Community pharmacies could be a key to getting more rural teens vaccinated for virus that causes sex-related cancers

Alabama Department of Public Health

There's a vaccine for a virus that causes sex-related cancer, but rural teens are less likely to get it or know about it. Rural pharmacies could help improve vaccination rates, writes Casey Daniel, a Ph.D. pharmacist who teaches in the family medicine department at the University of South Alabama.

"Human papillomavirus (HPV) is the most common sexually transmitted infection, with 80 million Americans currently infected and 14 million new cases of infection each year," Daniel notes, but only about two-thirds of 13-to-17-year-olds start the HPV vaccine series, and fewer than half have up-to-date vaccinations. Rural HPV vaccination rates are 11 percent lower than urban rates, partly because rural areas have fewer health-care providers, Daniel writes in the Journal of Rural Health.

He says that gap could be filled by pharmacies, which are more widespread than doctors' offices and open longer hours. "In the 2018 President's Cancer Panel report on HPV vaccination for cancer prevention, pharmacies were specifically recommended as a way to increase vaccine accessibility," he writes. "Most pharmacies are also ideally suited for immunizations because of their inherent infrastructure and storage capacity for various medications. Many pharmacies offer vaccines such as flu, pneumonia, and shingles, and therefore, they have established immunization protocols that can be easily adapted to HPV."

Convenience is important for HPV immunization "because this vaccination is a multi-dose series requiring subsequent visits," Daniel writes. "While large chain pharmacies have a broad, mass market appeal, there is a considerable case to be made for collaborating with 'community pharmacies' as alternative settings for HPV vaccination, particularly in rural and small-town settings. In these areas, independent community pharmacies are often an established part of the community. Community pharmacists frequently have personal relationships with their patients, knowing them both within and outside the bounds of the pharmacy, and have a unique, established trust. They are trusted providers within the community, acting as the first line of health care and consultation for many patients."

That's also important for HPV immunization because research has shown that rural parents are less likely to be aware of HPV and the vaccine. Community pharmacists "frequently have personal relationships with many local individuals," Daniel writes. "Therefore, they can function in both education and reinforcement regarding the importance of HPV vaccination. . . . In the exploration of alternative settings to increase HPV vaccination, community pharmacies have been significantly overlooked. Particularly in rural settings, these pharmacies have vast potential to reach under-served, disparate populations and serve crucial roles in addressing community health care needs and filling resource gaps."

Rural HIV infection rates rise as urban rates fall; crisis 'can't be ignored any longer,' journalism professor writes

HIV infection rates are falling in many large U.S. cities, but rates are rising in much of rural America.

"There have of course always been cases of HIV in sparsely populated parts of the country, but in these places far from cities, the conditions that lead to HIV transmission are now intensifying — and rural America is not ready for the coming crisis," Northwestern University journalism professor Steven Thrasher writes for The New York Times. "Unlike large urban areas that have dealt with similar health and substance crises in the past, and that have networks of service providers and consumers in place, small rural health jurisdictions often lack the infrastructure to confront the crisis and have little history of dealing with comparable health issues."

The opioid epidemic is a major factor in the explosion of rural HIV infections, since opioid users are more likely to engage in risky behavior such as having unprotected sex while high or sharing needles. (Prescription opioid abusers often turn to higher-octane intravenous opioids like heroin.) In West Virginia's Cabell County and Huntington, for example, where there is a massive prescription opioid addiction problem, 80 new HIV infections have been diagnosed over the past year. "This avoidable crisis has been exacerbated by unemployment, declining coal mining production and economic pressures on regional press to act as effectively as a watchdog," Thrasher writes.

Most frustratingly, the rise in rural HIV infection rates was predictable, Thrasher writes: "After a hepatitis C and HIV outbreak in Scott County, Ind., in 2014 and 2015 that was fueled by deindustrialization and opioids, the CDC released a list of 220 counties similarly vulnerable to such outbreaks among people who use intravenous drugs. The densest concentration of those counties is along the Appalachian Trail, with 28 of them in West Virginia — more than half of the state’s 55 counties."

However, many rural areas are ill-equipped to prevent or deal with an HIV outbreak because they frequently refuse to effective policies such as needle-exchange programs, more comprehensive sex education, and LGBTQ+ public health efforts, Thrasher writes. Rural HIV patients also may be reluctant to admit they're infected or seek treatment because of the stigma associated with it. That leads to worse health outcomes and more infections. Thrasher says the problem "can't be ignored any longer."

