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F A Guide toOAIDSCResearch andU Counseling Volume 11 Number 4 March 1996S study of services for gay men, the fact Returning with AIDS: that rural communities “are more conser- vative, ingrown, traditional, religious and Supporting Rural Emigrants less tolerant of diversity.”5 Finally, long Michael Shernoff, MSW distances to medical facilities and the reluctance of medical personnel to pro- vide HIV-related services are significant The majority of the 22,800 people with barriers to care in rural areas.3,4,5 (Several AIDS who live outside of urban areas in researchers are evaluating a model linking the United States are men who have sex rural satellite health care clinics with with men, some of whom identify as gay, urban facilities, whereby physicians expe- although there are increasing numbers of rienced in HIV-related treatment would people who have contracted HIV in other 3 1,2 train and consult with local providers. ways. Many of these men are emigrants Confidentiality is a particularly trouble- returning from urban lives to their rural some barrier to care in rural areas. Patricia families of origin. Gunter states: “Confidentiality is a diffi- An informal survey of 12 therapists who cult issue within the rural environment. work with large numbers of people with Because of the limited geographic bound- HIV disease in seven cities in different aries and ‘incestuous’ nature of the sys- parts of the U.S. revealed that all but one tems, personal associations, work and have treated gay men who returned to leisure time activities, and work patterns small towns or rural areas near the end of are usually well-known to all in the com- their lives. But most rural communities, munity. The high level of visibility places cocooned from the epidemic thus far, have the individual in jeopardy, particularly had little chance to develop social services when receiving health and welfare ser- for people with HIV disease and their vices.”5 Gunter also states that due to families, and as prevalence increases, HIV- funding problems in rural communities, 3 related stigma is on the rise. This article many agencies use paraprofessionals and details the research on this topic and volunteers as staff members and that, “For suggests approaches for urban providers some reason, paraprofessionals, volun- with clients returning to rural homes. teers and nonprofessional workers in rural communities appear not to feel bound by Barriers the rules of confidentiality.” In tight-knit There is little research on HIV-related rural communities, entire families may be services in rural areas. Among the barriers stigmatized by association to an HIV- to care cited in a 1996 study are the lack infected family member, effectively of adequately trained medical specialists; depriving people with HIV disease of geographical distances and isolation from much needed support.4 sources of social support; insufficient or Ironically, people with HIV disease and unreliable sources of transportation; and their families have been able to access a the lack of a cohesive support community variety of social services through informal for infected gay men and women.4 systems already functioning in rural Additional barriers include the lack of areas. Comprised of family, friends, neigh- information and resources and responsive bors, fraternal and civic organizations, educational, health care, and social ser- and religious institutions, these systems vice systems, and according to another deliver services ranging from crisis inter- are in physical decline. Isolation Editorial: Rural Support is common and distance from Robert Marks, Editor medical services requires coop- eration from friends, family, and neighbors. Rural areas have not After 15 years, it’s hard to with family in the final stages of had the time to develop the know what “wave” of the epi- illness. By providing counseling same community commitment to demic is engulfing us now, but to both parties before the move the care and comfort of people whether it’s the second or the and continuing after the move, with HIV disease that now exists third, it is clear that the “city” Shernoff facilitates reconcilia- in some urban centers. epidemic is comfortably tion when necessary, educates ensconced in the “country.” For a families about HIV disease, The Power of Rural Communities number of reasons, HIV-specific helps identify local medical and Health and mental health services are not as well-estab- emotional support resources, practitioners face these same lished in rural areas as they are and supports clients in adjusting difficulties engaging the good in U.S. cities. In particular, sup- to their new surroundings and will and services of people in port services for both people conflicts. rural communities who might with HIV disease and their fami- Tartaglia rattles off some help provide support. But the lies remain underdeveloped. impressive statistics about the return for this effort can be role of religious institutions in substantial: rural communities Basic Human Relations frontline counseling throughout and rural congregations are In this issue of FOCUS, the United States. He suggests traditionally tightly knit and Michael Shernoff and Alexander that an institution so prominent when their energies are mar- Tartaglia outline two approaches in the lives of rural residents shaled, they can be a powerful to providing emotional support can play a central role in provid- force. To muster these in rural areas. Shernoff, a decid- ing support to people with HIV resources, not only must these edly urban pioneer in HIV coun- disease—both natives and immi- communities and congregations seling from New York, may at grants—and their families. put aside ignorance and fear, but first appear a strange commen- In both of these cases, people also clinicians must put aside tator on this subject, but he with HIV disease face basic prejudices about the abilities suggests that support in the challenges of human relations: and willingness of rural institu- country can begin in the city. finding acceptance in situations tions to provide support. Shernoff observes that many rife with ignorance, stigma, Applying education, patience, people with AIDS in rural areas prejudice, and fear. The stakes and clarity has worked to create begin their acquaintance with are higher than usual, because committed community support HIV infection in the city and many people with HIV disease in the city; this same approach migrate to the country to be move to rural areas when they can work in the country. vention, child care, and emotional and When clients raise the possibility of financial support to in-home health care. returning to live with parents, it is gener- When these informal systems resist homo- ally a good idea to thoroughly explore phobia and fear of AIDS, they can provide other options, for example, an assisted a type of care that draws numbers of living residence for people with HIV dis- people with HIV disease to return to the ease or the home of a friend or family communities in which they were raised. member living in the city. Considering Addressing rural HIV disease requires these options is especially important if strengthening and supplementing these the client expresses any ambivalence informal networks as well as formalizing about moving to his or her parent’s home. HIV-specific services. If finances are the major factor in decid- ing to move, the therapist should explore Moving from Urban to Rural America with the client what resources may be It is never too early for people with HIV available including financial support from disease to begin considering contingency families and from non-profit organiza- plans for living with a progressive and tions. For example, the Actor’s Fund of debilitating illness. As illness progresses, America’s AIDS Initiative Program offers therapists should seek appropriate financial assistance to people with AIDS moments to ask clients to discuss the who have been theater professionals any- plans they are considering to ensure their where in the country. care. Urging clients to face this issue early Clients should also consider whether on can help avoid future crises. their new home is appropriate for a dis- 2 FOCUS March 1996 abled person. Is it well-heated? Is it acces- clients express fears of being infantilized sible? Is it served by home health care by their parents since they are critically agencies and an AIDS service organiza- ill, in need of a great deal of assistance, tion? Do they drive, and will there be a car and are returning to live in their parents’ available for their use? How do local enti- home. For parents, it may be difficult to tlements and other respect the adulthood and autonomy of a benefits compare grown child who is in reality once again to current ones? physically, emotionally, and possibly Individuals who decide Are there compe- financially dependent. In such situations, tent health and the lack of alternatives to returning to the to return to a rural mental health care family of origin may leave some clients providers in rea- feeling as if their lives were bankrupt. In community often feel sonable proximity? addition to the ordinary anger about hav- that they no longer Answers to these ing AIDS and weathering loss, the client questions will may feel anger about being trapped into have any other options clarify for the returning home to parents with whom he client the benefits or she may have an ambivalent relation- for maintaining a and drawbacks of ship. For some, the return invalidates his or her future their lives as adults who have lived an reasonable quality of home. They will unapologetic and openly gay life. also suggest life and adequate care. actions the client Maintaining Contact and Providing Support This recognition is often and his or her It may be useful, prior to the return, to family might take arrange telephone conference calls that accompanied by intense prior to the move.

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