Expert Commentary

Sexually transmitted infections on the rise in rural America: A research roundup

The latest research analyzing the spread of HIV, gonorrhea, syphilis and chlamydia across the United States.

Vernon, FL Family Health Center
(Royalbroil/Wikimedia Commons)

Sexually transmitted infection rates for chlamydia, gonorrhea and syphilis are at all-time highs, according to the U.S. Centers for Disease Control and Prevention’s Sexually Transmitted Disease Surveillance Report. Between 2016 and 2017, rates of chlamydia increased by 6.9%, totaling 1.7 million reported cases. Gonorrhea rates increased 18.6% over the same one-year period, with 555,608 cases reported in 2017. And 30,664 cases of syphilis were reported in 2017, increasing by 10.5% over a one-year period.

New research suggests that the spread of these infections is particularly affecting rural areas, where these diseases had been less common. Historically, STIs had been concentrated mostly in urban areas. The geographic shift presents new public health challenges. “Compared with urban hubs, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address it because of socially conservative views toward homosexuality and nonmarital sex,” Lauren Weber writes for Kaiser Health News.

Journalist’s Resource has collected and summarized scholarly research that looks at the issue. Academics are studying geographic and demographic changes in sexually transmitted infection testing, risk behaviors and incidence rates. Below we’ve summarized a sampling of the latest research, which analyzes the spread of HIV, gonorrhea, syphilis and chlamydia across the United States.

Does Core Area Theory Apply to Sexually Transmitted Diseases in Rural Environments?
Gesink, Dionne C.; et al. Sexually Transmitted Diseases, January 2013.

This study looks at gonorrhea and syphilis rates in North Carolina between 1999 and 2010 to track the spread of these diseases across the state. “Our objective was to determine the extent to which geographical core areas for gonorrhea and syphilis are located in rural areas as compared with urban areas,” the authors write.

Key findings:

  • Gonorrhea and syphilis rates were high in rural areas. Gonorrhea rates were “highest in the rural parts of the eastern coastal region of the state;” syphilis rates were “particularly high” in the southern rural part of the state.
  • However, the core areas for these diseases – areas with “significantly elevated rates of infection” that lasted for five or more years – were located in urban parts of the state. In other words, rural areas did not have persistently high enough rates of infection to be labeled “core areas.”
  • To explain these findings, the authors suggest “that the communities of rural North Carolina are too small and isolated for STI epidemics to persist at endemic levels and thus create core areas.” They explain that STIs might be transmitted between interconnected urban, micropolitan, small town and rural areas.

Screening for Sexually Transmitted Infections After Cervical Cancer Screening Guideline and Medicaid Policy Changes: A Population-Based Analysis
Parekh, Natasha; et al. Medical Care, July 2018.

This study looks at screening rates for STIs among women enrolled in Medicaid in Pennsylvania between 2007 and 2013. In 2012, the U.S. Preventative Services Task Force updated its guidelines relating to cervical cancer screening. While previous guidelines recommended an annual Pap smear, new guidelines recommended screening only every three years. The researchers were interested in whether these changes would result in less frequent STI screening. They were also curious to see the impact of a state Medicaid program that covered STI testing for uninsured women that started in 2007. The researchers analyzed screening rates by race and ethnicity and according to whether women lived in urban or rural areas and participated in a family planning program.

Key findings:

  • STI screening increased by 48% from 2007 to 2011.
  • Urban residents were more likely to have had STI screening than rural residents. “Given that we observed higher screening among women residing in urban areas, interventions could target improved screening in rural populations,” the researchers write. “Our observation that increased outpatient visits were associated with annual STI screening suggests that increasing access to primary care could increase STI screening.”
  • Black women were more likely to have STI screening done than white women. Hispanic women were more likely to have testing than non-Hispanic women.
  • Those enrolled in a family planning program were more likely to have been tested than those who were not.

Chlamydia and Gonorrhea Acquisition Among Adolescents and Young Adults in Pennsylvania: A Rural and Urban Comparison
Pinto, Casey N.; et al. Sexually Transmitted Diseases, February 2018.

This study analyzes 10 years of data collected on chlamydia and gonorrhea cases in people between the ages of 15 and 24 in Pennsylvania. Two data sets were used for analysis: The Pennsylvania Department of Health National Electronic Database Surveillance System (PA-NEDSS) and the National Center for Education Statistics (NCES) school lunch data set. The first data set was used to calculate STI rates. The second was used to determine poverty levels within school districts (as measured by the percentage of students in the district at or below 185% of the poverty level) and residency status – i.e., urban, suburban, town or rural.

Key findings:

  • Between 2004 and 2014, there were 220,109 cases of chlamydia and 44,197 cases of gonorrhea reported among the sample.
  • Distribution by gender was similar over the time period studied, but overall, the annual incidence rate increased from 2004 through 2014.
  • “Adolescents and young adults living in areas with the highest poverty rate (>75% of the students living at or below 185% of the national poverty level) had higher case rates of both gonorrhea (1,573.73/100,000 person-years) and chlamydia (5,849.91/1000,000 person-years) than any other group.”
  • A shift in the urban-rural distribution of these diseases occurred over the time period studied. “Historically, rates of chlamydia or gonorrhea were higher in urban populations,” the authors write. “Yet this research demonstrates that rates in rural areas are no different than urban populations, and in one case higher in rural populations.” (Women between the ages of 18 and 19 had a higher risk of acquiring chlamydia in rural areas).
  • The authors recommend further research to understand the factors behind this shift.