Nov. 7 webinar will look at HIV/AIDS in rural America

The Rural Health Information Hub will host a webinar Nov. 7 to discuss HIV and AIDS in rural America. The free event will begin at 11 a.m. ET and will last about an hour. A recording will be available on the RHI Hub website afterward.

The webinar will review a recent Centers for Disease Control and Prevention report that says the decline in HIV infections has hit a plateau because effective prevention and treatment efforts aren't adequately reaching some populations with the highest need for such services, including rural areas.

Speakers will provide an overview of a federally funded initiative called "Ending the HIV Epidemic: A Plan for America. They will also discuss the rural distribution of medical providers funded by the Health Resources & Services Administration's Ryan White HIV/AIDS Program, and highlight the work of a Ryan White grantee in rural Alabama. Click here to learn more or to register.

Anti-abortion rule prompts rejections of family-planning funds; CVS squeezes mail-order contraceptive sellers

Rural residents may soon find it more difficult to access some forms of reproductive health care.

Planned Parenthood and some other reproductive-health providers, including some governments, have announced they will stop taking about $60 million in annual federal funding for low-income women's reproductive health services because a new Trump administration rule bars grantees from making referrals for abortions. "That loss in federal funding could deliver a heavy blow to already cash-strapped, non-profit clinics that are often the only providers in their communities offering low cost services," particularly in rural areas, Jessie Hellman reports for The Hill. "Other organizations, including Maine Family Planning, have dropped out of the program because of the new rule. Governors in Hawaii, Illinois, New York, Oregon and Washington have all stated they will withdraw . . . and state legislatures in Maryland and Massachusetts have passed laws saying they would."

The family-planning program, Title X, has provided birth control and other reproductive care to young, poor women for almost 50 years. It serves about 4 million patients a year, most of them black or Hispanic, and sends $260 million a year to clinics. "The program has helped fill gaps in health care access including cancer screenings, STD testing and annual exams for women who are poor or don't have health insurance. It does not fund abortion care," Nicquel Ellis reports for USA Today. "Planned Parenthood has been the largest provider, serving 40 percent of all Title X patients."

Program participants had to submit statements to the government by Monday saying they would comply with the new rule, which will be enforced starting Sept. 18. "In addition to the ban on abortion referrals by clinics, the new Title X rules include financial separation from facilities that provide abortions, designating abortion counseling as optional instead of standard practice and limiting which staff members can discuss abortion with patients," Ellis reports. "Clinics would have until next March to separate their office space and examination rooms from the physical facilities of providers that offer abortions."

Planned Parenthood is the only Title X recipient in some areas—such as the entire state of Utah—and serves a disproportionate amount of the poor in other places, including many rural areas. Alexis McGill Johnson, the acting president and CEO of the Planned Parenthood Federation of America, said that if Planned Parenthood facilities are forced to scale back or close, it will be impossible for other health centers to fill the gap, Ellis reports.

"Planned Parenthood and a host of states are suing the administration, with an appeals court holding hearings next month," Hellman reports.

Meanwhile, in July CVS Caremark began reimbursing mail-order prescription delivery companies less, including birth-control service Pill Club. Pill Club protests that the rate change threatens its ability to keep operating, Garnet Henderson reports for Vice.

Mail-order services like Pill Club, Nurx, and Pandia Health allow patients to get a prescription via virtual consultation with a doctor, then deliver the meds by mail. It's popular in rural areas, especially for women who don't have insurance or have other difficulties finding reproductive care. "According to Pill Club, 70 percent of its users previously had difficulties obtaining birth control, and 55 percent said they would have to stop taking birth control without Pill Club," Henderson reports.

CVS Caremark is a pharmacy-benefits manager, a third-party company that manages prescription benefits on behalf of insurers and Medicaid programs. It's a subsidiary of CVS Health and sister to the ubiquitous CVS Pharmacy chain. A CVS Caremark spokesperson confirmed the rate change, but said Pill Club's accusations were "extremely misleading" and that the decision was not specifically aimed at, nor would have any impact on, access to contraceptives, Henderson reports.

Sophia Yen, CEO and co-founder of Pandia Health, said small pharmacies (which is essentially what such services are) are threatened because they can't get discounts by buying in huge volumes like the top three or four pharmacy benefit managers can. She also noted that CVS offers its own mail-order service, and suggested the move might be an attempt to undercut competition, Henderson reports.

