may face increased STI risk.²⁹ In part, this is because rural SGM (especially transgendered individuals) face substantial stigma and are less likely to utilize healthcare.^30,31 For example, research at a Pride Festival in Minnesota found that while many adolescent SGM see primary care providers, only 29% are offered STI screening.³² Data from a national online survey indicate that rural SGM are less likely to be STI screened or to receive free condoms and prevention counseling, and they perceive less community tolerance for nonheterosexuals.³³ Regarding STI risk, rural SGM may also be more likely to find partners online (due to fewer nearby social/entertainment establishments and a desire for privacy or anonymity), and rural HIV-infected males are at increased risk of syphilis (especially those engaging in drug use).^34,35

Substantial numbers of racial and ethnic minorities (R/EM) live in rural areas. Black and Hispanic populations comprise 8.2% and 9.3 %, respectively, of rural and small town areas.³⁶ The majority (54%) of American Indian/Alaska Native (AIAN) people live in rural and small-town areas, 68% live on or near their tribal homelands, and experience increased rates of poverty.^37,38 Economic disparities affecting R/EM are larger in rural settings than elsewhere and are a major predictor of high rates of STIs (and other related factors such as substance use).³⁹ Further, rural R/EM have less access to/use of healthcare than non-Hispanic Whites, and rural AIAN face delays to STI treatment, again, related in part to economic disadvantage.^40,41 These factors contribute to possible increased STI risk, as reflected in a studies finding that: 19% of rural Black and Hispanic females were diagnosed with a non-HIV STI in the past year; CT rates were approximately 4x higher among AIAN females than White; and Northern Plains AI females report more past STI than White females.^42–45

Rural STI risk and healthcare services

Healthcare access in rural settings is notoriously low. In one recent study, 26% of rural residents reported not getting needed healthcare in the past few years.⁴⁶ Low healthcare access is thought to be due in part to poverty and economic disparities, but in rural areas is also impacted by limited service availability and increased distance to healthcare settings. Though ~19% of the population is rural, less than 12% of primary care physicians work in rural areas, with that total continuing to drop, and the majority of rural counties are health professional shortage areas (primary care).^47–49 Actual facility access is also in decline, with nearly 7% (120+) rural hospitals closing and 25% facing closure risk since 2010.⁵⁰ These somewhat dire data reflecting substantial declines in healthcare availability in rural areas were reported before the SARS-CoV-2 pandemic instigated as-yet-to-be determined financial harm to healthcare organizations.

These access trends are important as the large majority of STI are diagnosed outside of STD clinics.⁵¹ For example in IL, private physicians and hospitals are the two greatest reporting sources; and for nearly all rurality levels.⁵² Though emergency departments treat more CT than private physicians (66.1vs.44.9%, p<.01), the cost of treating STI in the ED can be 80% higher than STD clinic settings.^53,54 On the other hand, clinician rates of screening their eligible patients range from 47.6% (preferred provider organizations) to 58.1% (Medicaid).⁵⁵ So even though clinicians are significant screening providers, the lack of consistent and comprehensive service to all patients may be contributing to bias and disparities.

Another source of screening and treatment are dedicated STD clinics. A 2014-2015 assessment identified 4079 clinics in the US (defined by their possession of negotiated prescription pricing). Overall, 62.0% were affiliated with a local health department (LHD); the proportion of clinics within LHDs ranged from 52.6% (metropolitan counties ) to 90.6% (rural); and 35.1% of counties had no clinic at all.⁵⁶ Even within LHD STD clinics, there remain rural disparities. In Pennsylvania, females attending urban LHDs are annually screened slightly more frequently, and rural Kansas LHDs were less likely to offer STI screening.^57,58 A study of 16,075 STI diagnoses from Yakima County, Washington state finds that living ≥10 miles from screening site and residence in micropolitan, small towns, and rural areas was associated with treatment delay or non-receipt.⁵⁹

Though not as widespread as traditional medical facilities or LHDs, Title X-supported family planning clinics often also provide STD screening and/or referral. A survey of 558 Title X–supported clinics in 16 Great Plains and Midwestern states found that: the proportion of clinics offering walk-in appointments was lower in isolated small rural towns (47%) than other rural-urban commuting area categories (67–73%); and availability of evening or weekend appointments fell from 73% in urban areas to 29% in isolated small rural towns.⁶⁰ Finally, there are a large number of one-off screening programs managed by local/community-based organizations.⁶¹ However, many are sustained by unreliable and short-term grant funding.

