October 2009 | Back to Table of Contents

Pulse

Going the Distance

Minnesota was first introduced to the notion that HIV/AIDS was part of the state’s rural landscape in 1987, with the publication in the St. Paul Pioneer Press of Jacqui Banaszynski’s Pulitzer-prize winning story “AIDS in the Heartland.” With poignant detail, Banaszynski told the story of a gay couple from Glenwood who were dealing not only with the ravages of the disease but also with a mix of support, shock, fear, and judgment offered by friends and neighbors.

Much about that story would be different today. First, the fact that it took place in rural Minnesota would not seem so novel. Approximately 800 people with HIV/AIDS live outside of metro areas. Second, the subjects of the story might not be 30-something male Lutheran farmers. Instead, they might be a Sudanese-born factory worker, an older adult who has returned to the state to care for an aging parent, or a young Latina mother. “I would say the population trends older than in the metro area,” says Charles Hempeck, executive director of the Rural AIDS Action Network (RAAN), which helps people with HIV/AIDS find appropriate care and services. “And we have a higher percentage of women as clients. And now, we’re seeing African-born and Latino patients.”

Of course, the most important difference is that the story’s main characters would survive. What hasn’t changed in two decades is that living in a rural area complicates the experience of living with HIV/AIDS.

Travel is the biggest challenge for patients, according to Hempeck and others. “In greater Minnesota, you may have to travel 60, 70, 80 miles one way to see a specialist,” he says. Those distances are an improvement over the situation 20 years ago, when HIV specialists were concentrated in the Twin Cities. Now, Hempeck says, patients can see HIV experts in Mankato, Duluth, Fargo-Moorhead, Rochester, and Sioux Falls as well as in the Twin Cities. Still, because patients now live many years with HIV, the cost of travel to clinics is significant.

Transporting patients to their appointments is a big part of what Cheryl Yarnott, R.N., does as a medical case manager for RAAN. Yarnott, who is based in Bemidji, says she’s traveled as far as 70 miles to pick up a patient to take them another 70 miles to the clinic, only to repeat the trips to get herself and her client back home. She says she uses the drive time to listen to the patient’s concerns or to talk about what they need to cover with the physician.

Yarnott says many of her clients won’t tell family or friends what’s wrong with them, “so they won’t say, Can you take me to the doctor on Friday?” In addition, because they want to hide their diagnosis, they’re hesitant to get care at their local clinic or purchase their HIV drugs from their local pharmacy.

Infectious disease expert Linda Van Etta, M.D., who sees HIV patients in Duluth, says she thinks such concerns have lessened in recent years. She notes that evidence shows that patients have better outcomes when they’re treated at HIV/AIDS centers. However, if a patient has a good relationship with their local doctor and if their HIV is under control, she’ll work with that provider to develop a plan so that the patient can get much of their care closer to home.

Still, Hempeck, who has known people to say they have cancer or hepatitis C rather than admit to being HIV positive, says privacy remains a big concern for people with HIV in rural communities. “That’s part of the uniqueness of living with HIV in greater Minnesota.”—Carmen Peota

Immunity and the Gut

Minnesota researchers believe the answer to a key question about why antiretroviral therapy (ART) doesn’t restore immunity in people infected with HIV lies in the gut.

A team led by Timothy Schacker, M.D., a professor of medicine at the University of Minnesota, found that when a person is infected with HIV, fibrosis occurs in the lymph nodes—the home of infection-fighting T-cells. Once fibrosis occurs, T-cells can’t repopulate the lymph nodes when treatment for the infection begins. They also found that fibrosis occurs more rapidly and to a greater extent in the portion of the gut that contains T-cells than in other lymphatic tissues.

In the study, Schacker and his team treated seven HIV-infected patients very early after infection and found that they experienced a greater degree of immune reconstitution than patients who were treated during the chronic or end-stage of the disease.

They argue that the findings make the case for early treatment of patients with HIV. They also suggest that antifibrotic drugs may have a role as adjunctive therapy for people with HIV.

Results of the study were published in the August 15, 2008, Journal of Infectious Disease.

Tracking Trends

The number of reportable sexually transmitted diseases in Minnesota increased to a new high of 17,650 in 2008, up from 17,057 in 2007, according to Minnesota Department of Health data. Here’s a look at the numbers for three diseases:

According to Department of Health officials, there is a two- to five-fold increased risk of HIV infection when syphilis is present. The number of reported HIV infections held steady at 326 in 2008.

Source: Minnesota Department of Health STD Surveillance Report, 2008.