Quick hits: Impossible Burger goes big; online gaming without broadband; S.D. ag town tries to be a mural mecca

A mural on a 110-foot grain elevator in Faulkton, S.D.
(Progressive Farmer photo by Greg Lamp)

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

Burger King started offering the plant-based Impossible Burger in test markets on April 1. It's been such a hit that the chain now plans to offer the "Impossible Whopper" nationwide later this year. Read more here.

"Drug maker Gilead Sciences will give $11.3 million to help prevent and treat hepatitis C in Kentucky, Indiana, West Virginia, Tennessee and North Carolina. That money is part of a five-year project aimed at a region that’s been hit hard by the viral disease," Lisa Gillespie reports for Ohio Valley ReSource.

A rural farming community of 700 in South Dakota has made a name for itself as a mural mecca, Greg Lamp reports for DTN/The Progressive Farmer.

Online gaming is difficult at best without reliable broadband, so a gaming company has come up with an innovative solution to ensure rural gamers can play. Read more here.

Syphilis spreading in rural U.S. because of intravenous drug use, stigma, lack of funding, and other factors

Rural counties across the Midwest and West are seeing a spike in syphilis. While the disease "is still concentrated in cities such as San Francisco, Atlanta and Las Vegas, its continued spread into places like Missouri, Iowa, Kansas and Oklahoma creates a new set of challenges," Lauren Weber reports for Kaiser Health News. "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."

How bad is the problem? In 1999 around 35,000 cases were reported, but by 2017 that number grew to 101,500, according to the Centers for Disease Control and Prevention, Weber reports.

Syphilis is easily treatable and curable with antibiotics, but can cause permanent brain damage, blindness, birth defects and/or death if left untreated. It's making a comeback partly because of increasing drug use, which often leads to risky sexual behavior. In rural areas, that's compounded by the stigma of seeking help for a sexually transmitted disease or reluctance to reveal homosexual activity. Another problem: Syphilis has been so rare until recent years that many health-care providers have never seen it in patients, and don't easily recognize it, Weber reports.

In 1999 the CDC had a plan to eradicate the disease in the U.S. by focusing on hotspots in the South, California, and major urban areas, "but health officials are losing the fight because of a combination of cuts in national and state health funding and crumbling public-health infrastructure," Weber reports. "Federal funding for STD prevention has stayed relatively flat since 2003, with $157.3 million allocated for fiscal year 2018. But that amounts to a nearly 40% decrease in purchasing power over that time, according to the National Coalition of STD Directors."

Why is medication to prevent HIV so hard to find in rural South? Stigma, poverty, racism, ignorant doctors . . .

Rate of people with HIV per 100,000 in 2017. (Map by AIDSVu)

A prescription medication called Truvada can protect users from HIV infection, but it's difficult to find in the rural South. That's a big part of the reason the South had about 20,000 new HIV diagnoses in 2017, more than the rest of the U.S. combined, Lenny Bernstein reports for The Washington Post. "Stigma, poverty, inadequate access to health care and lingering racial bias" are also reasons the South have a disproportionately large share of HIV infections.

The Trump administration says it wants to reduce HIV transmission by 75 percent within five years and at least 90 percent by 2030, but it's unclear how that will be implemented. President Trump's proposed 2020 budget would fund a program targeting HIV transmission in the rural South, but would also slash funding for Medicaid, which most people in poverty, some of them with HIV, depend on. Beyond that, it's unlikely the budget will pass in Congress as is, Bernstein reports.

Bernstein writes that the most effective way to fight HIV transmission is to increase access to Truvada (to prevent infection), and antiretrovirals to lower the viral load of already infected people so they can't transmit the disease. "Theoretically, you could end the epidemic tomorrow if you did that," Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases and one of the architects of Trump's plan, told Bernstein.

But in 2015, a third of primary-care doctors surveyed said they had not heard of Truvada, according to the federal Centers for Disease Control and Prevention. "Persuading many more people to take the drugs will require more federal money for health clinics as well as for education and outreach to certain groups, especially black men who have sex with other men. At current rates, half that group will be diagnosed with HIV infection," Bernstein reports.

More women using opioids, meth and heroin means more babies are born with congenital syphilis in the U.S.

Pew Charitable Trusts chart: Yellow line shows syphilis cases
in women; blue bars show cases in babies (click it to enlarge)

Due to increased opioid and methamphetamine use, more American babies are being born with syphilis. That's because women are more likely to engage in risky sex while using drugs, and stimulants like meth can increase one's sex drive, making such behavior even more likely.