Racial/Ethnic Disparities in Delayed HIV Diagnosis Among Men Who Have Sex with Men, Florida, 2000–2014
Sheehan, Diana M.; et al. AIDS Care, March 2017.

Early diagnosis of human immunodeficiency virus (HIV) is key to stopping its spread and ensuring that those with the virus receive timely care. This study looks at trends in delayed HIV diagnosis among men who have sex with men (MSM) in Florida. Delayed diagnosis was defined as cases in which patients received an AIDS diagnosis within three months of their initial HIV diagnosis; AIDS is the final stage of HIV infection. Through analysis of data collected on 39,301 men in Florida between 2000 and 2014, the researchers found:

  • Nearly one-third of the sample (27%) were diagnosed late.
  • Black men were more likely to have a delayed diagnosis compared with white men.
  • Black and Latino men who lived in rural areas were at a higher risk for late diagnosis.
  • Black men born outside of the U.S. had a higher risk of late diagnosis. On the other hand, white men born outside of the U.S. were less likely to have delayed diagnosis than white men born in the US.
  • The authors conclude that “social and/or structural barriers to testing in rural communities,” such as a lack of social support, stigma and concerns about maintaining confidentiality “may be significantly contributing to delayed HIV diagnosis among minority MSM.”

Repeat Human Immunodeficiency Virus Testing by Transmission Risk Group and Rurality of Residence in North Carolina
Billock, Rachael M.; et al. Sexually Transmitted Diseases, October 2018.

People who are at higher risk of acquiring HIV are recommended to get tested annually. Two such groups are men who have sex with men and people who inject drugs (PWID). This study analyzed 600,613 men and women who were tested at urban and rural publicly-funded HIV testing sites in North Carolina to see who was and was not getting repeat testing. Rurality of residence was determined by categorizing ZIP codes by the U.S. Department of Agriculture’s 2010 Rural-Urban Commuting Areas classifications.

Key findings:

  • The group most likely to engage in repeat testing was MSM.
  • People who inject drugs were less likely to have repeat tests done than those who did not identify as either MSM or PWID.
  • People who inject drugs and live in metropolitan areas were 6.4 percentage points more likely to get tested annually compared with their rural counterparts.
  • “Our findings suggest a need for public health efforts to increase access to and support for repeat HIV testing, particularly among rural PWID,” the authors conclude.

Rural-Urban Differences in HIV Testing Among U.S. Adults: Findings from the Behavioral Risk Factor Surveillance System
Henderson, Emmett R.; et al. Sexually Transmitted Diseases, June 2018.

This study looks at nationally representative survey data collected through the 2015 Behavioral Risk Factor Surveillance System to analyze differences in HIV testing among men and women in the U.S. “The BRFSS is a cross-sectional survey administered annually by the CDC to all 50 U.S. states, the District of Columbia, and 3 U.S. territories (Puerto Rico, Guam, and the U.S. Virgin Islands),” the authors write. “The purpose of the survey was to collect data on people’s health-related risk behaviors, chronic health conditions, and use of preventive services.” The sample included 250,579 respondents over age 18. Geographic area was determined by metropolitan status codes.

Key findings:

  • Urban residents were more likely to have ever received an HIV test than rural residents. Among urban residents, 26.9% had received a test at some point in their lifetimes, compared with 21.5% of rural residents.
  • Urban residents were more likely to have received an HIV test in the past year – 24.5% had, compared to 20.2% of rural residents.
  • Rural residents were more likely to have received an HIV test at the hospital or emergency room than a doctor’s office.
  • “Targeted interventions are needed to remove structural barriers in rural communities, such as long distances to clinics and low availability of free HIV testing at clinics serving the uninsured or underinsured,” the authors write. “Furthermore, rural providers should be encouraged to routinely offer HIV screening to their patients.”

HIV Risk Behaviors and Utilization of Prevention Services, Urban and Rural Men Who Have Sex with Men in the United States: Results from a National Online Survey
McKenney, Jennie; et al. AIDS and Behavior, July 2018.

This study looks at confidential online survey data collected from 8,166 men who have sex with men in the U.S. The sample consisted of 43% rural respondents and 57% urban respondents. The researchers were interested in rural-urban differences in HIV risk factors and behaviors.

They found:

  • Rural men were less likely to have ever been tested for HIV than men who lived in urban areas.
  • Rural men were also less likely than their urban counterparts to have received free condoms or individual prevention counseling in the past year.
  • Rural men were less likely to have been tested for syphilis, gonorrhea or chlamydia over the previous year.
  • Rural men felt their communities were less tolerant of LGBTQ individuals than urban men.
  • There were no significant differences between rural and urban men in terms of how often they’d had sex without a condom in the past year or with their most recent sex partner. Rural and urban men were equally likely to report that their most recent sex partner was HIV-positive or of unknown status.


For more on rural America, check out journalist Sarah Smarsh’s tips for covering rural areas, our roundup on rural-urban health care disparities and featured research on rural mothers.


This photo, taken by RoyalBroil and obtained from Wikimedia Commons, is being used under a Creative Commons license. No changes were made.

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