It’s true that rural areas in Southern states are at a disadvantage regarding care and resources for people living with HIV. But some impressive exceptions could serve as a model for other rural regions. As described in the feature article “The Rural Disadvantages in Accessing HIV Care,” AIDS Alabama’s hub-and-spoke model emanating out across the state from Birmingham is one example.

Another one is Five Horizons, an HIV service agency straddling 68 rural counties in Alabama and Mississippi. The agency’s chief of staff, Landon Nichols, just moved to one of them—Alabama’s Perry County, which is 724 square miles. “We’ve lost almost half our population since the 2010 Census,” he says. “In the whole county, we have two pharmacies, one ambulance, no hospital and no Walmart. The nearest hospitals are 30 to 40 miles away, reachable only on small, curvy roads.”

Five Horizons optimizes access to its six clinics throughout those 68 counties with a strategic combination of telehealth and on-site care. Care teams, including a medical case manager and a phlebotomist (for blood draws), fan out to small rural satellite clinics where they meet with patients while tele-consulting with HIV specialists at one of the agency’s six hub sites across both states. 

“We’re currently serving more than 4,000 people with HIV in an area that’s seven hours from one corner to the other,” says Nichols. “If we weren’t there, you’d have a lot of people lost to care because they wouldn’t be able to get to Birmingham, Mobile or Jackson.”

Meanwhile, Claude Martin is the longtime executive director of Acadiana Cares, which offers HIV primary care via an AIDS Alabama-like hub-and-spoke model radiating from the city of Lafayette, Louisiana, into the surrounding rural counties. “We got into primary care 10 years ago because when people were testing HIV positive, it was taking them anywhere from four to six months from diagnosis to get an appointment at the local charity hospital,” he says. “That was just unacceptable.” (Longstanding medical guidelines urge people testing positive for HIV to start treatment ASAP—the same day if possible.) 

Because “we have absolutely no intercounty public transit system,” says Martin, Acadiana Cares uses a combination of Medicaid, other federal funding and its own general fund to send cabs to clients to fetch them for appointments at its Lafayette clinic (which includes a food pantry), then back home. This can result in up to four hours of driving time and $150 in driver fees. The agency also owns a building, a former nursing home, that provides private rooms and baths and three meals seven days a week to 15 low-income people living with HIV. The building also houses a 66-bed long-term substance-use program. 

On top of all that, the agency also uses federal HOPWA (Housing Opportunities for Persons With AIDS) and HUD (Department of Housing and Urban Development) money to rent 130 apartments throughout the region for its low-income clients. “The more rural you get,” says Martin, “the less quality housing opportunities there are. Rural areas are not as receptive as urban ones to adding people living with HIV and/or people who use drugs to their statement of need” when applying for housing funding, he says.

Despite all these geographic barriers, Martin says the single greatest barrier to better HIV care in his region is the stigma people with HIV experience living in small towns where attitudes about HIV and LGBTQ people are not as enlightened as in urban areas. “If you live in New York City, Atlanta or New Orleans, you can have anonymity by moving five blocks away, whereas in these towns, everyone knows everyone’s business.”

That fear of being outed can lead to some dire health outcomes. “At least once a year,” says Martin, “somebody always presented at the emergency room near death with AIDS, just like in the 1980s. And often, they were living with family members and afraid that if they revealed their HIV status, they’d lose that support.”

But he adds that the atmosphere of silence around HIV isn’t always necessarily malign. “In one little town, everyone knew that a certain person was living with HIV even though he didn’t want them to know. So they rallied around him and brought him food.”