Congenital syphilis cases among newborns increased 154 percent between 2013 and 2017. During the same time period, the use of meth, heroin and other intravenous drugs among women with syphilis more than doubled, Alayna Alvarez reports for Stateline.

"There’s a clear connection, as we’re seeing, between drug use, the opioid crisis and the rise of syphilis and congenital syphilis," said Brian Katzowitz, a spokesperson for the U.S. Centers for Disease Control and Prevention.

Syphilis is much more serious in babies than adults. When adults contract the disease, it can be cured with antibiotics. But a baby born with congenital syphilis can have "deformities, severe anemia, an enlarged liver and spleen, jaundice or brain and nerve problems such as blindness or deafness," Alvarez reports. "Up to 40 percent of babies born to women with untreated syphilis may be stillborn or die as a newborn" according to the CDC.

"Many addicted pregnant women forgo prenatal visits for fear of being drug tested and losing custody of their babies, doctors say. And mothers with untreated syphilis have an 80 percent chance of infecting their unborn babies, contributing to a growing crisis that many states have tried to combat in recent years," Alvarez reports. Most states require syphilis testing at the first prenatal visit, and 18 states require third-trimester screenings for women considered at high risk of infection.

Louisiana and Washington attempt 'Netflix-style' model for Hepatitis C medications to treat the poor, to save money

Louisiana and Washington state are trying a new way to fight the rise of hepatitis C among Medicaid recipients and prisoners: a Netflix-style model in which the states pay a flat fee for an unlimited supply of drugs to treat the liver disease. Washington also plans to supply the drugs to state employees, retirees and teachers, Michael Ollove reports for Stateline.

"The new design illustrates how states are trying to think creatively to tackle one of their costliest but most important long-term challenges: providing health care access to low-income residents and people in the state’s care," Ollove reports.

Hepatitis C is a growing threat in rural areas, often spread by opioid users who share needles or engage in risky sexual behavior while under the influence. Nationwide, it kills more Americans each year than any other infectious disease, Ollove reports. About 2.4 million Americans had the disease in 2016, according to the federal Centers for Disease Control and Prevention, and many of them aren't aware they're infected.

"In the Washington model, the winning bidder would provide the drugs until 2023 for a set treatment course price up to a total maximum each year, about the $80 million the state spent last year," Ollove reports. "Once that maximum is reached, the manufacturer would provide the drugs for a negligible amount, perhaps as little as pennies per course of treatment."

Louisiana would cap the amount it spends on antivirals to $35 million for five years, the amount it spend in 2018. The winning bidder would agree to provide all the needed antivirals to the state for that amount, Ollove reports.

It's unclear if the subscription model will work. Bids for the project are not yet due, and while it's unknown whether any of the major manufacturers of hep C drugs are interested, Ollove reports that they've submitted "detailed questions" to both states about the plans.

"Even if Washington and Louisiana officials aren’t able to negotiate better prices through the Netflix model, health officials said it will offer more certainty about how much the states spend to treat hepatitis C from one year to the next," Ollove reports. States are obligated to provide medications required to treat the disease to the poor and prisoners, according to recent court rulings in several states. It can get expensive. Kentucky, which has the nation's highest rate of new hep-C infections, spent $83,673 per case in the 2015-16 fiscal year.

Stigma, limited privacy, lack of sex education, shortage of health insurance hamper rural efforts to fight HIV and AIDS

President Trump said in his State of the Union address that he wants to stop the spread of HIV in the U.S. within 10 years. "In addition to sending extra money to 48 mainly urban counties, Washington, D.C., and San Juan, Puerto Rico, Trump's plan targets seven states where rural transmission of HIV is especially high," Jackie Fortier reports for NPR. Health officials in those states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma and South Carolina) welcome the funding, but told Fortier that ending or slowing rural HIV transmission is a big challenge.

In rural areas,there is still a stigma attached to being gay and/or having HIV or AIDS, says Dr. Michelle Salvaggio, medical director of the Infectious Diseases Institute at the University of Oklahoma Health Sciences Center in Oklahoma City, a federally funded HIV clinic. It employed a case manager to serve a nearby rural area, but eliminated the position because no patients went to see her, Salvaggio told Fortier: "They didn't want to be seen walking into the HIV case manager's office in that tiny town — that can only mean one thing."

That lack of anonymity is not just a problem in small towns. When Native Americans, an at-risk population in Oklahoma, "go into an Indian Health Service clinic, it is possible that they will see their cousin behind the desk, and their cousin's brother-in-law working in medical records, and their niece's boyfriend working in the pharmacy," Salvaggio said.

