A Qualitative Study of Barriers to the Utilization of HIV Testing Services Among Rural African American Cocaine Users

• Published date: 01 July 2013
• DOI: 10.1177/0022042613476260
• Date: 01 July 2013
• Author: Geoffrey M. Curran,Katharine E. Stewart,Patricia B. Wright,Brenda M. Booth
• Subject Matter: Articles

Journal of Drug Issues

43(3) 314 –334

© The Author(s) 2013

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DOI: 10.1177/0022042613476260

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476260JODXXX10.1177/0022042613476260Journal of Drug IssuesWright et al.

1University of Arkansas for Medical Sciences, Little Rock, USA

2VA HSR&D Center for Mental Healthcare Outcomes and Effectiveness, North Little Rock, AR, USA

Corresponding Author:

Patricia B. Wright, College of Nursing, University of Arkansas for Medical Sciences, 4301 W. Markham, Slot 529, Little

Rock, AR 72205, USA.

Email: wrightpatriciab@uams.edu

A Qualitative Study of Barriers to

the Utilization of HIV Testing

Services Among Rural African

American Cocaine Users

Patricia B. Wright1, Katharine E. Stewart1,

Geoffrey M. Curran1,2, and Brenda M. Booth1,2

Abstract

This qualitative study is about barriers to the utilization of HIV testing as perceived by African

Americans who have recently used cocaine and who live in the rural Delta region of Arkansas.

Affordability, physical accessibility, and geographic availability were not perceived as barriers to

HIV testing in this sample, yet acceptability was still perceived as poor. Acceptability due to

social mores and norms was a major barrier. Many said testing was unacceptable because of fear

of social costs. Many were confident of being HIV-negative based on risky assumptions about

testing and the notification process. Small-town social and sexual networks added to concerns

about reputation and risk. System approaches may fail if they focus solely on improving access to

HIV services but do not take into consideration deeply internalized experiences of rural African

Americans as well as involvement of the community in developing programs and services.

Keywords

HIV testing, African American, rural, barriers, cocaine

The impact of drug use on the spread of HIV in the United States is not limited to the estimated

9.4% of adults in the United States diagnosed with a substance-use disorder (Brown et al., 2006).

Drug use directly and indirectly accounts for about 30% of AIDS cases each year (Centers for

Disease Control and Prevention [CDC], 2002) and 40% of AIDS deaths in the United States

(National Institute on Drug Abuse [NIDA], 2012). Anyone under the influence of drugs or alco-

hol is at increased risk of contracting or transmitting HIV/AIDS through the risk behaviors it

engenders (NIDA, 2006). Substance use affects judgment and is associated with unsafe sex

behaviors such as inconsistent condom use and trading sex for drugs or money, as well as unsafe

drug injection practices such as sharing used needles and equipment (NIDA, 2006).

Wright et al. 315

Rural African American cocaine users are a medically underserved and difficult-to-reach

population with limited access to HIV testing and prevention services. This study is about barri-

ers to the utilization of HIV testing and other HIV services as perceived by African Americans

who have recently used cocaine and who live in the rural Delta lands of Arkansas. Although there

are many definitions of rural, the definition used in this study is the Office of Management and

Budget (OMB) definition, which refers to all counties outside metropolitan areas with at least

10,000 but no more than 50,000 people as rural nonmetropolitan counties (U.S. Department of

Agriculture, Economic Research Service [USDA, ERS], 2007). This study is designed to provide

critically needed information about personal, social, and organizational/system factors that influ-

ence HIV testing utilization among rural African American substance users.

Background

HIV/AIDS has had a greater impact on African Americans in the South than any other area of

the country. The South, as compared with other regions of the country, has led the nation in

overall number of persons living with AIDS since 1993, and reported incidence cases or new

cases per year since 2001 (Qian, Taylor, Fawal, & Vermund, 2006). According to the CDC

(2011a), African Americans account for 50.1% of HIV diagnoses among adolescent and adult

men in the South as compared with 42.1% among men in the Northeast. African Americans

account for 70.9% of HIV diagnoses among women in the South as compared with 60.0% in the

Northeast (CDC, 2011a). In the South, HIV/AIDS disproportionately affects more heterosexuals

and those who live in rural areas (CDC, 2008; Southern AIDS Coalition, 2008). Heterosexual

transmission accounted for more than 85% of HIV among African American women in the

South, and injection drug use for only 14% (CDC, 2011a).

Drug use has been recognized as one of the driving forces in spread of the epidemic as well

as a major barrier to service utilization (Brown et al., 2006; U.S. Government Accountability

Office, 2009). Substance use, especially noninjecting cocaine use, is prevalent among African

Americans in the rural South, putting rural African American substance users at even greater risk

(Booth, Leukefeld, Falck, Wang, & Carlson, 2006; Chu & Selwyn, 2008; Farley, 2006; Fleming,

Lansky, Lee, & Nakashima, 2006; Wright et al., 2007). HIV risk behaviors associated with

cocaine use include having unprotected sex, using condoms inconsistently, having multiple con-

current sexual partners, having sex when using drugs, and trading sex for drugs or for survival

needs (Adimora, Schoenbach, & Doherty, 2006; Fleming et al., 2006; Reif, Geonnotti, &

Whetten, 2006; Stratford, Ellerbrock, & Chamblee, 2007; Wright et al., 2007).

Draus and Carlson (2009) describe the combination of small social circles, limited scope of

acquaintances and economic opportunities, inadequate drug treatment, and abundant drug supplies

as a “vortex” effect that can magnify drug use in rural areas. For example, if there is a great deal of

overlap of drug-using networks with other networks such as work, family, and neighborhood, then

a person’s access to non-drug users would be much more limited, making it much more difficult to

escape the “vortex.” The same factors can create a sexual-risk vortex in small towns that magnifies

the spread of HIV. Chronic drug use is often driven by associations with other users (Draus &

Carlson, 2009). Rural drug users are often marginalized within their small-town environments

similar to urban crack users. This makes it even more difficult to avoid drugs and access alternative

social networks. The closeness of social relationships and unavoidable proximity in rural areas can

severely restrict individual behavior. Essentially, rural drug users, particularly African American

rural drug users, belong to what Sabar (2002) describes as a “paradoxical social network,” one that

gives the individual a strong sense of identity and yet actively confines the individual.

Another driving force in the HIV epidemic is lack of HIV testing. The CDC estimates that

approximately 21% of persons living with HIV/AIDS in the United States are unaware of their