Rural STI risk and political/economic factors

Consensus statements from public health organizations have deemed poverty and economic stability to be key components of the social determinants of health model that effect the health and well-being of populations.⁶² More specifically in the present context, poverty is associated with STI risk.⁶³ Theoretically, poverty can increase such risk through multiple mediating pathways such as decreased access to health services, decreased access to STI preventive resources, and increased sexual risk-taking related to higher rates of substance and alcohol use.⁶⁴ Rural populations on average across the U.S., have been found to have lower socio-economic status compared to their suburban and urban counterparts, as measured by multiple indicators (e.g., poverty rates, employment, recovery from economic recession) during the last decade.^65,66 These disparities are often concentrated in Appalachia, the Mississippi Delta Region, and on Native American lands.⁶⁷ Additionally, homelessness, especially among youth, is also increasing faster among rural areas, and is related to increased STI risk via higher rates of transactional sex among homeless persons.^68,69

Policy characteristics of settings such as policies that criminalize or limit the rights of populations (e.g., sex workers, PWUD) who have higher rates of STIs are also theoretically related to infection risk. For example, criminalization of substance use and sex work often deter or discourage people who engage in these activities from engaging with healthcare services, especially those offered by governmental entities, for fear their behavior will be reported to authorities.^9,10 Even sex workers and PWUD who do seek care are much less likely to report their illegal behaviors to healthcare providers if they believe that any written documentation of such behaviors could be used against them legally. Healthcare providers who are not aware of these risk behaviors (sex work and/or substance use) are thus less likely to conduct broad STI screening. Even to the extent that these discriminatory policies do not vary locally, their enforcement often does (e.g., variation in drug arrest rates).⁷⁰ While few studies have directly examined a relationship between discriminatory policies (or law enforcement practices) and STI outcomes, the existence of such policies and variation in their enforcement is known to predict HIV outcomes, which are in turn related to STI risk.⁷¹

Rural STI risk and social factors

The degree to which stigma and discrimination against various groups such as SGM are normatively acceptable in a given setting is an important predictor of STI outcomes.⁷² One clear pathway underlying this relationship is through reluctance to access medical care. Multiple studies show that sex workers, people who use drugs, racial and ethnic minorities, sexual and gender minorities, or other groups fearing stigma or discrimination by healthcare providers will defer seeking care.^11,73–76 However, stigma and discrimination experienced outside of healthcare settings are also related to STI outcomes through other pathways. For example, perceived discrimination by Black individuals is associated with increased sexual risk-taking, binge drinking, unprotected intercourse, and STI.^77,78 Reported rates of stigma and experienced discrimination among PWUD, R/EM, and SGM can be elevated in rural settings, further increasing STI risk among these groups.^79,80

PROPOSED ACTIONS

There are a large number of interventions which have been shown to be effective in reducing STI risk and increasing screening and treatment. However, few have been operationalized or tested in rural areas. Further, methods to directly address STI epidemiology and health services utilization are infrequently considered in the context of the political ecology model. Based upon the literature and experience, we propose the following general strategies across all four model domains.

Influence epidemiology and health services by increasing screening availability and use

CT and GC screening among sexually active women under 25 are United States Preventive Services Task Force ‘B’ recommendations and CT screening is a HEDIS measure (since 2000).^81,82 There are multiple methods to increase compliance with STI screening in primary care; including electronic health record prompts, clinician training, and quality improvement changes.⁸³ Access can be increased by expanding hours/days for appointments, and offering/expanding STI screening in emergency departments.^84–86 Increasing Medicaid reimbursement for screening may be disproportionately influential in rural areas where physicians see greater proportions of such patients.⁸⁷ From a capacity and incentivization standpoint, expanding the Federally Qualified Health Center program could help with reducing the incidence of not only STIs in rural communities, and other socio-economic related issues that are the cornerstone of health. This might be more specifically designed to benefit rural communities by offering incentives, increased reimbursements, and funding preferences to those operating in rural communities. As an alternative venue, LHDs exist in nearly every US county. To improve LHD STD services, there is a need to address comprehensive services, quality improvement, and accreditation; many also report needing training on revenue and billing (95% bill Medicaid, 70% 3^rd party).^88,89 Increased funding for staff may be effective, as many rural LHDs face challenges with staff size and technology, limited prevention and education resources, and have a greater reliance upon state and federal funding.^90,91