An HIV-positive Cherokee, Ky Humble, told Fortier that rural Oklahomans with HIV and AIDS need more than medical funding; they also need more access to related services like food pantries, mental health therapy, and transportation assistance.

Another difficulty: Oklahoma, and many other states with large rural populations, don't require comprehensive sex education that could help teens learn about cheap, effective methods of preventing HIV, such as use of condoms. Lack of health insurance will also likely hamper efforts to get rural residents tested and treated, especially in states that did not expand Medicaid, Fortier reports.

Sexually transmitted diseases are on the rise as funding to prevent and treat them falls

Health officials are worried about this strain of gonorrhea that
is resistant to antibiotics. (Centers for Disease Control photo)

"Health officials are tracking record-breaking rates of sexually transmitted disease, including a resurgence of some infections which had been considered rare, such as gonorrhea and syphilis. These STDs are on the rise amid cuts to public health budgets dedicated to testing, prevention, and public outreach," Mary Meehan reports for Ohio Valley ReSource, which covers Kentucky, Ohio and West Virginia.

The Centers for Disease Control and Prevention reported 2.4 million new cases of STDs in 2017; about 40 percent of those were among people aged 15 to 25. The number of babies born with syphilis increased from 362 in 2013 to 918 in 2017, mostly in Southern and Western states. In some Ohio Valley communities, chlamydia infections rose more than 200 percent and gonorrhea rose 1,000 percent or more between 2011 and 2017, Meehan reports.

The surge among younger people could stem from a greater likelihood to engage in risky sexual behavior. Jim Thacker, spokesperson for the Madison County Health Department in Kentucky, told Meehan that people born after the AIDS epidemic was largely contained may be less fearful about STDs. And the availability of effective, long-term birth control might make young adults and teens less prone to use condoms, he said.

Some of those affected by STDs are much younger than teens: according to a recent CDC report, more infants are dying after catching syphilis from their mothers during birth. Syphilis is easily treated with antibiotics, but an untreated pregnant woman has up to an 80 percent chance of passing it on to her baby during birth, Meehan reports.

Matt Prior, spokesperson for the nonprofit National Coalition of STD Directors, told Meehan that STDs are a public health crisis often hitting areas already hurting from the opioid epidemic, such as Appalachia.  Meehan reports, "As rates go up, Prior said, funding has gone down. So while STDs have increased by 30 percent in the last five years to reach an all-time high, the amount of federal money for prevention and education has consistently gone down since 2003. Prior says that federal funding is critical for states like Kentucky, West Virginia and Ohio."

Prior told Meehan, "The federal STD prevention line is the only line or funding streams these states have so it is really the first and last line of defense."

Sept. 18 webinar will explore why rural areas lag in getting children a vaccine that can prevent a major type of cancer

The Rural Health Information Hub will hold a webinar to discuss the Centers for Disease Control and Prevention's recent report showing that rural teens are less likely than their urban peers to know about the human papilloma virus or meningococcal conjugate vaccines or receive them. HPV is the known cause of several genital, anal, and throat cancers. Featured speakers will be:

• Tanja Walker, an epidemiologist at the CDC’s National Center for Immunization and Respiratory Diseases
• Electra D. Paskett, a cancer-research professor at Ohio State University
• Robin C. Vanderpool, an associate professor in the Department of Health, Behavior & Society in the University of Kentucky College of Public Health

The free webinar will take place at noon ET on Sept. 18. A recording will be available on the RHI website afterward. Click here for more information or to register.

Appalachia at high risk of HIV and hep C, but stigma and other factors hamper testing, monitoring and treatment

Bloodborne diseases like HIV and hepatitis C are an increasing threat to public health in Appalachia, but the stigma associated with such diseases may be hindering monitoring, testing and treatment, ultimately increasing the risk of outbreaks.

A big part of the risk comes from sharing needles while shooting opioid drugs such as heroin. In 2016 the Centers for Disease Control and Prevention found that Appalachian counties were some of the most vulnerable in the U.S for HIV and Hepatitis C. A cluster of 43 recent HIV cases has popped up in northern Kentucky, and in West Virginia the CDC "just released a report on 40 new HIV cases diagnosed in 2017 in 15 mostly rural counties," Roxy Todd reports for WKMS-FM in Murray, Ky. Health officials worry that many more could be infected and not know it.

The number of HIV cases reported (left) vs. the possible number of cases both reported and unreported (right)
(CDC map; click on the image to enlarge it.)

Tania Basta, who chairs the College of Health Sciences at Ohio University and has researched the effects of stigma in rural Appalachia, said some rural health-care providers still stigmatize their patients. "They may feel that, unfortunately, some people with HIV, they did this to themselves," she told Todd. "Testing is an issue . . . And I’m not saying that stigma is any higher in rural areas. It’s just that, because of the nature of living in small towns, where everybody kind of knows everybody, word travels quickly."

The CDC report on the HIV outbreak in West Virginia also said lack of health literacy and transportation from remote areas to treatment or syringe exchanges also contributes to the spread of the disease. "Fourteen of the 15 counties where new cases were identified were on the CDC’s 2016 list of counties at high risk of disease. Yet only three of the counties had syringe service programs, which medical evidence shows is an effective way to reduce harm from drug use. Syringe services, also known as needle exchanges, can also serve as an opportunity to test for needle-borne disease," Loh reports. They also offer opportunities to get users into treatment.

Vaccine to prevent HPV-caused cancers gains ground among teenagers, but rural areas lag

The vaccine is administered in three shots.

The federal Centers for Disease Control and Prevention says more teenagers nationwide are getting the human papillomavirus vaccine, but rural areas are still lagging. "Sixty percent of adolescents received one or more doses of the HPV vaccine in 2016, an increase of 4 percentage points from 2015, researchers found. About a decade ago, the figure was less than 30 percent," Aneri Pattani reports for The New York Times.

But rural HPV vaccination rates are 15 percentage points lower than in cities. The report speculates that the discrepancy could be because of differences in parents' opinions or a shortage of pediatricians in rural areas. Shannon Stokley, the co-author of the study and the associate director for science at the Immunization Services Division of the CDC, says, "It’s a new finding, and at this point we really don’t know what’s behind that. We need to better understand what’s going on in rural communities."

"The vaccine protects against strains of HPV that can cause cancers of the cervix, penis, anus and back of the throat. Close to half of all Americans are infected at any given time, and nearly 32,000 get cancer from the virus each year," Pattani reports. The vaccine could have prevented 90 percent of those cases, according to the CDC. New guidelines may make it easier for teens to complete the series; last year the CDC changed the guidelines from three doses to two doses for teens under 15.

Rural counties in Ky. overcome opposition to start syringe exchanges to head off disease outbreaks

Small, rural counties are leading the way in establishing syringe exchanges to prevent outbreaks of HIV and hepatitis C among intravenous drug users in Kentucky, according to a top state drug official.

Van Ingram, executive director of the Kentucky Office of Drug Control Policy, spoke with Mary Meehan of Ohio Valley ReSource, a regional journalism collaborative of public broadcasters in Kentucky, Ohio and West Virginia. He cited Powell County, in the Appalachian foothills east of Lexington, as an example of rural counties that are changing the perception of how addiction is perceived in the state, shifting the focus toward treatment and public health initiatives and away from the criminal justice system.

So far, syringe exchanges have been approved in 25 of the state's 120 counties; several others are having debates like the one that went on in Powell County, population 13,000, reports Melissa Patrick of Kentucky Health News.

In nearby and much larger Madison County, the Board of Health supports a syringe exchange, but was met with "mixed feelings" about the program at a county Fiscal Court meeting, with some members concerned that the program condoned IV drug use, Ricki Barker reports for The Richmond Register. The county will host several forums to educate local citizens about the cost and benefits of the program and answer any questions that the public may have about it. Health officials told Barker that the department sees about eight to 10 patients a day with hepatitis C.

In Powell County, physician assistant Troy Brooks initially opposed a syringe exchange. "He said it seemed like a way to let addicts keep using their drug of choice without consequence," Meehan reports. But then local police showed him how bad the problems is by taking him to the playground in Clay City, where they collected 41 dirty needles, and he saw the need to protect children and first responders.

Six of the 25 syringe exchanges approved so far aren't operational yet. Thirteen are in counties deemed most vulnerable counties by the federal Centers for Disease Control, which identified 54 Kentucky counties as among the 220 most vulnerable in the nation to a rapid spread of HIV and hepatitis C infection among IV drug users.