One alternative to brick-and-mortar sites are mobile services. Evaluation studies indicate these can be acceptable, feasible, and effective.⁹² While there are a large number of programs (e.g. in jails, sex venues, mobile vans), there is limited data on cost-effectiveness and effectiveness.⁹³ In rural southern IL, such mobile service is performed by the Community Action Place (tCAP). tCAP offers infectious disease screening (CT/GC/TP annual positivity ~18%); sexual and drug use risk reduction education and supplies; and direct service to >150 unique individuals; has office space in three towns, and two vans; maintains regular ‘routes’ through 13 counties; and has a diverse and sustainable funding portfolio.⁹⁴ Still, this program is one-of-a-kind, and generalizable models of such service should be explored. Further, it is likely that the cost/service/person may be increased in rural areas due to lesser economies of scale, but that would not negate their potential utility and necessity.

Given the expense to establish and maintain brick-and-mortar and mobile sites, alternative strategies need consideration. Client biospecimen self-collection has repeatedly been shown valid and acceptable, and Internet-based screening has been successfully implemented generally and in rural areas.^95–99 There are multiple research and commercial websites offering a variety of screening options, and they may be especially useful to reach targeted populations. However, there may be issues with false positives and loss of kits; difficulties with client engagement; and lack of awareness. From a policy and individual perspective, cost for such services may be a significant barrier, and funding for reduced or eliminated fees for the individual should be explored (perhaps included in STI program grants to rural LHDs).

Influence political and economic characteristics

Future research should explore the relationships between discriminatory policies, variable enforcement, and STI risk in rural settings. This would include analysis of funding decisions and their downstream impact upon STI screening. Further, there could be more purposeful adoption of Community Policing as a paradigm of police-community engagement.¹⁰⁰ This may be especially effective in small, close-knit communities and serve to increase individual efficacy and encourage health seeking behavior. This potentially addresses underlying aspects of equity and justice for marginalized populations.

Influence social characteristics

There should be purposeful consideration for how other types of strategies, including aspects of individual and community engagement, may be explored via purposeful funding opportunities. Examples of such are included in the CDC’s Community Engagement Toolkit to expedite localized/focused intervention efforts.¹⁰¹ There are a large number of one-off interventions that have been effective in reducing STI risk and/or increasing screening among specific populations and locations.^{43, 102–104}. Localized outreach and CBO engagement should be encouraged, especially in response to identified populations at increased risk or difficulty of engagement. It is also important to realize that just as rural areas have characteristics distinct from their metropolitan peers, there are also distinction across seemingly-similar rural areas. For example, we might expect local epidemiology, healthcare access, politics and social norms to significantly differ between rural New Mexico and rural Mississippi. In fact, the differences between rural areas across the four model domains may be more significant in regards to intervention development and effectiveness than that between larger cities where infrastructure, public health funding, and resources may be more similar due to scale and standardized processes.

Given the evidence that stigma is an important barrier to healthcare among some groups that have high rates of STIs, and that the majority of STI are reported in primary and emergency care settings, interventions should be developed and evaluated which to reduce stigmatizing attitudes among providers and staff working in primary care, urgent care, and hospital settings. Such work is called for by CDC guidance, and may be addressed through education regarding sexual health across the life span.^105,106

DISCUSSION

There is substantially more diversity within rural communities than may be surmised. The risk of STI may be greater than in some more urban areas. Not only do rural areas have fewer resources in toto, but screening may be done less frequently even among available healthcare providers. Strategies requiring high volume/participation to be sustainable may be infeasible. It is likely more efficient and effective to expand existing, non-traditional resources. More data on rural program effectiveness is needed to develop rural-specific guidance. Further, increasing effective engagement in rural STI screening may be a critical aspect of achieving EHE, and engagement in this type of routine care may lead individuals who are otherwise marginalized or underserved to utilize other primary services. Lack of research in these areas, and rural STI risk in general, can be noted in the recently released Sexually Transmitted Infections: Adopting a Sexual Health Paradigm (National Academies of Sciences, Engineering and Math) where “rural” is referenced a mere handful of times. While multiple Priority Populations (Ch.3) are addressed, rural as a distinct context and environment is notably absent, indicating a need for more work to be focused on creating better infectious disease capabilities and further removing barriers to sexual healthcare for these rural communities.¹⁰⁷