Updated map available at http://chfs.ky.gov/dph/epi/HIVAIDS/prevention.htm

What have been the leading causes of death in your county? Study maps 21 major causes, 1980-2014

Researchers from the University of Washington and the Erasmus University Medical Center in the Netherlands have charted county-level data for 21 major causes of death in the U.S. from 1980 to 2014. The study, published in The JAMA Network, found that "geographic regions with elevated mortality rates differed among causes." For example, the map below shows that mortality rates from self-harm and interpersonal violence were particularly high in southwestern counties and in Alaska.

The study includes information on communicable, maternal, neonatal, nutritional and noncommunicable diseases and injuries. Below, a screenshot of the study's interactive map shows where substance-abuse disorders are most prevalent. Leading the way is Rio Arriba County, New Mexico, which is home to the Rio Grande Sun, which has extensively covered the issue, as well as Dakotas counties with large Native American populations and in Central Appalachia.

Abstinence pledges do little to reduce youth sexual activity, STDs, pregnancies, studies conclude

Abstinence pledges—sometimes called purity pledges—don't keep young people from having sex, contracting sexually transmitted diseases or avoiding pregnancy, according to a pair of studies, Denise-Marie Ordway reports for Journalist's Resource. The main problem may be that students are not receiving enough sex education. A Centers for Disease Control and Prevention report from December 2015 found that "fewer than half of high schools and only a fifth of middle schools teach all 16 topics recommended by CDC as essential components of sexual health education."

A 2005 study by Yale and Columbia universities found that 88 percent of youth who take the abstinence pledge engage in premarital sex, Ordway writes. "The study found that pledgers were just as likely to get exually transmitted diseases as those who never made a pledge of virginity." (CDC graphic)

A more recent study, published in April in the Journal of Marriage and Family, found that among students in grades 7 to 12, "as a whole, young women who did not take abstinence pledges and those who did but broke them were equally likely to acquire HPV," human papilloma virus, a common STD, Ordway reports. "Approximately 27 percent of each group tested positive for HPV. Of the young women who had two or more sex partners, pledge breakers were more likely to have HPV. The difference was largest among women who had between six and 10 sex partners. One-third of women who had not taken a pledge and had six to 10 sex partners tested positive for HPV. Meanwhile, 51 percent of pledgers who had six to 10 sex partners acquired HPV. About 30 percent of pledgers and 18 percent of non-pledgers became pregnant within six years after they began having sexual intercourse outside of marriage."

"In the U.S, the teen pregnancy rate is higher than in any other Western industrialized country, according to the CDC," Ordway writes. "At the same time, a growing number of American teens and young adults have been diagnosed with sexually transmitted diseases. While individuals aged 15 to 24 make up 27 percent of the U.S. population that is sexually active, the CDC estimates that they account for half of the 20 million new infections occurring annually."

Undocumented workers in some rural agricultural communities have high rates of STDs

In rural agricultural towns like Mendota, Calif., (Best Places map) where there is not much to do when the work days ends, the sex industry thrives, and sexually transmitted diseases, especially among undocumented workers, are a cause for concern, Diana Aguilera reports for Valley Public Radio. Fresno County has one of the highest rates of STD’s in the state.

"Lack of access to health care, six-day work weeks and tough living conditions makes it hard for many farmworkers to visit a doctor," Aguilera writes. City councilmember Joseph Riofrio told Aguilera, “There’s a lot of unsafe sex because of people, you know, drinking, getting drunk, feeling lonely, far away from home. There’s people that come from Fresno or Merced. They’re looking for customers either at the motel across the street or the motel right here, and they’ll rent the room throughout the night.”

One problem is a lack of data on STD rates among migrant workers, Aguilera writes. George Lemp, who took part in a 2005 study by researchers from University of California-Berkeley and experts in Mexico, told Aguilera, “We found that there was a significant increase in risk behaviors after migration to the United States. Their risk of engaging in sex with sex workers went up about two and a half fold.” He said "farmworkers were also more likely to have sex while under the influence of drugs and alcohol after coming to the states. In addition, they were six times more likely to perform sex work for pay and 13 times more likely to have sex with men."

While local campaigns have sought to educate people and provide free condoms, undocumented worker Francisco told Aguilera, “If anyone has anything they don’t say it because they’re embarrassed. We’re very shy; we don’t talk about sex. I think its part of our culture, and that’s the reality.” (Read more)

In impoverished rural Alabama, officials hoping to educate teens about HIV through video games

In one of the poorest regions of the country, where African American males have significantly higher rates of contracting HIV and schools do little to nothing to educate about safe sex, one health official is turning to video games in an attempt to teach about the virus, Dan Carsen reports for NPR. The hope is that video games can be used to reach teenage boys who might not be interested in learning through other mediums.

Civil Rights Movement Veterans graphic

The 18-counties of Alabama's "Black Belt" region "is predominantly African American, the poorest part of a poor state and home to underfunded, segregated schools, a weak health care system and an alarming number of new HIV cases," Carsen writes. "Here, young black men are at least 10 times likelier than the state average to contract the virus. But with talk of HIV still largely taboo in rural Alabama, one nursing professor has turned to an unlikely technology in hopes of changing things: video games."

Comfort Enah of the University of Alabama at Birmingham came up with the idea. She told Carsen, "Gaming is particularly appropriate for adolescents because of where their brains are. We have a scenario where we have hormones, but they don't have the brain capacity to anticipate long-term consequences. So gaming can tap into that mismatch and kind of force them to see consequences right now."


As part of the game, "players build avatars, customizing their appearance, hobbies and personality," Carsen writes. "Then they respond to age-tailored but potentially risky situations any way they want. In the do-over world of the game, consequences include points, praise, good health and money . . . or embarrassment, unemployment, HIV and even death."

The game is still in its infancy, and teens have responded that it's boring or has out-dated graphics, but those are the kind of responses officials are looking for in an attempt to continue tweaking the game until it is one that teens can be drawn to, because teens—especially males—tend to identify more with games than with reality, Carsen writes. And in this case, that could be a good thing.

Debra Lieberman, director of the University of California Santa Barbara's Center for Digital Games Research, told Carsen, "Avatars that the player identifies with are especially powerful. You'll hear players saying, 'Oh, I did this' or 'Oh, look what happened to me.' They are just totally transported into the game, and that avatar is them. There have been studies that have found that when your avatar engages in health behaviors, then you are more likely to go out into your daily life and adopt those behaviors." (Read more)

Rural southern minorities new face of HIV/AIDS; states that failed to expand Medicaid hit hardest

AIDS was once thought to mainly affect middle-class, often white gay men living in urban areas. However, because states like New York offer free health care to uninsured or underinsured residents who are HIV positive, as opposed to limited and expensive care in the South, "today, the face of AIDS is black or Latino, poor, often rural—and Southern," Teresa Wiltz reports for Stateline. (Associated Press photo: Sterling Williams hammers in markers representing the 3,423 people in Shelby County, Tennessee, who have died from AIDS.)

"Southern states now have the highest rates of new HIV diagnoses, the largest percentage of people living with the disease, and the most people dying from it, according to Rainey Campbell, executive director of the Southern AIDS Coalition, a non-profit group serving the 16 Southern states and Washington, D.C.," Wiltz writes. "Fifty percent of all new HIV cases are in the South. The HIV infection rate among African-American and Latina women in the South now rivals that of sub-Saharan Africa. In some Southern states, black women account for more than 80 percent of new HIV diagnoses among women."

"States in the South have the least expansive Medicaid programs and the strictest eligibility requirements to qualify for assistance, which prevents people living with HIV/AIDS from getting care, according to a Southern AIDS Coalition report," Wiltz writes. "In the South, Campbell said, people living with HIV have to reach disability status before they qualify for aid. This is significant, because nationally the vast majority of HIV/AIDS patients rely on Medicaid for their health insurance, according to research conducted by the Morehouse College of Medicine." 

The nine deep South States with the highest rates of new HIV/AIDS diagnoses—Alabama, Georgia, Florida, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee and Texas—have all refused to expand Medicaid under federal health reform, Wiltz writes. "Those states also have the highest fatality rates from HIV in the country, according to the Southern AIDS Coalition."

A White House Council of Economic Advisers study found "that if the nine deep South States expanded Medicaid coverage, more than $65 billion in federal funding would flood those states, and an additional four million people would have insurance coverage," Wiltz writes. Campbell told Wiltz, “Jurisdictions throughout the South fail at nearly every level of HIV prevention and care, ignoring proven strategies that could help to address the uncontrolled epidemic and alarming death rate."

Part of the problem is the Southern attitude towards AIDS, Wiltz writes. "The escalating HIV rates are the result of a perfect storm of social factors including poverty, racism, persistent anti-gay attitudes, increasing homelessness and a lack of transportation in rural areas. In the South, AIDS still has the taint of the plague. Fear of being judged and ostracized keeps some people away from clinics and the care they need. Those who don’t know they’re infected will infect others, creating what the University of Alabama’s (Dr. Michael) Saag calls a 'silent epidemic.'” (Read more)